University of Michigan Health - West

“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: 53475 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], specifically the failure to provide an appropriate Medical Screening Exam for 1 patient (P-6) of 22 patients reviewed, and failed to provide an appropriate transfer for 1 (P-8) of 22 patients reviewed, resulting in the potential for less than optimal outcomes for P-6 and P-8. Findings include: See Tags: 2406 - Medical Screening Exam 2409 - Appropriate transfer”

“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: 53475 Based on interview and record review, the facility failed to ensure that 1 (P-6) of 22 patients, presenting to the Emergency Department (ED), received ongoing assessments in the ED waiting area in accordance with hospital policy while awaiting completion of the Medical Screening Examination (MSE), resulting in delayed treatment and the potential for negative outcomes. Findings include: On 6/20/2026 at 1400, during medical record review, P-6, a 63 year-old female, arrived at the ED on 1/6/2026 at 1539 from home with a chief complaint of “Fatigue (Fatigue, not eating, to (sic) weak to stand).” An Emergency Severity Index (ESI-standardized five-level triage tool indicating clinical acuity and expected resources needed) score of 3 was assigned at 1609, indicating stable vital signs and an expected need for two to three resources to manage care in the ED. Vital signs were assessed at a1605 in triage and at 1945 in the ED. Abnormal vital signs were noted. Vital Sign: Time: 1605 (Triage) Time: 1945 (ED Room) Temperature: 36.5 °Celsius (C) (97.7 °F) - Pulse: 72 73 Respiration: 18 20 Blood Pressure: 128/69 183/80 (High)* Oxygen Level 99 % (Room Air) 97% (Room Air) *Reference Range: (BP = 120/80 = Normal Range) On 1/6/2026 at 1906, P-6 was brought back to an ED treatment room and was seen by the provider at 1925. No reassessments were documented in triage between 1605 and 1906, resulting in a lapse of more than three hours without ongoing evaluation. Point of Care Testing (POCT) was not ordered until 1921 and 1922 in the ED, at which time multiple laboratory studies were initiated, along with orders for a chest X ray and a Computed Tomography (CT) scan of the head. Following completion of the MSE and stabilization, P-6 was admitted to the Inpatient Unit on 1/6/2026 at 2334 with the following clinical impressions: “Difficulty walking, malaise, and fatigue, acute urinary tract infection, and alcohol consumption binge drinking.” On 6/10/2026 at 1405, the Director of the Emergency Department Staff A and the ED Manager Staff B were interviewed regarding reassessment expectations for patients in the Emergency Department waiting area. Staff A and Staff B stated that the “Vital Signs and Monitoring” policy required reassessments at a minimum of every two hours, unless a patient’s condition necessitated more frequent evaluation. Review of the “Vital Signs and Monitoring, ED-D150” policy effective 1/1/2026 reveals that “All individuals, regardless of age, presenting to the Emergency Department seeking medical care will have their vital signs obtained and reassessed per patient condition. A patient’s condition may improve or deteriorate during their stay and a change in vital sign collection frequency may be appropriate ...ACTION 1 Patient incurring a wait will have their vital signs reassessed no less frequently than every 2 hours ...””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 53475 Based on interview and record review, the facility failed to document the required elements for an appropriate transfer for 1 (P-8) of 2 patients reviewed for transfer, resulting in insufficient information and the lack of identified resources needed to support transfer for P-8. Findings include: On 6/10/2026 at 1444, during a medical record review, it was noted that Patient P-8, a 34-year-old male, arrived in the Emergency Department (ED) on 1/22/2026 at 2050 by ambulance following a motor vehicle accident. P-8 was accompanied by law enforcement, and the documented chief complaint was the need for a psychiatric evaluation and medical clearance. An Emergency Severity Index (ESI-standardized five-level triage tool indicating clinical acuity and expected resources needed) score of 2 was assigned at 2054. Prior to arrival, P-8 was an outpatient enrolled in a Partial Hospitalization Program (PHP) for treatment of borderline personality disorder. P-8 had self-medicated for anxiety. P-8 was petitioned and certified for inpatient psychiatric treatment. After completion of the medical screening examination (MSE), P-8 was transferred by ambulance and admitted to a psychiatric inpatient unit on 1/22/2026 at 2204 with a final impression of borderline personality disorder. No transfer form was completed. On 6/10/2026 at 1450, the Director of the Emergency Department Staff A and the ED Manager Staff B were interviewed about the use and expectations of the transfer form. Both acknowledged that the facility’s “Ambulance Interfacility Transfer Form” approved on 4/12/2023, should have been completed to document transfer resources, consent to transfer, and the physician certification for transfer. Review of the “Emergency Medical Treatment and Labor Act (EMTALA) COMP-18” policy effective 5/20/2026 states “The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that guarantees individuals who present to a hospital emergency department for examination or treatment receive a medical screening exam and stabilizing treatment prior to discharge or transfer to another facility regardless of ability to pay ... B. Patient with an EMC Patients with an emergency medical complaint (EMC) must be provided further medical examination and stabilizing treatment within UMHW Capacity and Capability and/or UMHW staff will arrange for an appropriate transfer to a receiving hospital in accordance with EMTALA ... 5. Medical records are provided to the receiving facility in accordance with the Transfer Documentation section of this policy ... TRANSFER DOCUMENTATION A copy of the medical record related to the emergency condition for which the patient has presented will be provided to the receiving facility. The following information must be included: 1. Status of the individual’s emergency medical condition at the time of transfer. 2. Available history. 3. A copy of all medical records related to the emergency medical condition available at the time of transfer. Historical records not yet available will be sent as soon as possible after transfer. 4. Observation of signs and symptoms. 5. Preliminary diagnosis. 6. Results of diagnostic studies or telephone reports of the studies. Test results not yet available will be sent as soon as possible after transfer ...””

“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 observation, interview and record review, the facility failed to ensure nursing staff implemented fall prevention interventions for 3 (P-2, P-18, and P-25) of 8 patients reviewed for fall risk, resulting in harm to 1 patient (P-2) 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 Failure to implement fall prevention interventions”

“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 observation, interview and record review, the facility failed to ensure nursing staff implemented fall prevention interventions for 3 (P-2, P-18, and P-25) of 8 patients reviewed for fall risk, resulting in harm to 1 patient (P-2) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include: P-2 On 3/31/2025 at 1540 a record review occurred of P-2’s medical record. According to P-2’s medical record P-2 was sent to the Emergency Room for evaluation for an “unwitnessed fall” at the long-term care facility (nursing home) and becoming somnolent since the fall. The medical record also noted, “is normally confused but alert and conversative.” P-2 arrived at the Emergency Room at 1312 on 1/12/2025. On 1/12/2025 at 1322 under the subtitle “Neuro Assessment,” P-2’s level of consciousness documented, “reactive; lethargic,” orientation documented as other with notation “uta; unable to answer questions,” cognition/behavior, “confused”, and communication, “delayed responses.” On 1/12/2025 at 1543 P-2’s level of consciousness documented, “alert,” orientation documented as “confused; pt able to recall name, unable to recall anything else, including birthday,” cognition/behavior, “poor,” attention/concentration; short term memory loss; long term memory loss; poor safety awareness; confused; impulsive; poor judgement,” and communication, “delayed responses....” P-2 underwent a CT (computed tomography) scan on 1/12/2025 at 1322. P-2 CT scan results were the following: “Multicompartmental acute intracranial hemorrhage including a right temporal lobe hemorrhagic contusion, mixed density right subdural hematoma, layering intraventricular hemorrhage, and subarachnoid hemorrhage in the left parietal lobe. There is mild local mass effect related to the right temporal lobe hemorrhagic contusion, but no midline shift or evidence of herniation.” The DPOA (durable power of attorney) was contacted and the decision was made by the DPOA to make the patient comfort measures only. According to documentation P-2 sustained a fall on 1/12/2025 between 1517 and 1520 in the Emergency Room. On 1/12/2025 at 1520 staff Z, ED RN documented, “sudden interruption in cardiac rhythm with consecutive failures of all cardiac leads alarming “asystole”. RN to room to assess; pt found supine in room with head underneath overhang of sink in room feet towards the entryway with significant amounts of blood to face and pooling around head and upper torso on underlying floor....” On 3/31/2025 at 1600 an interview was conducted with staff W, Registered Nurse for P-2 on 1/12/2025. Staff W was queried if he remembered P-2. Staff W stated he did remember P-2 related to the incident of the fall. Staff W was asked if he could describe P-2. Staff W stated that when P-2 arrived at the ED on 1/12/2025 that P-2 was obtunded and was quiet. Staff W continues that P-2 would mumble but didn’t interact much during his assessment. Staff W was then queried if there were any concerns with P-2 being a fall risk. Staff W stated, “No, not really. He was very despondent.” Staff W was asked if he knew why P-2 was brought to the ED. Staff W responded that P-2 had a change in interaction with the staff at the long-term care facility that he resided at since his fall a few days prior. Staff W was queried if P-2 was in a direct line of sight from the nurse’s station. Staff W stated, “No. He was in room 13 ...patients go where there is an open bed, as much as we try to put them near a nurse’s station if they’re confused it is not guaranteed ...and he was obtunded.” On 4/1/2025 at 1045 a tour of the ED was conducted. Room 13 was observed to be located on the right side of a short hallway and not in a direct line of view from the nurse’s station. The nurse’s station was also noted to be behind frosted glass obscuring view of any rooms on the other side of the glass. Staff B, ED Manager confirmed that the frosted glass did not allow for visualization of any rooms in front of the nurse’s station. On 4/1/2025 at 1215 a review occurred of the policy titled, “Fall/Injury Prevention, NUR-30,” PolicyStat ID #12721065, revision date 01/2023. The attachment named “Morse Fall Risk Assessment Scale,” NUR-30 Attachment A was not utilized in P-2’s medical assessment. However, according to the scale P-2 met the following criteria according to P-2’s medical record: History of Falls - Yes - 25 (P-2 fell two days prior to ER visit), Secondary Diagnosis - Yes - 15 (P-2’s secondary diagnoses included anxiety disorder, peripheral vascular disease, dysphagia, muscle weakness, hyperlipidemia, alcohol abuse (uncomplicated), other seizures ....per medical record from transferring facility). Ambulatory Aid - bedrest - 0, IV/Saline lock - Yes - 20, Gait/Transferring Bed Rest - 0, Mental Status - Forgets Limitations - 15. Total Score - 75. According to the Morse Fall Scale P-2 score would have been considered at high risk for falls. On 4/1/2025 at 1310 a review occurred of attachment B “Safety Interventions.” The attachment indicates the following to be used with “high” fall risk patients. High Fall Risk Interventions include but not limited to: 5. Consider moving the patient to a room with best visual access from the nursing station, 6. Consider the use of bed alarms or a personal alarm, 7. Consider the use of a patient observer (family or patient companion). The facility failed to provide a fall risk evaluation for P-2 and failed to implement high fall risk interventions. P-18 On 3/31/2025 at 1025 during a tour of the Emergency Room P-18 was located in trauma bay #1. During the tour of the ER the curtains to trauma bay #1 were closed. Trauma bay #1 was observed to be clean. P-18 was alert and oriented to person, time, place, and situation. P-18 was brought to the ER for a broken hip due to a fall on the morning of 3/31/2025. P-18 was asked if he could show a call light to use in case he needed assistance. P-18 was unable to locate a call light. Staff B, ER manager was queried where P-18’s call light was located. Staff B located P-18’s call light on the wall out of reach of P-18. P-25 On 4/1/2025 at 0935 during the tour of the Emergency Room P-25 was located in room #8. During the tour of the ER the door for room #8 was closed. An interview was conducted with P-25 and P-25’s family members that were bedside. P-25 was brought to the ER via ambulance on the morning of 4/1/2025 for signs and symptoms of stroke. P-25 was alert and oriented at the time of interview. The call light was viewed on the wall out of reach. Staff B, ER manager was queried where P-25’s call light was located. Staff B located P-25’s call light on the wall out of reach of P-25. According to the attachment, NUR-30 Attachment B, under the subtitle, Safety Interventions, it revealed the following for all patients as a fall safety intervention: “Low and Moderate Fall Risk Prevention Interventions: 1. Create a safe patient room environment by conducting rounding for outcomes including: a. Placing the call light within reach...””

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 36887 Based on 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], specifically the failure to maintain a complete central log with arrival times for patients arriving through the emergency department lobby, failure to provide a timely medical screening exam for 2 (P-1 and P-3) of 25 patients reviewed, and failed to provide an appropriate transfer for 3 (P-8, P-9, P-15) of 4 transfers reviewed resulting in the potential for delayed treatment, unrecognized and unmet patient needs and poor patient outcomes for all emergency patients served by the facility. Findings include: See Specific Tags: A-2405 Incomplete central log A-2406 Delay in medical screening exam A-2409 Incomplete transfer documentation”

“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: 36887 Based on observation, interview, and record review, the facility failed to have a complete central log for the ED which included an accurate arrival time of the patients, resulting in the failure to identify all patients who left prior to evaluation by a provider and the failure to capture an accurate time all patients coming through the ED lobby were waiting to be seen by the nurse and/or provider. Findings include: On 4/1/2025 at 0945, surveyors, ED Manager Staff B, and Accreditation Coordinator Staff C went to the ED lobby to observe the triage area. Upon entrance, it was noted there were 12 patients seated in the waiting room and there was a line of 4 patients/families that were waiting. At the head of the line was a sign indicating patients needed to wait in line there to be triaged. The first three patients were in wheelchairs and the fourth was standing leaning against a wall. The triage desk was busy with a patient at the desk. It was noted the man in the third wheelchair back was visibly short of breath. It was unknown how long he had been waiting in line to be seen. Approximately two minutes after the surveyor’s arrival to the area, the ED technician approached the man in the third wheelchair and obtained vital signs. She went back and spoke to the triage nurse. Upon the nurse finishing the triage with the patient at the desk, the ED technician came and got the man who was short of breath and took him ahead of the others to the triage desk for assessment. The woman who was in the wheelchair first in line got up and walked out the door accompanied by a man who was with her. They did not return. Observations continued with more patients entering, some with a security officer giving direction, and standing in the growing line waiting for triage. After observing for approximately 10 minutes, ED Manager Staff B was asked to relieve the triage nurse so she could be interviewed. During interview, Triage Nurse Staff N was queried as to if she was aware the female patient had left, and she said she was. She was then queried as to the patient’s name and the reason she was there to be seen. Staff N stated she didn’t know because she hadn’t triaged her yet. When asked how long the patient had been waiting prior to leaving, Staff N responded she thought the patient had been there approximately five minutes. Staff N was queried as to why the arrival times were not tracked and the triage nurse clicked the arrival time at the same time as the triage time. Her response was that was what they had been instructed to do as the encounter was created at the time of triage. A name would have to be present to note an arrival time and names of patients were not known until they were at the desk for triage. No quick registration system was in place in triage. All patients were registered in the main ED at bedside. During review of medical records on 3/31/2025 and 4/1/2025, patients who came in through the ED lobby had the following arrival and triage times: P-1 Arrival: 1249 Triage 1249 P-4 Arrival 1013 Triage 1013 P-5 Arrival 0207 Triage 0208 P-6 Arrival 1837 Triage 1837 P-8 Arrival 1027 Triage 1027 P-10 Arrival 1449 Triage 1449 P-12 Arrival 0849 Triage 0849 P-13 Arrival 1449 Triage 1449 P-14 Arrival 2237 Triage 2237 P-16 Arrival 1040 Triage 1040 P-17 Arrival 0301 Triage 0301 Review of facility policies for EMTALA (Emergency Medical Treatment and Labor Act) and Triage did not address capture of the arrival times vs. triage time.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to a timely medical screening exam for 2 (P-1, P-3) of 25 patients resulting in the potential for poor patient outcomes. Findings include: Review of the medical record for P-1 revealed he was a 47-year-old male who presented to the Emergency Department (ED) via private vehicle on 11/4/2024 at 1249 with a chief complaint of abdominal pain. Triage documentation with the chief complaint has in parenthesis, “Pt reports ’ Extreme abdominal pain. Hx (history) of hiatal hernia. PLEASE HELP ME IM IN SO MUCH PAIN ’ . Family reports ‘He had a big meal last night. Nausea, no vomiting. ULQ (upper left quadrant) pain. Sharp. Started after eating oatmeal.’” The triage assessment further indicated there was no radiation of the pain. Initial vital signs at 1251 were as follows: Temperature (T)-98.6, Pulse (P)-85, Respirations (R)-16, Blood Pressure (BP)-167/105, and Oxygen Saturation (SpO2)-98% on room air. Pain was 10/10. Triage documentation indicated P-1 was irritable and boisterous; however, was not threatening. P-1 was listed as an acuity 3 (The emergency severity index {ESI} level three indicates a patient that requires prompt attention but can wait up to 30 minutes for assessment and treatment). On 11/4/2024 at 1303, Triage Nurse Staff L documented the family was requesting a robe and stating P-1 was hot. He noted P-1 was “pacing in triage.” P-1 was roomed on 11/4/2024 at 1347 (58 minutes later) and ED Physician Staff M saw the patient immediately. Physician notes dated 11/4/2024 by the resident indicated P-1 was in “obvious pain”, having abdominal pain with radiation to his shoulder. By the end of the exam, P-1 was reporting pain in both shoulders. An EKG (electrocardiogram) and labs were obtained at 1357 (1 hour, 8 minutes from time of triage). The resident documented, “My personal interpretation of the EKG was ST elevation in leads II, III and aVF and ST depressions in lead V2 consistent with an inferior STEMI (ST elevated myocardial infarction-heart attack). (Physician Staff M) was notified by the nurse of the EKG findings as well. At this point, the STEMI protocol was activated. The patient continued to be nauseated and continued having “intense abdominal pain, left-sided and back pain with left arm numbness.” Pain medications and blood thinners were given, and P-1 was emergently transferred from the ED to the catheterization lab at 1423. He was admitted to the hospital following his heart catheterization. During interview on 4/1/2025 at 0913, Triage Nurse Staff L stated he did recall P-1 coming in with “abdominal pain that worsened after eating.” He stated he asked P-1 “if he was having chest pain and he said no.” Staff L recalled P-1 was pacing, and, at some point, was taking off his shirt. Staff L asked P-1 to keep his shirt on. When queried as to if a patient stating pain was 10/10, and the patient was pacing, and did not appear to be able to get comfortable would be a cause for concern, Staff L stated pain was “very subjective but taken note of.” When asked if a patient or family member interrupted him while with another patient to say symptoms were worse or were asking for help what he would do, Staff L stated he would direct them to “get back into (the triage) line” so they could be reassessed. During the course of survey, it was discovered the facility did not have a quick registration process in place and all patients were registered at bedside. Patients were first seen by the triage nurse and the triage nurse would document the patient’s time of arrival the same as the time of triage. When queried, Staff L was unable to recall how long P-1 waited from his actual time of arrival to the time of triage. Review of the medical record for P-3 from the receiving facility (Facility B) revealed he was a 75-year-old male who was being sent by a nursing home facility for evaluation of hematuria (blood in the urine). In the medical record was a copy of the ambulance run sheet which was also reviewed. The ambulance run sheet was dated 2/4/2025 and the call was initialed at 0220. They were on scene with the patient at 0239. It was noted the nursing home that the patient resided in was on the same road as the subject facility (Facility A). In the narrative portion of the ambulance run sheet, it was stated, “Initially Patient was taken to (Facility A) and when EMS (emergency medical services) arrived with the patient facility staff turned EMS away stating they were on diversion and were not taking any patients by EMS at this time so EMS asked patient and they requested to be taken to (Facility B).” Review of the Diversion Log for the past 12 months revealed Facility A had been on diversion four times including the time frame from 2/3/2025 at 1958-2/4/2025 at 1347 (17 hours, 49 minutes). Review of the EM Track (Emergency Track-radio communication system between hospitals and ambulances) Log revealed an entry dated 2/4/2025 at 0245 for a 75-year-old male with “hematuria x1 day, (catheter) replaced last week.” It noted it was a “Bravo” call (low priority level) and which ambulance service was calling. Estimated time of arrival was 2/4/2025 at 0307. The “status” column stated “Received.” On 4/1/2025 at 1150, Director of ED Staff A stated that “received” indicated the call was received from the ambulance. In a general interview with Charge Nurse Staff E on 3/31/2025 at 1050, she was queried about diversion and stated she was aware of only 1 time being on diversion in the past year. That one time was the beginning of this year (2025) and was because there were too many patients being boarded (waiting for inpatient bed or to be transferred) in the ED and it was decided they “couldn ’ t adequately care for all of the patients.” When queried as to what she would do if a patient arrived via ambulance while they were on diversion, she said, “If the patient is on hospital grounds, we do take them unless we are on diversion.” On 4/1/2025 at 1342, Staff E was re-interviewed upon discovery she had been the charge nurse on 2/4/2025 during the early morning hours. She stated she had just come on shift on 2/4/2025 at 0300 and knew the facility was still on diversion. An alert went off from the EM Track for ambulance communication. Staff E stated she hit the “divert” button which sends a tone to the ambulance alerting them the facility was on diversion. She did not answer the call. Staff E then instructed the unit secretary to call the ambulance company office and inform them the facility was still on diversion. Staff E stated she performed a small, quick task, then walked back up the hallway and saw the patient and EMS crew standing in front of the charge nurse desk when she rounded the corner. “I asked them what was going on and told them I hit the divert button and the office had been called. They said, ’ Oh, we must have missed it. ’ They then asked the patient where else he would like to go, and they left.” Staff E admitted she did not try to stop them from leaving. On 4/1/2025 at 1615, Paramedic Staff Q stated he worked a 1800-0630 shift on 2/3 into the early morning hours of 2/4 and was aware the facility had been on diversion earlier in the night. At 0300, he thought the diversionary status had lifted as “generally they do not last that long.” Upon arrival to the facility, he and EMT Staff P took the patient into the building. They were met by the charge nurse who asked what they were doing and informed them the facility was on diversion, and she had hit the divert tone when the call had come in. “I told her we must have missed it. I then asked the patient where he would like to go... and we left.” Staff Q stated the charge nurse did not attempt to stop them from leaving. When queried as to how he was unaware the facility was still on diversion, Staff Q stated it was very uncommon for a facility to be on diversion for such a long period and when in the field it was very easy to miss updates on their phones and/or tablets when tending to a patient or driving the ambulance. Facility policy NUR-16 titled “Diversion (EMS Policy, NUR-16” retrieved 3/2025 states, “Diversion of ambulances may become necessary... If an ambulance disregards the diversion instruction and comes to the hospital, the hospital is obligated to provide the emergency screening exam and stabilizing treatment under EMTALA (Emergency Medical Treatment and Labor Act).””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to provide all information required for transfer for 3 (P-8, P-9, P-15) of 4 Emergency Department transfers reviewed resulting in the potential for unsafe and/or inappropriate transfers. Findings include: Review of the medical record for P-8 revealed an “EMTALA (Emergency Medical Treatment and Labor Act) Transfer Form” dated 1/8/2025 that failed to document whether or not the patient had been stabilized. Review of physician notes also did not include comment on the patient’s stability. Additionally, the form did not address the resources-both qualified personnel and medical equipment-needed to safely transport the patient. Review of the medical record for P-9 revealed there was no EMTALA Transfer Form present. No documentation was found elsewhere in the medical record that described patient stability, benefits/risks of transfer, nor resources needed for transfer. On 4/1/2025 at 1140, ED Manager Staff B stated the EMTALA Transfer Form should be filled out for every transfer to an outside facility. Review of the medical record for P-15 revealed an EMTALA Transfer Form dated 1/13/2025 that failed to document whether or not the patient had been stabilized. Review of physician notes also did not include comment on the patient’s stability. Additionally, the form did not address the resources needed to safely transport the patient. Facility policy #17269324 titled “Transfers to Acute Care Hospitals, NUR-46” effective 1/2025 states, “Transfers to outside acute care hospitals or facilities, either by request of patient/family, medical necessity, or for services not provided at UMH-West are conducted with patient rights and safety ensured; and all regulatory/compliance requirements followed... A. Forms required for all transfers: 1. Physician Certification for Transfer/EMTALA Transfer Form... REQUIRED FOR EVERY TRANSFER. Must include name of receiving facility and name of accepting physician at receiving facility.” Facility policy #13463262 titled “Emergency Medical Treatment and Labor Act (EMTALA), COMP-18” effective 11/2023 states, “G. Transfers... 6. Transfers will be done by appropriate medical vehicle with appropriate medical personnel and appropriate life support equipment. Private vehicles do not meet EMTALA standards.””

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 48030 Based on interview and record review, the facility failed to 1) failed to follow their grievance process for 1 (P-1) of 11 patients reviewed and failed to 2) allow 1 (P-2) of 11 patients reviewed to be involved with care planning and treatment resulting in loss of patient rights. Findings include: See Specific Tags: A-122 Failure to resolve a grievance in a timely manner A-123 Failure to send notice of grievance decision A-130 Failure to allow patient involvement in care planning and treatment”

“MEDICAL RECORD SERVICES CFR(s): 482.24 The hospital must have a medical record service that has administrative responsibility for medical records. A medical record must be maintained for every individual evaluated or treated in the hospital. This Condition is not met as evidenced by: 36887 Based on interview and record review, the facility failed to maintain a complete and accurate record for 1 (P-2) of 1 patients resulting in a lack of communication amongst staff as well as physical and mental anguish for the patient. Findings include: See Specific Tags: A-0438 Maintaining a complete and accurate record”

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to address a grievance for 1 (P-1) of 11 patients reviewed in a timely manner and/or inform them of a lengthy investigation resulting in a loss of patient rights. Findings include: During an interview with the Clinical Risk Consultant (Staff V) and the Director of Patient Relations, Academic Medical Center (Staff W) on 2/4/2025 at 1330 the complaint filed by P-1’s wife on 10/30/2024 was reviewed. Staff V explained the facility ’ s Patient Relations Specialist (Staff WW) was on leave and was unavailable to review the work that was done on the complaint. Staff V revealed she had an email chain with information about the investigation that she was referencing. When queried if the facility used an electronic grievance/complaint system, Staff V revealed they do, but the follow-up had not been entered into the system. Staff V revealed The Patient Relations Specialist (Staff WW) spoke with P-1’s wife by phone on 10/30/2024 and a Acknowledgement letter was sent on 11/6/2024. On 12/20/2024 the Patient Relations Specialist received the findings of the investigation which found they were unable to substantiate the injury occurred during transfer and P-1’s wife was notified by phone of these findings. Staff V revealed a closure letter was drafted on 1/29/2025 but never mailed. When queried if the facility followed the facility policy regarding follow-up and notification to complainants and Staff V stated, “no, we didn’t send the 30 day follow-up letters or a closure letter and added “we would have normally sent a letter, but we learned that the patient had died and we were being sensitive to this fact”. Review of the Patient Relations Calls, and Complaints or Grievance Log confirmed the following entries related to P-1 on the following dates: 11/6/2024 - Acknowledgment Letter Sent - “I will need to consult with our hospital leadership team to thoroughly investigate the matter.” and “You will continue receiving communication from us every 30 days, until the review is complete unless it is completed sooner.” 1/29/2025 - Closure letter drafted (never sent) - “I have consulted with our hospital leadership team, and a thorough review of your medical record was completed.” and “On extensive review, including speaking with staff and leadership, we were unable to substantiate this event.” 1/30/2025 - (P-1’s wife) - needs closure - Awaiting Return call Review of facility policy titled “Patient Complaints and Grievances, RM-25”, policy #9764750 and last revised 9/2021, Documentation Section reveals, “If the concern can be solved within 7 calendar day, the Patient Relations Coordinator will send a Resolution Letter...” and if the concern is unable to be resolved in 7 days a letter of acknowledgement should be sent within 7 days, a follow-up letter every 30 days and a Resolution Letter as soon as possible.”

“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 interview and record review, the facility failed to provide 1 (P-1) of 11 patients reviewed with written notice of a grievance investigation closure letter, resulting in denying a patient of their right to a complete grievance process. Findings include: The complainant was contacted on 2/3/2025 at 0930 to confirm the allegations. The complainant revealed a formal complaint was made with the facility on 10/18/2024 and they have “not been cooperative about getting back to me and I just want to make sure this doesn’t happen to other patients.” During an interview with the Clinical Risk Consultant (Staff V) and the Director of Patient Relations, Academic Medical Center (Staff W) on 2/4/2025 at 1330 a complaint filed by P-1’s wife on 10/30/2024 was reviewed. Staff V explained the facility’s Patient Relations Specialist (Staff WW) was on leave and was unavailable to review the work that was done on the complaint. Staff V revealed she had an email chain with information about the investigation that she was referencing. Staff V revealed a closure letter was drafted on 1/29/2025 but never mailed. When queried if the facility followed the facility policy regarding follow-up and notification to complainants and Staff V stated, “no, we didn’t send the 30 day follow-up letters or a closure letter and added “we would have normally sent a letter, but we learned that the patient had died and we were being sensitive to this fact”. Review of facility policy titled “Patient Complaints and Grievances, RM-25”, policy #9764750 and last revised 9/2021, Documentation Section reveals, “If the concern can be solved within 7 calendar day, the Patient Relations Coordinator will send a Resolution Letter...” and if the concern is unable to be resolved in 7 days a letter of acknowledgement should be sent within 7 days, a follow-up letter every 30 days and a Resolution Letter as soon as possible.”

“PATIENT RIGHTS:PARTICIPATION IN CARE PLANNING CFR(s): 482.13(b)(1) The patient has the right to participate in the development and implementation of his or her plan of care. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to allow patient participation in the plan of care for 1 (P-2) of 5 patients reviewed for C-section resulting in the loss of patient rights. Findings include: Review of the medical record for P-2 revealed she was a 27-year-old female G (gravida-number of total pregnancies) 7, Para (P-number of live births) 1, SAB (Spontaneous abortion - miscarriage) 5, who presented to the facility 10/18/2024 at 38 weeks, 1 day for induction of labor due to fetal growth restriction. Upon arrival to the unit, the baby was in cephalic (head) presentation. Induction was started and labor progressed until she was dilated to 8 cm (centimeters). P-2 received an epidural 10/19/2024 at 1712. An exam done by the resident just prior to rupture of membranes on 10/19/2024 at 1854 revealed a foot was present - a discovery that the baby had flipped and was currently in the breech position (buttock presentation). Education was provided regarding manual manipulation of the baby back into the cephalic presentation versus having a C-section done. P-2 elected to do the C-section. Review of the OP (operating) Report revealed a start time of 1957. A baby girl, 5 pounds, 6 ounces, was delivered at 2007. The stop time was 2040. The report further detailed the events leading up to the beginning of surgery including consent, preparation, draping, surgical time out, testing of anesthesia and incision as well as detailing the surgery itself. Review of the C-section documentation and the medication administration record (MAR) for 10/19/2024 revealed the following timeline for events and medications: 1712 Epidural started 1942 Patient in OR 1942 Bupivicaine 0.5% with Epinephrine 1:200,000 injectable 5 ml (milliliters)-epidural 1946 Bupivicaine 0.5% with Epinephrine 1:200,000 injectable 5 ml - epidural 1957 Incision start 2007 Baby delivered 2009 Pitocin 30 units in 500 ml normal saline at 350 ml/hr (milliliters per hour) 2010 Zofran 4 mg (milligrams) IV, Decadron 4 mg IV (intravenous) 2013 Versed 2 mg IV 2019 Versed 2 mg IV 2021 Morphine 2 mg IV 2022 Propofol 20 mg IV 2025 Propofol 20 mg IV 2028 Propofol 20 mg IV 2032 Toradol 30 mg IV 2036 Propofol 20 mg IV 2039 Pitocin reduced to 100 ml/hr IV 2040 Incision closed 2047 To recovery 2052 Epidural stop Review of P-2 vital sign documentation revealed the following: 10/18/2024 - 1631 Admission: T (Temperature)-98.2, HR (heart rate)-99, R (respirations)-16, BP (blood pressure)-111/69 10/19/2024 - 1635 Labor prior to epidural: T-97.7, HR-77, R-18, BP-118/75 10/19/2024 between 1957 start of C-section at 2021 to administration of Morphine (narcotic pain reliever): HR-91 to 142, BP-140/80 to a high of 125/109 10/19/2024 - 2135 Recovery: HR-77, R-16, BP-108/73 10/20/2024 - 1620 Post-partum: T-98.1, HR-82, R-16, BP-96/59 10/22/2024 - 0745 Closest to discharge: T-98.1, HR-76, R-16, BP-109/60 No documentation was found that an incident report was made neither was there documentation in the medical record that indicated the patient was painful during the C-section. A “Comment” made by Anesthesiologist Staff QQ in the anesthesia medication information on 10/19/2024 at 2013 stated, “Patient is out of control anxious, asking to be put under general anesthesia or give her something ot (sic) relax her after the baby has been delivered. I told her that the medicine i (sic) will give will give her amnesia (loss of memory)..” On 2/4/2025 at 0858, Attending OB/GYN Physician Staff CC stated he was on call on 10/19/2024. P-2’s need for a C-section was not emergent. It was his practice to do a “private clamp test” by using a clamp to pinch the area where he would make his incision to check for patient feeling. When pinching, he would look to the anesthesiologist to see if the patient reacted in any way as he was unable to see the patient’s face due to the drape. In this case, there was no reaction by P-2, so he started his incision. Staff CC stated he had cut the skin and fascia without incident; however, when he got into the deeper tissue, P-2 was able to feel what he was doing. He explained he “paused, and based on the reaction of the patient, she could feel. I asked anesthesia if we needed to do something differently. He rechecked something and said I was okay to go.” Staff CC further explained when something unusual or emergent happens in the OR (operating room) with vital signs or pain, anesthesia would control the situation. He stated he anticipated the patient would be intubated and put under general anesthesia; however, the patient had expressed it was her wish to hear her baby’s first cry and anesthesia was aware of that wish. He also stated anesthesia didn’t “like giving general pain meds because it crosses the placenta quickly and can affect the baby.” It was explained to the patient we could continue, or she could be given general anesthesia in which case her husband would have to leave the room, and she would be unable to hear that first cry. “The patient initially elected to continue.” Staff CC recounted that he and assisting Resident Staff JJ “paused multiple times” as P-2 was screaming and stating she was painful. P-2 was able to move her legs and feet slightly which Staff CC described as being “atypical” and “gave us pause.” With questioning, Staff CC stated in general, a non-emergent C-section can deliver the baby in 3-5 minutes. In this case, it took 2-3 times longer than it normally would have due to the pauses brought on by the patient’s reaction during surgery. When queried as to if the patient was experiencing anxiety and the expected pulling/tugging sensations normally felt with C-section versus pain, Staff CC stated he did not know what the patient was experiencing and admitted that at times the pulling/tugging can be interpreted as pain. He further stated in other cases in which the epidural did not seem to be working as well, and the patient seemed to have a high level of sensation to what was happening, that most of the time the case was converted to general anesthesia. Staff CC further stated he spoke with Anesthesiologist Staff QQ following the C-section who told him the “levels of anesthesia” (epidural) was fine and that the patient was “out of control.” On 2/4/2025 at 1139, First -Year Resident Staff HH corroborated Staff CC’s statements and added P-2 was “yelling and screaming in pain asking to be put under but it did not happen. I’m not sure why.” On 2/4/2025 at 1148, Fourth year Resident Staff JJ stated the patient “voiced being uncomfortable” and stated surgery was stopped multiple times. She then stated, “She asked to be put under and (OB/GYN Staff CC) said he was okay with general anesthesia. Anesthesia talked to the patient and then told us to continue. The patient was screaming...” On 2/4/2025 at 1115, Registered Nurse (RN) Staff GG stated she had cared for P-2 on 10/19/2024 day shift. P-2 had told her she had anxiety but had good coping skills. Occasionally, she would need someone to “help her through it.” After the epidural was placed, P-2 had reported being able to still feel on the left side. Staff GG assisted the patient to the left side to help the medication distribute to the left. She stated she checked dermatomes (areas of nerves in the skin) and found P-2 was numb at the umbilicus, but it was lower on the left side and could not recall placement. Upon looking in the medical record, she stated she had “forgotten to document” the dermatomes and no documentation was found that the patient could feel on the left side. When queried as to if she had notified anesthesia, she stated she had not because it was shift change, and it was about that time the resident had discovered the baby had turned and they were calling for a C-section. Staff GG assisted with prepping the patient and said she stayed by her head during the C-section. P-2 was anxious, and Staff GG was encouraging her and letting her know pulling and tugging was normal. Staff GG stated P-2 then began screaming and saying she could feel the pain. “She asked them to stop or to be put under.” Anesthesia talked with the patient, but Staff GG was unable to hear what was being said. She said surgery resumed, but “nothing had changed. The patient began screaming again.” Staff GG admitted this was the first time in 10 years of being a labor and delivery nurse she had seen something like this happen. On 2/4/2025 at 1434, RN Staff LL stated she was the oncoming night nurse on 10/19/2024. She stated P-2 was “more than a little bit anxious during the incision and said, ’ I can feel them. ’ That caused P-2 to panic, and she requested help in calming down. I don’t know at what point things shifted, but she started being less anxious and was stating she could feel what was happening. The OB stopped and asked (the anesthesiologist) if he needed to give anything. Nothing was given. Anesthesia told the OB to keep going, and he did.” Staff LL stated things began to escalate. P-2 was screaming saying, “I can feel everything. Please put me under.” Staff LL said P-2 was asked if she was put under if it was okay if her husband left and (P-2) said no. Staff LL further stated it was “very possible (P-2) changed her mind after making that statement.” Staff LL further stated in recovery, P-2 did not complain of pain; however, she repeated over and over, “That was awful.” On 2/4/2025 at 1608, Anesthesiologist Staff QQ stated he was on-call and received a page for a C-section. He found the epidural to be working for P-2. She was very anxious, but this was something he cared for on a regular basis. He tried to educate P-2 on sights on sounds without overloading her with information. “She was freaking out a lot.” Once they started the C-section and the incision was made, P-2 “started yelling. When the surgeon stopped, she stopped.” He said he was debating about starting general anesthesia and recalled P-2 had stated she wanted to hear the baby’s first cry and have skin-to-skin contact, so he told her he could not sedate her until the baby was out. Staff QQ was unable to recall P-2 requesting “to be put out.” He stated he was trying to give the patient options and “if she had truly been painful, she would have been painful no matter what.” He was queried as to when he would decide to change the plan to which he stated it would “be in conjunction with the OB because medications can affect the baby very quickly... I would get a verbal consent from the patient. It is not an independent decision to make... This is not a common thing that happened.” On 2/5/2025 at 1258, Chief Medical Officer Staff C stated a patient does have the ability to change her mind regarding her care “as long as she has the decisional capacity to do so.” On 2/5/2025 at 1333, Nurse Manager of the Childbirth Center Staff N stated “a patient can change their mind at any time from the initial plan. Increasing or changing medications during surgery would be a discussion with the doctors.” On 2/5/2025 at 1348, Patient Relations Administrative Manager Staff YY stated a “patient can change their mind at any time to share goals of care to the degree the team can accommodate.” Facility policy #15641740 titled “Patient Rights and Responsibilities, RM-27” effective 8/2024 states, “Patients Have: A. The right to participate in the development and implementation of their plan of care 482.13(b)(1) A patient has the right be fully informed, in advance, of proposed care and treatment and to actively participate in the planning and implementation of their care and treatment. B. The patient or their representative (as allowed under State law) has the right to make informed decisions regarding their care, be informed of their health status, and be involved in care planning and treatment and request or refuse treatment...””

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to ensure staff accurately and completely documented all treatments, interventions and patient response to treatments, interventions and care for 1 (P-2) of 10 patients reviewed according to facility policy and professional standards of practice resulting in lack of communication amongst the interdisciplinary team leading to severe pain and mental anguish for the patient. Findings include: Review of the medical record for P-2, the patient of concern, revealed she was a 27-year-old female who presented to the facility 10/18/2024 at 38 weeks, 1 day for induction of labor due to fetal growth restriction. Upon arrival to the unit, the baby was in cephalic (head) presentation. Induction was started and labor progressed until she was dilated to 8 cm (centimeters). P-2 received an epidural 10/19/2024 at 1712. Registered Nurse (RN) Staff GG stated during interview on 2/4/2025 at 1115 that she checked P-2’s dermatomes (areas of skin that send signals to the brain through the spinal nerves) and P-2 was still able to feel on her left side after receiving the epidural. She turned P-2 to her left side to “have the medication flow that direction.” Staff GG was unable to recall the levels on either side of the patient where the dermatomes could be felt but stated the dermatomes were documented in the medical record. Staff GG was encouraged to find her documentation; however, on getting to the area of the nursing flow sheet where the documentation should be, none was found. Staff GG stated, “I must have forgotten to do it on this patient.” Staff GG was queried as to if she reported her findings to an anesthesia provider to which she stated she had not discussed it with him as it was change of shift and she was giving report to the oncoming nurse. Further review of the medical record revealed an exam was done by the resident just prior to rupture of membranes which revealed a foot-a discovery that the baby had flipped and was currently in the breech position (buttock presentation). Education was provided by the resident regarding manual manipulation of the baby back into the cephalic presentation versus having a C-section done. P-2 elected to do the C-section. On 2/4/2025 at 0858, OB/GYN Physician Staff CC stated he P-2’s need for a C-section was not emergent. It was his practice to check for patient feeling. P-2 did not react to a pinch test with a surgical clamp. Staff CC stated he had cut the skin and fascia without incident; however, when he got into the deeper tissue, P-2 was able to feel what he was doing. He explained he “paused. Based on the reaction of the patient, she could feel. I asked anesthesia if we needed to do something differently. He rechecked something and said I was okay to go.” Staff CC explained when issues arose in the OR (operating room) regarding vital signs or pain, anesthesia would be in control. He stated he anticipated the patient would be intubated and put under general anesthesia; however, the patient had expressed it was her wish to hear her baby ’ s first cry and anesthesia was aware of that wish... It was explained to the patient we could continue, or she could be given general anesthesia in which case her husband would have to leave the room, and she would be unable to hear that first cry. “The patient initially elected to continue.” Staff CC recounted that he and assisting Resident Staff JJ “paused multiple times” as P-2 was screaming and stating she was painful. P-2 was able to move her legs and feet slightly which Staff CC described as being “atypical” and “gave us pause.” With questioning, Staff CC stated in other cases in which the epidural did not seem to be working as well, and the patient seemed to have a high level of sensation to what was happening, that most of the time the case was converted to general anesthesia. Staff CC further stated he spoke with Anesthesiologist Staff QQ following the C-section who told him the “levels of anesthesia” (epidural) was fine, and that the patient was “out of control.” No documentation was found in the operative report or other physician documentation of P-2 regarding her wish to hear baby’s first cry, being able to feel what was being done, screaming with pain, being able to move her legs and/or feet, or having a discussion following surgery with Anesthesiologist Staff QQ. On 2/4/2025 at 1139, First-year Resident Staff HH corroborated Staff CC’s statements and added P-2 was “yelling and screaming in pain asking to be put under but it did not happen. I’m not sure why.” No documentation was found in the medical record of these findings. On 2/4/2025 at 1148, Fourth-year Resident Staff JJ stated the patient “voiced being uncomfortable” and stated surgery was stopped multiple times. She then stated, “She asked to be put under and (OB/GYN Staff CC) said he was okay with general anesthesia. Anesthesia talked to the patient and then told us to continue. The patient was screaming...” No documentation was found in the medical record of these findings. RN Staff LL was the oncoming night nurse on 10/19/2024 and was the circulator that was documenting events during the C-section. During an interview on 2/4/2025 at 1434, she stated she received report from RN Staff GG. “It was a little chaotic because they had just called for a C-section for P-2. She stated P-2 did not look uncomfortable, just anxious and she did not recall reporting to anesthesia that the patient had differing dermatomes on the right and left sides. While anesthesia and the OB/GYN surgeon were testing for numbness, P-2 stated she was anxious and would need to be reassured and calmed down. Staff LL stated P-2 was “more than a little bit anxious during the incision and said, ‘I can feel them.’ That caused P-2 to panic, and she requested help in calming down. I don’t know at what point things shifted, but she started being less anxious and was stating she could feel what was happening. The OB stopped and asked (the anesthesiologist) if he needed to give anything. Nothing was given. Anesthesia told the OB to keep going, and he did.” Staff LL stated things began to escalate. P-2 was screaming saying, “I can feel everything. Please put me under.” Staff LL said P-2 was asked if she was put under if it was okay if her husband left and (P-2) said no. Staff LL further stated it was “very possible (P-2) changed her mind after making that statement.” Staff LL recounted she had seen many patients who were anxious, and some that panicked, but P-2 was screaming, and she felt that was unusual. Staff LL further stated in recovery, P-2 did not complain of pain; however, she repeated over and over, “That was awful.” No documentation was found in the medical record regarding P-2 seeking reassurance for her anxiety, screaming with pain, asking to be put under general anesthesia, or of her statements made in recovery. The interviews by RN Staff GG and RN Staff LL regarding events in the OR were corroborated by Charge Nurse Staff NN, Nursery RN Staff PP, and OB Technician Staff OO on 2/4/2025. No documentation was found in the medical record by any of these staff members regarding P-2 being painful, screaming, and requesting to be “put under” during the C-section. On 2/4/2024 at 1608, Anesthesiologist Staff QQ stated he found the epidural to be working for P-2. She was very anxious, but this was something he cares for on a regular basis. “She was freaking out a lot.” Once they started the C-section and the incision was made, P-2 “started yelling. When the surgeon stopped, she stopped.” He said he was debating about starting general anesthesia and recalled P-2 had stated she wanted to hear the baby’s first cry and have skin-to-skin contact, so he told her he could not sedate her until the baby was out. Staff QQ was unable to recall P-2 requesting “to be put out.” He was queried as to when he would decide to change the plan to which he stated it would “be in conjunction with OB because medications can affect the baby very quickly... I would get a verbal consent from the patient. It is not an independent decision to make... This is not a common thing that happened.” No documentation was found in the medical record regarding P-2 expressed desire to hear baby’s first cry and have skin-to-skin contact or screaming she was painful. A “comment” was made by Anesthesiologist Staff QQ in the anesthesia medication information on 10/19/2024 at 2013. The comment stated, “Patient is out of control anxious, asking to put under general anesthesia or give her something ot (sic) relax her after the baby has been delivered. I told her that the medicine i (sic) will give will give (sic) her amnesia..” Further review of the medical record revealed an entry dated 10/21/2024 was found in the medical record by Anesthesia Care Nurse Staff EE noting P-2 “reports no complications from epidural anesthesia.” During interview, Staff EE on 2/4/2025 at 0950 she stated she was unaware there had been issues during the C-section; however, while they were talking P-2 had stated she had been uncomfortable. When queried about her documentation, Staff EE stated the note was “an assessment of (P-2’s) post-epidural state. There was no residual numbness, bruising etc.” Staff EE further stated she would not document that the patient had discomfort because it was not something she “could take care of in the moment.” Continued review of the medical record revealed an “Anesthesia Progress Note” dated 10/22/2024 at 1043 which stated, “She is awake...no issues/complications with the epidural for the anesthesia. Recollection of her events during that case were reviewed and discussed in the presence of her husband and (Staff EE)...She is aware and recognizes her pre-existing anxiety disorder which complicates her ability to cope in stressful situations especially in unusual situations like during the c section (sic) when she was completely awake, unable to control anything, and remembers being calm with occasional unpleasant recurrent panic attacks up to the time when incremental doses of midazolam and propofol provided mild sedation. However, she is appreciative of the opportunity to witness the birth of her daughter and the appropriate timing of her sedation.” During an interview with P-2 on 2/3/2025 at 1236 she stated she had obtained a copy of her medical records and found them to be inaccurate-specifically the documentation by Anesthesiologist Staff QQ. She stated the documented “anxiety with coping issues” was inaccurate. She cited the only coping issue she had was with the death of her father 10 years previous. P-2 further stated she was not on any medications for anxiety. She stated she was not calm but was screaming in pain and begging to be “put under.” She denied ever having a panic attack and was “definitely not appreciative” of the timing of the anesthesia as none was given until after they were “sewing me up.” P-2 further stated both she and her spouse have had to seek counseling because of the traumatic C-section and the events surrounding it. Facility policy #14704975 titled “Rules and Regulations of the Medical Staff, MS-24” effective 2/2024 states, “Operative and/or Procedural Documentation...Operative Note Shall (sic) include any procedure requiring sedation or anesthesia, including, but not limited to surgical procedures, endoscopy, interventional radiology, invasive cardiology, and cardiac catheterization procedures. Such reports must include a description of the techniques, findings and tissues removed or altered and signed by the operating surgeon. Operative reports are to include the following information and are required to be entered into the record within 24 hours: a. Name and hospital identification number of the patient, b. Date/time of surgery...g. Complications (if any)...” Facility policy #15591656 titled “Section of Anesthesiology, MS-28” effective 5/2024 states, “Intraoperative/procedural anesthesia (time-based record of events) A. Immediate review prior to initiation of anesthetic procedures...B. Monitoring of the patient...C. Doses of drugs and agents used, times and routes of administration and any adverse reactions.. D. The type and amounts of intravenous fluids used... E. The techniques(s) used and patient position(s). F. Intravenous/intravascular lines and airway devices that are inserted, including technique for insertion and location. G. Unusual events during the administration of anesthesia...” The American Nurses Association’s “Principles for Nursing Documentation Guidance for Registered Nurses” dated 2010 states, “Nurses document their work and outcomes for a number of reasons: the most important is for communicating within the health care team and providing information for other professionals, primarily for individuals and groups involved with accreditation, credentialing, legal, regulatory, and legislative, reimbursement, research, and quality activities...Nurses and other health care providers aim to share information about patients and organizational functions that is accurate, timely, contemporaneous, concise, thorough, organized, and confidential...Timely documentation of the following types of information should be made and maintained in a patient’s EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high quality care in the continuity of patient care. Assessments; Clinical problems; Communications with other health care professionals regarding the patient; Communication with and education of the patient, family, and the patient’s designated support person and other third parties...Patient responses and outcomes, including changes in the patient’s status...””

“POST-ANESTHESIA EVALUATION CFR(s): 482.52(b)(3) [The policies must ensure that the following are provided for each patient:] A post-anesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section, no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures, which have been approved by the medical staff and which reflect current standards of anesthesia care. This Standard is not met as evidenced by: 36887 Based on interview and record review, the facility failed to ensure a post-anesthesia assessment was performed according to facility policy for 1 (P-2) of 5 patients reviewed who had received surgical intervention, resulting in the potential for unidentified patient needs and poor patient outcomes. Findings include: Review of the medical record for P-2 revealed she was 27-year-old female who received a C-section on 10/19/2024 at 1957. Review of the “Anesthesia Progress Note”, which included vital signs, medications, pain, assessment, and notes of discussion with patient, were dated 10/22/2024 at 1043. During interview on 2/4/2025 at 1608, Anesthesiologist Staff QQ was queried as to why the post anesthesia evaluation was completed more than 48 hours post procedure, to which he stated the level of anxiety of P-2 was “not a common thing to happen.” He chose to “wait a couple of days” to enjoy her newborn baby. Facility policy #15591656 titled “Section of Anesthesiology, MS-28” effective 5/2024 states, “A postanesthesia evaluation completed and documented by an individual qualified to administer anesthesia, as specified in paragraph (a) of this section no later than 48 hours after surgery or a procedure requiring anesthesia services. The post-anesthesia evaluation for anesthesia recovery must be completed in accordance with State law and with hospital policies and procedures that have been approved by the medical staff and that reflect current standards of anesthesia care... Inpatient: Anesthesiologist familiar with the anesthesia management of the patient will visit the patient post-op within 48 hours, review and document the following: Cardiopulmonary status, Level of consciousness, Any follow-up care and/or observations and patient instructions, Any complications occurring during post anesthesia recovery, Patient concerns regarding anesthesia provided, Temperature, Pain, Nausea and vomiting, Postoperative hydration””

“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: 28042 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], specifically the failure to provide a complete medical screening exam, stabilizing treatment, and an appropriate transfer for 1 of 20 patients (P-1), resulting in the potential for less than optimal outcomes for all patients seeking emergent care. See specific tags: 2406 Failure to provide a medical screening exam 2407 Failure to provide stabilizing treatment 2409 Failure to provide an appropriate transfer”

“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: 28042 Based on interview and record review, the facility failed to provide a complete medical screening exam (MSE) for one (P-1) of 20 patients reviewed for an emergency medical condition, resulting in the potential for an adverse outcome. Findings include: On 06/25/2024 at 1400, review of P-1’s medical record revealed he was a 13-year-old male who presented to the emergency department via ambulance with his parents on 04/11/2024 at 2209. Nursing triage note dated 04/11/2024 at 2211 indicated his parents reported that P-1 was hearing voices, and he told his parents that he needed to kill himself that night and was scared. The triage note indicated P-1 reported having thoughts of suicide. On 06/25/2024 at 1400, review of mental health social work note documented by Staff M, for P-1 dated 04/11/2024 with creation time of 2243 indicated Social Work (SW) consulted by attending provider. Social Work handoff was documented as “medically cleared for discharge: No, Assessed: no. Seeking placement ...” Review of nursing documentation revealed no nursing re-assessment of P-1’s mental health status, thoughts of self-harm, hallucinations or level of fear, or vital signs since arrival or prior to discharge. Review of the one ED Provider note for P-1 dated 04/11/2024 at 2220 revealed P-1 had a prior psychiatric history with prior admission and was on multiple psychiatric medications. P-1 had reported hearing voices which had told him to kill himself. The note indicated P-1 was seen by social worker, who made arrangements for P-1 to follow-up the next day for psychiatric evaluation at a nearby children’s hospital. Disposition listed as discharge with final impression as auditory hallucinations. In an interview on 06/26/2024 at 1110, Staff N (Director of Case Management and Social Work) stated there is a template for a mental health assessment to be completed for a social work consult. After review of P-1’s presentation and orders for consultation, Staff N stated it would be her expectation that the template for a complete mental health assessment should have been used for P-1. Review of P-1’s medical record revealed, there was no documentation of a psychiatric examination by a qualified licensed individual. In an interview on 06/26/2024 at 1000, Staff O (ED physician director) stated even though P-1 was medically cleared, his psychiatric needs were not met. On 06/26/2024 at 1215, review of the facility, “Emergency Medical Treatment and Labor Act (EMTALA), Comp-18” policy, revised date 11/2023 revealed under II. Policy Standards ...B. Patient with an EMC ...must be provided further medical examination and stabilizing treatment within UMHW Capacity and Capability and/or UMHW staff will arrange for an appropriate transfer ... On 06/26/2024 at 1215, review of the facility, “Emergency Department (ED) Structure Standards” policy, review date 02/2023 revealed “RN complete and document an assessment related to chief complaint and current status of the patient prior to discharge.” Review of policy “Vital Signs and Monitoring, ED-D150” last revised on 02/2024, under procedure, step 2, revealed “Once in a treatment area, each individual will have vital signs rechecked and documented within the following initial frequency but is subject to change based on patient condition: ...ESI Level 2 - no less frequently than every 60 minutes until medically cleared then no less than every 4 hours ...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 28042 Based on interview and record review, the facility failed to provide stabilizing treatment for one (P-1) of 20 patients reviewed for an emergency medical condition, resulting in the potential for an adverse outcome. Findings include: On 06/25/2024 at 1400, review of P-1’s medical record revealed he was a 13-year-old male who presented to the emergency department via ambulance with his parents on 04/11/2024 at 2209. Nursing triage note dated 04/11/2024 at 2211 indicated his parents reported that P-1 was hearing voices, and he told his parents that he needed to kill himself that night and was scared. The triage note indicated P-1 reported having thoughts of suicide. When asked in in the past month if he wished he were dead or could go to sleep and not wake up, P-1 answered yes. When asked in the past month if he actually had thoughts of killing himself, P-1 answered yes. When asked if he had intention of acting on these thoughts or had a plan, P-1 stated no. When asked if in his lifetime he had started to do anything, or prepared to do anything to end his life, P-1 stated yes, but not within the past 3 months. P-1 was categorized a low acute suicide risk upon documented assessment. Review of “SMART” medical clearance form completed at 2219 by emergency provider revealed: Suspect new onset psychiatric condition: No. Abnormal medical conditions: no. Risky Presentation: no. Psychiatric emergency screening completed at 2220 by emergency department (ED) Registered Nurse (RN) asked if P-1 presents with any acute psychosis, mania, paranoia, and/or delusions, the assessment indicated P-1 did. Behavioral assessment indicated P-1 was lethargic, with flat affect. ED provider placed an order at 2220 for Mental Health Safety Precautions and Social Work assessment and disposition. Lab results at 2350 revealed urine drug screen negative. On 06/25/2024 at 1400, review of mental health social work note documented by Staff M, for P-1 dated 04/11/2024 with creation time of 2243 indicated Social Work (SW) consulted by attending provider due to P-1 seeing and hearing voices telling him to kill himself, sudden onset that evening, P-1 was fearful in presentation, eval/treat/psych. The note indicated for SW to please assess P-1 in the morning with mental health assessment and make clinical recommendations. Social Work handoff was documented as: medically cleared for discharge: No, Assessed: no. Seeking placement: SW. Behavioral updates: Calm and anxious. 1115 pm social work note indicated the social worker spoke with staff member at another hospital to arrange pre-arrival at the second hospital ED for psychiatry evaluation the next day, 04/12/2024. Social work note indicated family was willing and agreed on safety plan and monitoring child (P-1) for the evening... Follow-up in the morning with the secondary hospital emergency department. The social work note indicated summary of referrals to include a packet was sent to two psychiatric inpatient hospital facilities. However, the note did not indicate any communication back from either facility. The note did not include an assessment of P-1’s mental health status, suicidal thoughts, status of hallucinations, or level of fear. Review of nursing documentation revealed no nursing re-assessment of P-1’s mental health status, thoughts of self harm, hallucinations or level of fear, since arrival or prior to discharge. Review of the one ED Provider note for P-1 dated 04/11/2024 at 2220 revealed P-1 had a prior psychiatric history with prior admission and was on multiple psychiatric medications. P-1 had reported hearing voices which had told him to kill himself. The note indicated urine drug screen negative, P-1 was seen by social worker, who made arrangements for P-1 to follow-up the next day for psychiatric evaluation at a nearby children ’ s hospital. Disposition listed as discharge with final impression as auditory hallucinations. In an interview on 06/25/2024 at 1535, Staff M (Social Worker, SW) stated she met with P-1 and his parents while he was in the emergency department on 04/11/2024. She offered multiple options to P-1’s parents including going to another hospital’s inpatient psychiatric urgent care. Staff M stated she spoke to a staff member in the pre-arrival department of the emergency department at a nearby children’s hospital and arranged with the pre-arrival registration staff for P-1 to go to their emergency department the next morning. When Staff M was queried about Emergency Medical Treatment and Labor Act (EMTALA) requirements and if P-1 was stable for discharge home until the next morning, Staff M stated she was not familiar with EMTALA. In an interview on 06/26/2024 at 1110, Staff N (Director of Case Management and Social Work) stated there is a template for a mental health assessment to be completed for a social work consult. After review of P-1’s presentation and orders for consultation, Staff N stated if would be her expectation that the template for a complete mental health assessment should have been used for P-1. When queried about P-1’s discharge, Staff N stated no, it would not be her expectation nor the facility’s process to discharge a patient with instructions which included follow up with another hospital’s emergency department. In an interview on 06/25/2024 at 1525, Staff L (ED Physician) stated he saw P-1 when he presented to the ED with auditory hallucinations and thoughts of suicide. He stated P-1 was to follow the plans of the social worker, which was to follow up at a children’s hospital the next day. Staff L said the social worker made a safety plan with P-1’s parents for the night and arranged for them to take P-1 to the children’s hospital the next morning for a more thorough psychiatric evaluation. In an interview on 06/26/2024 at 1000, Staff O (ED physician director) stated he had reviewed the medical record for P-1 and the discharge for P-1 was out of the normal process for what the facility would do. Staff O stated with pediatric patients it is not unusual to safety plan and set up plans for post discharge in order to get them home. However, a safety plan would not include going to another hospital’s ED after discharge. Staff O stated even though P-1 was medically cleared, his psychiatric needs were not met. It is not protocol when discharging a patient to tell them to go to another emergency department. On 06/26/2024 at 1400, review of P-1’s medical record from facility B’s emergency department visit on 04/12/2024 revealed P-1 arrived at the second children’s hospital emergency department on 04/12/2024 at 0859 with a chief complaint of “was seen at another hospital yesterday and referred here because P-1 was hearing voices. Provider note indicated P-1 was a 13-year-old male with anxiety and history of suicidal ideation, presented to ED with parents with concern for behavioral health concerns. Father reported concern due to P-1 taking his nighttime medications along with Mucinex, Benadryl and Sudafed, then 20 minutes later experienced hallucinations and hearing voices. Father reported P-1 was terrified begging him to kill him and threatening to kill himself. P-1 stated he felt good “now”, was calm, cooperative and social work assessed. P-1 was discharged from facility B at 1101. No medical interventions were provided by the hospital to address the patient’s EMC and there was no evidence the patient was stabilized before discharge. On 06/26/2024 at 1215, review of the facility, “Emergency Medical Treatment and Labor Act (EMTALA), Comp-18” policy, revised date 11/2023 revealed “Stabilized: With respect to an emergency medical condition, means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during a transfer or discharge. An individual will be deemed stabilized if the treating physician has determined, with reasonable clinical confidence, that the emergency medical condition has been resolved.” “Stable for Discharge: The hospital has provided medical services necessary to assure that no material deterioration of the condition is likely to result from discharge, as a matter of reasonable medical probability. Further, the physician has determined that the patient’s continued care, including further diagnostic workup and/or treatment can be reasonably performed as an outpatient or later as an inpatient, and the patient is provided a plan for appropriate follow-up care with discharge instructions. A psychiatric patient is considered “stable for discharge” if the patient is not considered to be an imminent threat to self or others.” On 06/26/2024 at 1215, review of the facility, “Emergency Department (ED) Structure Standards” policy, review date 02/2023 revealed “RN complete and document an assessment related to chief complaint and current status of the patient prior to discharge.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 28042 Based on interview and record review, the facility failed to restrict transfer to another facility’s care before providing stabilizing treatment for one (P-1) of 20 patients reviewed for an emergency medical condition, resulting in the potential for an adverse outcome. Findings include: On 06/25/2024 at 1400, review of P-1’s medical record revealed he was a 13-year-old male who presented to the emergency department via ambulance with his parents on 04/11/2024 at 2209. Nursing triage note dated 04/11/2024 at 2211 indicated that P-1 was hearing voices, and he told his parents that he needed to kill himself that night and was scared. The triage note indicated P-1 reported having thoughts of suicide. On 06/25/2024 at 1400, review of mental health social work note documented by Staff M, for P-1 dated 04/11/2024 with creation time of 2243 indicated Social Work (SW) consulted by attending provider due to P-1 seeing and hearing voices telling him to kill himself. Social Work handoff was documented as: medically cleared for discharge: No, Assessed: no. Seeking placement ... 1115 pm social work note indicated the social worker spoke with staff member at another hospital to arrange pre-arrival at the second hospital ED for psychiatry evaluation the next day, 04/12/2024. Social work note indicated family was willing and agreed on safety plan and monitoring child (P-1) for the evening. Follow-up in the morning with the secondary hospital emergency department. The social work note indicated summary of referrals to include a packet was sent to two psychiatric inpatient hospital facilities. However, the note did not indicate any communication back from either facility. The note did not include an assessment of P-1’s mental health status, suicidal thoughts, status of hallucinations, or level of fear. Review of the one ED Provider note for P-1 dated 04/11/2024 at 2220 revealed P-1 was seen by social worker, who made arrangements for P-1 to follow-up the next day for psychiatric evaluation at a nearby children’s hospital. Disposition listed as discharge with final impression as auditory hallucinations. In an interview on 06/25/2024 at 1535, Staff M (Social Worker, SW) stated she met with P-1 and his parents while he was in the emergency department on 04/11/2024. Staff M stated she spoke to a staff member in the pre-arrival department of the emergency department at a nearby children’s hospital and arranged with the pre-arrival registration staff for P-1 to go to their emergency department the next morning. When Staff M was queried about Emergency Medical Treatment and Labor Act (EMTALA) requirements and if P-1 was stable for discharge home until the next morning, Staff M stated she was not familiar with what EMTALA was. In an interview on 06/26/2024 at 1110, Staff N (Director of Case Management and Social Work) stated it would not be her expectation nor the facility’s process to discharge a patient with instructions which included follow up with another hospital’s emergency department. In an interview on 06/26/2024 at 1000, Staff O (ED physician director) stated he had reviewed the medical record for P-1 and the discharge for P-1 was out of the normal process for what the facility would do. A, safety plan would not include going to another hospital’s ED after discharge. Staff O stated even though P-1 was medically cleared, his psychiatric needs were not met. It is not protocol when discharging a patient to tell them to go to another emergency department. There was no documentation demonstrating the physician communicated with anyone (outside of the pre-arrival clerk) at the receiving hospital or verification that the receiving hospital had the necessary resources to provide further treatment options that the current facility lacked. The patient was discharged without receiving any medication management, a safe transfer arrangement, or a physician certification of risks/benefits. On 06/26/2024 at 1400, review of P-1’s medical record from facility B’s emergency department visit on 04/12/2024 revealed P-1 arrived at the second children’s hospital emergency department on 04/12/2024 at 0859 with a chief complaint of “was seen at another hospital yesterday and referred here because P-1 was hearing voices. On 06/26/2024 at 1215, review of the facility, “Emergency Medical Treatment and Labor Act (EMTALA), Comp-18” policy, revised date 11/2023 revealed “Stabilized: With respect to an emergency medical condition, means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during a transfer or discharge. An individual will be deemed stabilized if the treating physician has determined, with reasonable clinical confidence, that the emergency medical condition has been resolved.” “Stable for Discharge: The hospital has provided medical services necessary to assure that no material deterioration of the condition is likely to result from discharge, as a matter of reasonable medical probability. Further, the physician has determined that the patient’s continued care, including further diagnostic workup and/or treatment can be reasonably performed as an outpatient or later as an inpatient, and the patient is provided a plan for appropriate follow-up care with discharge instructions. A psychiatric patient is considered “stable for discharge” if the patient is not considered to be an imminent threat to self or others.””