Essentia Health St Mary’s Medical Center

“DISCHARGE PLANNING - PT RE-EVALUATION CFR(s): The hospital’s discharge planning process must require regular re-evaluation of the patient’s condition to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes This Standard is not met as evidenced by: 40945 Based on interview and document review, the hospital failed to ensure staff re-evaluated and developed a safe discharge plan for 1 of 10 patients (P3) reviewed when P3 was discharged to her assisted living (AL) facility overly sedated from medications. P3 had a decrease in respirations and increased lethargy. P3 was sent back to the emergency department (ED). Findings include: P3’s ED Record identified the following information: - P3 as a 40-year-old female with diagnosis which included spastic quadriplegia cerebral palsy, neurofibromatosis, chronic pain, anxiety, neurogenic bladder, anemia, recurrent UTI, depression, seizure, and urostomy on current treatment for urinary tract infection (UTI). - P3 presented to the ED on 5/6/26 at 2:01 a.m. via EMS, was triaged and assigned an ESI (Emergency Score Index) of 3 (1-5 scale with one most unstable). - A chief complaint of non-traumatic left hip pain was listed, and P3 was treated for pain related to chronic incompletely healed comminuted and displaced fracture involving and ongoing urinary tract infection. - At 2:39 a.m. P3 was administered oxycodone (opioid narcotic) immediate release tablet 5 milligram (mg) dose and acetaminophen 1,000 mg dose. -At 3:43 a.m. P3 was administered droperido (antipsychotic) 10 mg injection. -At 5:39 a.m. P3 was administered levofloxacin (Antibiotic) 750 mg dose. -At 8:28 a.m. P3 was administered her scheduled morning medications per medical chart review which included methadone (opioid) 7.5 mg dose, duloxetine (antidepressant serotonin-norepinephrine reuptake inhibitor) 30 mg dose, and gabapentin (antiseizure)300 mg dose. - At 9:11 a.m. ED Note was set to be discharged by the physician on 1/19/26 at 5:50 p.m. P3’s ED Notes, dated 5/6/26 at 9:11 a.m. identified P3’s AL was updated regarding discharge from the ED. After visit summary and personal belongings sent with P3. Review of P3’s medical chart from ED visit dated 5/6/25, indicated the last documented vitals for P3 were noted to be obtained at 7:15 a.m. Pulse 66, oxygenation 94%, no blood pressure, or respiratory pattern were documented. EMS transport record indicated on 5/6/26 at 9:54 a.m. EMS was called to respond to P3’s AL facility. Intake note included responded to a 40-year-old female that was reported to be unresponsive with shallow breathing. Upon arrival staff reported P3 had received multiple medications prior to discharge from the hospital, and these may have caused P3’s decrease in response. Vitals obtained showed P3 was stable, however P3’s respirations were noted to be much lower than normal and were counted at approximately six per minute. A physician at the ED was consulted and agreed P3 would likely benefit from closer observations than what the staff could provide. P3 was monitored and transported to the ED for observation with no changes in condition noted. P3’s ED Provider Note, dated 5/6/26, indicated P3 was discharged this morning from the emergency department around 9:00 a.m. and was sent back to the hospital due to concerns P3 was over sedated. P3 received her morning medications which included multiple medications that cause sedation and P3 had not slept at all while she was in the ED. Upon discharge she was noted to be alert and talkative, which is her baseline. She does report she is tired now. She did receive droperidol for pain while in the emergency department around 3:40 a.m. P3 had no hypoxia and vitals were stable. P3 breathing was without respiratory distress and lungs were. Labs were held to check for hypercapnia and rule out hypoglycemia, monitoring continued. Sedation was related to medications including droperidol and other sedating medications with lack of sleep. Given the risk for deterioration, the case was discussed with the hospitalist and P3 was admitted for observation. During an interview on 7/22/26, at 2:01 p.m. medical doctor (MD)-A stated all patients being treated in the ED should be stable at the time of discharge. Ongoing monitoring of the patients prior to discharge included monitoring of vitals and would expect nursing to complete an assessment prior to discharging from the ED. MD-A was the provider who had treated P3 initially when she presented to the ED on 5/6/26. MD-A was not made aware of any change in condition P3 exhibited while in the ED prior to her being discharged. MD-A would have expected P3’s nurses to report any change in condition. P3 should have been monitored longer in the ED rather than P3 being sent back to the ED for treatment and admission. During an interview on 7/22/26, at 3:15 p.m. pharmacist (PHARM)-A stated there is always a pharmacist available for provider to consult with when prescribing medications in the ED. some opioids may cause sedation in patients. If a patient is showing signs of increased sedated, they would expect nursing staff to notify the prescribing provider or provider assigned to the pt at the time of the change in condition. Would expect ongoing monitoring of vitals and level of consciousness for patients prescribed opioid medications. Multiple attempts to interview P3’s assigned registered nurses who provided care and discharged P3 on 5/6/26, however were unsuccessful. A facility policy titled Discharge Planning Process in Acute Care Facilities dated 6/24/24, indicated the purpose of the policy is to facilitate the safe transition of patients from Essentia Health acute care facilities (inpatient/outpatient/observation status and critical access hospitals) to the patient’s home or to other health care or residential facilities upon discharge. The discharge plan will incorporate assessment and planning of the patient’s medical, psychosocial, and financial needs through coordinated efforts from the interdisciplinary team. A facility standard work document titled Discharge Planning & Patient Choice dated 10/12/2024, indicated in addition to the Discharge Planning Policy for acute care facilities, to provide a guideline for interdisciplinary staff to facilitate the safe transition of patients from Essentia Health acute care facilities, critical access hospitals and swing beds to the patient’s home or to other health care or residential facilities upon discharge. Ongoing discharge assessment/evaluation and planning occurs throughout a patient’s stay.”

“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: 40945 Based on document review and interview, the hospital failed to follow their grievance policy including providing written documentation to a patient of the actions taken to investigate the grievance, the name of a hospital contact person, the results of the grievance process, and the date of completion for 1 of 3 (P1) patient grievances reviewed. Findings include: A facility report titled Current Summary Grievance Feedback initial date 3/19/26, included under Resolution and Outcomes - Patient concern care ACTION tasked to manager. 3/23 Resolution letter mailed. No additional information was documented related to an investigation pf the complaints/concerns detailed in the grievance. On 4/1/26, at 10:01 a.m. the director of risk management (DRM) was interviewed. DRM stated the Grievance Summary for P1 was incorrectly marked as finalized and the initial acknowledgment letter was incorrectly identified and documented as a resolution letter. Because of this error, there was confusion in the status of grievance. This confusion caused a delay in the investigation process; however, the case has remained in open status, and an investigation is still in progress. On 4/1/26, at 10:48 a.m. patient care specialist was interviewed. PCS-A stated he was assigned to the grievance filed by FM-A on 3/19/26. Once a grievance is submitted it is assigned to a patient care specialist like himself who then shares this information with the unit manager where the patient was receiving care. The unit manager is then responsible for completing an investigation specifically related to the patient’s concerns. As part of the grievance process, an initial acknowledgement letter is sent out followed by a resolution letter which details the outcome of the investigation. PCS-A stated a letter was sent out to FM-A on 3/23/23, which was incorrectly marked as a resolution versus an acknowledgement letter. On 4/1/26, at 1:27 p.m., P1’s family member (FM)-A was interviewed. FM-A stated they shared multiple concerns related to care her family member received on 3/19/26 with the hospital social worker which included concerns involving staff professionalism, attentiveness, and the overall care her family member received. She had received a letter dated 3/23/26, however, the letter did not detail any steps taken regarding an investigation into the concerns nor had they received a resolution letter. She also sent an email to the hospital SW asking for an update to the concerns last week; however, she has not heard back from any hospital staff. FM-A stated P1 was still struggling with anxiety over her hospitalization and the care she had received. P1 was not available for an interview at this time. Review of the hospital’s policy and procedure titled Grievance and Complaint Process dated 3/9/2023, stated all verbal and written complaints regarding abuse, neglect, client harm, or facility compliance with regulations were considered grievances. All other grievances will be investigated promptly and whenever possible written response will be sent by Risk Management staff within seven (7) working days (excluding weekends and holidays). If the most effective communication method for follow up is oral, a written summary will be sent following oral discussion. Written notice of the grievance resolution will include name of the facility contact person; steps taken to investigate grievance; results of the grievance process; and the date of completion. If grievance cannot be resolved in real time, Risk Management, or other responsible department will follow up in writing to the patient/patient representative within seven (7) working days (excluding weekends and holidays) whenever possible. If unable to reach a conclusion within seven (7) working days, an acknowledgement letter will be sent to the patient/patient representative. A follow-up letter may also be required not to exceed 30 working days (excluding holidays/weekends) (from the date of acknowledgment letter) to inform you that the review is still in progress. Upon completion of the review, a closure letter will be sent to patient. In every procedure, if a grievance was not resolved or a review not completed within specified time’s, the facility must inform the patient and/or legal representative that the facility was working to resolve the grievance. The facility would follow up with a written response to the patient within 7 days. The facility must respond to the substance of grievance and identify, investigate, and resolve any systemic issues related to grievance.”

“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: 40945 Based on interview and document review, the hospital failed to ensure a comprehensive medical screening examination (MSE) was completed for 1 of 20 patients (P1) reviewed when the patient presented to the emergency department (ED) with complaints of active labor. P1 was not provided a medical screening examination to ensure a potentially life-threatening emergency medical condition (EMC) did not exist or worsen. The immediate jeopardy began on 4/27/25 at 11:24 p.m., when a patient presented in active labor and was not provided a medical screen exam to determine whether an emergency medical condition existed to provide stabilizing medical treatment. The senior paralegal and two hospital quality partner II’s were notified of the preliminary findings on 5/8/25 at 3:25 p.m.. Findings Include: On 5/6/25, at 11:34 a.m. the emergency department (ED) entrance video was reviewed. The video did not have audio. The ED manager and security manger were present during review the of the video. P1 presented to the ED on 4/27/25 at 11:24 p.m. alone, via Lyft. The hospital security officer (SO)-A who was working at the ED entrance, proceeded to complete a weapons screening, where P1 appeared to pull out a small pocketknife from her purse and show it to the SO-A. P1 can be seen in the video crying and visibly distraught. Throughout the entire time in the ED entrance, P1 was rocking back and forth and at time would crouch down, bending at the knees. The video did not identify a medical provider in the ED entrance. At approximately midnight P1 was observed on the video leaving the ED and walking down the street in the direction of a neighboring hospital approximately 0.65 miles away. ED log dated 4/27/25 indicated P1 left without being seen. P1’s medical record for the initial hospital indicated on 4/27/25 at 10:11 p.m., P1 had called the triage nurse for the hospital’s obstetrical unit. The triage nurse instructed P1 that she needed to be seen, was to leave now, and go to the labor and delivery unit or the ED at Essentia Hospital St. Mary’s. P1’s medical record for the accepting hospital indicated P1 arrived at the emergency department on 4/28/25 at 12:23 a.m. A provider note dated 4/28/25, at 3:48 a.m., indicated P1 presented in early labor, P1 had a risk which included extensive history of miscarriages including a 20-week stillborn and was of advanced maternal age. P1 delivered her child on 4/28/25, at 11:53 p.m. On 5/6/25 at 10:23 a.m. security officer (SO)-B was interviewed. SO-B stated all patients who presented to the main ED entrance were subject to a weapons screening. If there was a patient who presented having a medical emergency and refused to have the weapons screening or turn over a weapon, he would call the ED medical provider and nursing to come to the entrance of the ED to assess the patient. SO-B stated a laboring or pregnant patient would be considered a medical emergency and would need to be seen. On 5/6/25 at 12:20 p.m. during an interview P1, a 37-year female, stated she presented to the ED on 4/27/25 at 11:24 p.m. in active labor. P1 stated she was dropped off by a Lyft vehicle and was alone with no support person. P1 stated the hospital security officer, SO-A, was working at the ED entrance. P1 informed SO-A she has a pocketknife with her that was her fathers who had passed away. P1 stated SO-A did not call the obstetrical unit or the ED to contact a medical provider to come assess her even though P1 had shared with SO-A that she was in labor, and the obstetrical unit was waiting for her to arrive due to being in active labor. P1 stated SO-A gave her three options. She could turn over the knife which would then be disposed of by security staff, P1 could place the knife in a vehicle, or P1 could place the knife in a bush or rocks outside and retrieve it once discharged from the hospital. P1 stated she felt she had no other choice other than to leave the ED and walk to the hospital down the street, without being seen. P1 walked approximately 0.65 miles at midnight alone in active labor to the neighboring hospital where she later delivered a baby. On 5/6/25 at 3:48 p.m. MD-A stated P1 was one of his patients. MD-A stated there had been concern for P1 because she had called on 4/27/25 in active labor, however P1 did not arrive at the hospital. He later was notified P1 had delivered her child at the neighboring hospital. MD-A stated it concerns him that P1 had walked to the neighboring hospital at midnight, alone and in labor. He would expect the security staff to follow policy and protocol to lock up the pocketknife and return it at discharge. On 5/7/25, at 10:06 a.m. ED medical director, MD-B was interviewed. MD-B stated every patient who presents to the ED is entitled to a medical screening exam. MD-B stated the fact that P1 was not provided a medical screening exam and walked to the neighboring hospital alone in labor is concerning. Her expectation was that all staff are following policy and procedure related to EMTALA, which included all patients who present to the ED with a medical emergency are entitled to a medical screening exam by a provider to ensure an emergency medical condition does not exist. On 5/7/25 at 10:37 a.m. security officer (SO)-A stated in an interview that P1 arrived at the ED alone. The entrance to the ED has a weapons screening entry point. P1 had told him that she had a pocketknife on her person and presented it to him. SO-A told P1 she could give the pocketknife to him, and it would be destroyed; it could be brought back to her car, or she could go hide if outside and find it after she discharged. P1 told SO-A the pocketknife had sentimental value. SO-A stated P1 was visibly upset, crying, and left the hospital stating she was going to the hospital down the road. He did not contact a provider to evaluate P1’s medical emergency presentation and did not know the hospital weapons policy allowed the hospital to securely store a weapon for a presenting emergency department patient. The facility policy Emergency Medical Treatment and Labor ACT reviewed 2/14/2023 to any Individual presenting on hospital property requesting examination or treatment of an EMC, or to any Individual presenting on hospital property whose appearance or behavior would cause (or not cause) a prudent layperson observer to believe that examination or treatment for a medical condition is needed. The policy further identifies Emergency Medical Conditions (EMC), which includes a pregnant woman who is having contractions (true labor is presumed unless the physician or QMP, after a period of observation, certifies the presence of false labor), inadequate time to effect a safe transfer to another hospital before delivery; or transfer may pose a threat to the health or safety of the woman or unborn child. The facility policy Weapons Free Workplace policy reviewed 11/13/2023 directed the security staff in extreme circumstances where a patient is admitted through the Emergency Department or admitted without a family member available, their weapon shall be securely stored until discharge.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(8) [Unless superseded by State law that is more restrictive,] (iii) Each order for restraint used to ensure the physical safety of the non-violent or non-self-destructive patient may be renewed as authorized by hospital policy. This Standard is not met as evidenced by: 48300 42587 Based on interview and document review, the hospital failed to obtain a physician order for the use of restraints for 2 of 3 patients (P23 and P29) whose non-violent restraint use was reviewed. Findings include: P23’s electronic health record (EHR) indicated P23 was admitted to the facility on 12/19/23, with diagnoses including autistic disorder and aggressive behaviors. P23’s EHR indicated P23 was placed into right and left wrist and right and left ankle soft restraints on 12/26/23 at 12:30 p.m. A provider order was obtained on 12/26/23 at 12:41 p.m. The restraints were discontinued on 12/26/23 at 1:30 p.m.. On 12/26/23 at 3:55 p.m. P23 was again placed into right and left wrist soft restraints. The medical record lacked a new physician order. On 11/12/24 at 2:06 p.m., registered nurse (RN)-D verified P23’s medical record identified P23 was in restraints on 12/26/23 at 3:55 p.m. through 10:00 p.m.. Staff did not receive a new physician order for that time when P23’s restraints had been re-applied after having been discontinued. On 11/13/24 at 2:13 p.m., RN-E stated restraints should be discontinued as soon as possible. If a patient needs restraints applied again, even in the same day, a new physician order is necessary. P29 was admitted to the intensive care unit (ICU) from the operating room on 11/8/24. P29 arrived at the ICU on a ventilator after completion of a surgical procedure at 5:51 a.m. that morning. P29’s record identified he was in right and left soft wrist restraints with restraint documentation beginning on 11/8/24 at 8:00 a.m.. P29 had orders for non-violent restraints on 11/8/24 at 5:53 a.m., and again on 11/9/24, at 10:59 p.m.. Each restraint order identified the order was valid for a limited time of 24 hours. On 11/13/24 at 2:33 p.m., registered nurse (RN)-A verified P29’s medical record identified P29 was in restraints from 11/8/24 at 8:00 a.m., through 11/11/24 at 6:00 a.m.. There was no new restraint order obtained to identify restraints were appropriate past 11/10/24 at 10:59 p.m., when the order expired. On 11/14/24 at 8:30 a.m., RN-B verified most patients were restrained when they were on ventilators for safety, to ensure they did not extubate (remove breathing tube) themselves. RN-B verified non-violent restraints were valid only for a maximum of 24 hours. On 11/14/24 at 8:57 a.m., RN-C verified most patients on ventilators required restraints. RN-C reviewed P29’s record and verified he was in restraints from 11/8/24 at 8:00 a.m., until 11/11/24 at 6:00 a.m.. RN-C agreed no new restraint order was obtained when the 11/9/24 order expired on 11/10/24 at 10:59 p.m.. P29 was restrained without a physician’s order for an additional 7 hours. Review of the Restraint and Seclusion policy dated 5/17/24, identified non-violent restraints must be renewed every calendar day based on assessment of continuing need. Restraints will be discontinued as quickly as possible and at the earliest possible time. When the restraint is discontinued, the order is discontinued as well. A new order is required to resume the use of a restraint once it has been discontinued.”