Sheridan Community Hospital

“COMPLIANCE FED, ST, AND LOCAL LAWS AND REGS CFR(s): The CAH is in compliance with applicable Federal laws and regulations related to the health and safety of patients. This Standard is not met as evidenced by: 48030 Based on observation and interview, the facility failed to post notice that the Emergency Department (ED) does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and how they will meet the medical needs of any patient with an emergency medical condition that present to the facility, resulting in the potential for all patients to not be informed of their right to have a medical screening exam and stabilizing treatment by a doctor of medicine or a doctor of osteopathy. Findings include: On 8/19/2025 at 0923 a tour of the facility Emergency Department (ED) was conducted and revealed a 6-bed, Level IV designated ED with two registered nurses (RN) and 1 ED physician available for patient care. During the tour it was revealed by looking at the provider schedule that the ED is staffed by physician assistants and nurse practitioners for some shifts. During the tour of the Emergency Department, signs that notified patients/families that a MD/DO were not available at the facility 24/7 were not found. During an interview with the ED provider (Staff I) that was working on 8/19/2025 at 0923 during the initial tour of the ED, it was revealed that he works 2 shifts per month as an ED provider and he also works as a general surgeon at the facility. Staff I revealed the facility is staffed by physician assistants and nurse practitioners when an MD/DO is not available. When queried how patients are notified that that a MD/DO are not available at the facility 24/7, Staff I did not respond. During review of the State Operations Manual, Appendix W, page 40 in the Section titled, “MD/DO 24/7 On-Site Presence” the manual states, “Individual notices are not required in the CAH’s dedicated emergency department (DED) (as that term is defined in 42 CFR 489.24(b)), but the DED must post a notice conspicuously, in a place or places likely to be noticed by all individuals entering the dedicated emergency department. The posted notice must state that the CAH does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition, as defined in 42 CFR 489.24(b) [the EMTALA definition], at a time when there is no doctor of medicine or doctor of osteopathy present in the CAH. If an emergency department patient is determined to require admission, then the individual notice provisions of 42 CFR 489.20(w) would apply to that patient.”

“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: 48030 Based on observation, 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 for one (P-8) patient, and stabilizing treatment for one patient (P-1) of 20 patients reviewed, resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include: See tags: 2406: Incomplete Medical Screening Exam 2407: Stabilizing treatment”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 48030 Based on observation and interview, the facility failed to post EMTALA signs in areas likely to be noticed by all individuals that visit the emergency department (ED), resulting in the potential for all ED patients to not be informed of their rights to have a medical screening exam and stabilizing treatment in the ED. Findings include: During the observational tour of the ED on 8/19/2025 at 0923, while accompanied by the Risk Manager (Staff C), it was noted that there were no EMTALA signs posted in the waiting room, treatment areas and at the ambulance entrance. On 8/20/2025 at approximately 1100, Risk Manager (Staff C) was queried about the lack of signs, she responded she would work on getting the signs placed immediately.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 48030 Based on record review, the facility failed to provide a complete medical screening exam for 1 (P-8) of 20 patients reviewed for emergency care, resulting in the potential for less than optimal outcomes for the patient. Findings include: On 8/20/2025 at 1124 record review revealed P-8 was brought to the Emergency Department (ED) by her mother on 6/21/2025 at 2359 for suicide attempt after she reportedly took 5 of her boyfriend’s Gabapentin pills, so she could sleep and never wake up. The record stated the ED provider medically cleared P-8 and recommended inpatient psychiatric care. However, there was no formal mental health evaluation by a qualified behavioral-health professional, making the screening examination incomplete. P-8 declined inpatient psychiatric treatment and left against medical advice. Review of facility policy titled “Screening Treatment and Transfer of Patients with Emergency Medical Conditions (EMTALA)” revised 2/15/2023 revealed “It is the purpose of the screening to determine if the individual has an emergent medical condition requiring immediate care and if the care necessary can be provided at (facility name) or if appropriate transfer is necessary ...Definitions: Medical Screening Examination: An examination within the capabilities of the hospital’s emergency department, including ancillary services routinely available to determine whether the individual has an emergency medical condition.”

“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: 48030 Based on interview and record review, the facility failed to provide stabilizing treatment for one (P-1) of twenty patients having an emergent medical condition resulting in the potential for an adverse patient outcome. Findings include: On 8/19/2025 at 1445 record review of an Emergency Nursing Note dated 6/30/2025 reveals P-1 left the ED on foot at 2310 and the state police brought her back at 2350. At 0000 P-1 requested the state police to take her home to see her cats and get a change of clothes, the police agreed, brought her back to the ED at 0025 and then left P-1 at the facility. At 0245 P-1 began punching the walls in her room and smashing sounds were heard with swearing and yelling and the police were called at 0255. Nursing documentation reveals police were notified the facility could not manage P-1 secondary to her violent outbursts and they were unable to chemically sedate her or physically restrain her due to lack of staff. At 0325 police notified ED staff that P1 was leaving with them because she needed to be in a facility that has security and staff to manage violent outbursts and not allow her to elope from the ED. A late entry was made by nursing staff (untimed) that reveals the community mental health worker called for an update at 0700 regarding P-1 and was informed that she was transported to (Facility-B) by police due to her violent behavior. No transfer paperwork/EMTALA paperwork was found in the record. Record review from the receiving facility (Facility-B) was conducted and reveals P-1 arrived at the facility on 7/1/2025 at 0350 with police for behavioral health concerns. Review of the note from the ED providers course of treatment from 2359 reveals P-1 was seen at Facility-A and had been petitioned and medically certified for a repeated overdose and she had “eloped multiples times and then was in her hospital room behaving violently and police were called.” During her admission to Facility-B, record review reveals P-1 required 5-point restraint at Facility-B after she became extremely agitated when they took her cell phone per facility protocol. P-1 was transferred from Facility-B to a behavioral health facility on 7/2/2025 at 1332. On 8/20/20205 at 0900 an interview with the physician assistant (Staff J) who was present when P-1 was in the Emergency Department (ED) was conducted and revealed he remembered P-1 and that he reviewed his note from 6/30/2025 prior to the interview. Staff J explained he had taken over care of P-1 from the dayshift provider, she had been medically cleared and waiting for placement at a behavioral health facility. Staff J revealed at the start of his shift the police were present in the ED with P-1, but they ended up leaving and around 2305 and she eloped from the ED, police were notified, and they brought her back at 2350. When queried why P-1 was allowed to leave the ED after she had a court ordered petition, Staff J explained the facility does not have Security and staff cannot put themselves in harms way to stop a patient that wants to elope. Staff J revealed later on in his shift P-1 wanted to go home to see her cats and get a change of clothes, so the police agreed to take her home at 0000 and she returned with police at 0025. Staff J stated the police were requested P-1 be sedated “for convenience” because they wanted to leave the facility but Staff J explained, “I did not think it was appropriate to restrain her.” Police notified Staff J they were going to take P-1 to another facility and he overheard them say Facility-B’s name but was unsure where they took her. Staff J explained he told P-1 and the police she would be leaving against medical advice (AMA). Staff J added, if we had “properly trained security guards we could have managed her care”, but I did not discharge her or transfer her to another facility. On 8/20/2025 at 0945 an interview with the registered nurse (Staff L) assigned as the primary nurse for P-1. Staff L revealed she remembered P-1 very well because she was injured when P-1 slammed a door shut into her arm when she asked her to turn her music down in the ED. Staff L added at that time the police had to be called to come back to the ED to help them calm P-1 down. Staff L explained P-1 was too violent to manage in their ED because they do not have security and she continued to want to leave. Staff L explained that the police requested that P-1 be sedated but the mental health network worker did not want her sedated because it would delay her placement. When queried if P-1 was transferred to another facility, Staff L revealed the police followed her out of the ED and she later learned she was taken to Facility-B, she was not discharged or transferred and left against medical advice. On 8/20/2025 at 0934 an interview with the registered nurse (Staff K) that was working in the ED on 6/30/2025 was conducted. Staff K revealed she remembered P-1 and that she was not her primary nurse but recalled she was a difficult patient to manage and there were 3 to 4 police officers with her at the beginning of her shift. Staff K explained she remembered P-1 left the ED even though she was petitioned, police were notified and brought her back and requested she be restrained and sedated. Staff K recalled the provider did not feel it was appropriate to sedate her because they did not have enough staff to sit with P-1. Staff K revealed she did not hear the provider say he was going to transfer P-1 to another facility or discharge her, but she did hear the police mumbling on the way out with P-1 that they were going to take her to Facility-B. During an interview with the Emergency Department (ED) Medical Director (Staff D) on 8/20/2025 at 1240 it was revealed he was not aware of the circumstances involving P-1 until he had reviewed the record on 8/19/2025. Staff D explained that based on his review of the record several concerns regarding the management of P-1’s care were identified. Staff D revealed he works in several different critical access hospitals that do not have Security available and that he was concerned about the ED providers (Staff J) hesitancy to chemically restrain or physically restrain P-1 to ensure she did not elope from the ED as she was at risk for harming herself and petitioned. Staff D added he identified some educational opportunities for providers, but he did not see in the record that the provider had planned to transfer or discharge P-1 from the facility and police made the decision to remove her from the ED and seek care elsewhere. Review of facility policy titled, “Screening Treatment and Transfer of Patients with Emergency Medical Conditions (EMTALA)”, last revision on 2/15/2023 reveals on page 8, under Requirements for Transfer, “c. If the physician opposes the transfer of an incapacitated patient at the request of the legal representative and believes the transfer may jeopardize the patient ’ s wellbeing or that the decision to transfer is not in the patient ’ s best interests: DO NOT arrange for the transfer.””