Mahnomen Health Center

“POSTING OF SIGNS CFR(s): [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: 43080 Based on observation, interview, and document review, the hospital failed to ensure signage for Emergency Medical Treatment and Active Labor Act (EMTALA) was posted in all areas likely to be noticed by patients who entered the Emergency Department (ED). This had the potential to affect all patients who presented to the ED seeking care and treatment via the ambulance bay patient entrance. Findings include: On 11/24/25, at 12:32 a.m., a tour of the emergency department (ED) was conducted with registered nurse (RN)-B. During the tour, RN-B identified a closed door that opened into the ambulance bay and indicated this doorway was where most patients who arrived via ambulance entered the facility. This doorway and adjacent areas lacked posted EMTALA signage. RN-B acknowledged there was no signage posted in this area, or in the hallway just outside the ambulance bay doorway, which led to the main ED area. During an interview on 11/24/25, at 1:48 p.m., the EMS manager identified they brought patients through the ambulance bay door once they were unloaded from the ambulance. Due to this door location, patients bypassed the main ED door and waiting room areas. When interviewed on 11/24/25, at 3:31 p.m., the director of nursing (DON) stated she expected EMTALA signage to be in the ED waiting area and the main ED; however, she was unsure about requirements for EMTALA signage in the ambulance bay. During an interview on 11/25/25, at 9:07 a.m., the ED medical director (MD)-A stated he expected EMTALA signage “at any entry part;” however, he did not consider the ambulance bay doorway an entry point. An EMTALA Assessment and Transfer Compliance policy, revised 3/31/25, directed the ED “must post” appropriate signage in English and Spanish that notified patients of their rights to a MSE and stabilization treatment. This signage was to be “posted at locations where patients enter the building or waiting areas.” The policy did not identify specific locations where patients entered from.”

“MEDICAL SCREENING EXAM CFR(s): (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: 43080 Based on interview and document review, the facility failed to provide a medical screening exam (MSE) to determine if a patient required emergency medical treatment for 1 of 21 patients (P1) reviewed for stabilizing treatment. P1 arrived by ambulance and was diverted to another hospital due to other cases and staffing. Findings include: A divert status report identified the facility’s last divert initiation was on 7/2/25, effective at 12:55 p.m., due to lab equipment concerns. This was lifted 7/3/25, at 9:25 a.m. An ED Log identified the following information: -One patient presented on 9/28/25 and discharged on 9/29/25 at 12:29 a.m. -The next entry indicated a patient presented on 9/29/25 at 3:30 a.m., related to a motorcycle crash with head laceration and arm injury. This patient remained the ED patient until 9/29/25, at 8:31 a.m., when a second patient presented. -The ED Log lacked information related to P1’s 9/29/25 facility presentation by ambulance. During an interview on 11/21/25, at 8:30 a.m., P1 stated he experienced increased shortness of breath (SOB), could not do anything, could not function, and could not think straight and called 911 because it was getting very bad. P1 explained that EMS brought him to the facility door; however, was told he needed to be “diverted” to another hospital. He did not question why because he was sick. He stated he expected the facility to have treated him. P1 identified he overheard someone indicate the facility managed a trauma patient, and he vocalized, “They did not have time for me ...they had their hands full.” P1 did not want to talk bad about the facility due to this and indicated he had already started to feel better due to the oxygen EMS applied to him; however, he was not overly happy he was hauled around the county side all night. P1 stated once he got to the secondary hospital, he was stabilized there; however, ultimately ended up being transported to a larger hospital where he was admitted for end-stage COPD (chronic obstructive pulmonary disease). During an interview on 11/24/25, at 3:21 p.m., the director of nursing (DON) stated the facility could not turn anyone away unless a divert response was enacted related to situations as a broken piece of equipment needed for stabilizing care. The DON identified the facility was able to maintain adequate staffing patterns and if a heavier care patient presented to the ED, they utilized an all-hands-on approach. The DON was unaware of any episodes where patients were turned away upon EMS presentation and not provided an MSE. During an interview on 11/25/26, at 9:07 a.m., the ED medical director (MD)-A stated patients who presented to their facility were expected to be triaged and evaluated by a medical provider. “If you come here, we take care of you.” MD-A explained there were occasions where the divert process was utilized, such as when equipment needed for care malfunctioned. He indicated this occurred once in the last few months. He was unaware of any episodes where patients were turned away upon EMS presentation and not provided an MSE. After MD-A was provided information related to P1’s experience, he explained he expected P1 to have received an initial triage “at the very minimum,” along with appropriate care and disposition. Even if they managed a trauma, staff were still expected to follow the process, and they could have worked with EMS for monitoring of P1 while staff attended to the trauma patient. When interviewed on 11/25/25, at 11:07 a.m., registered nurse (RN)-A stated, when provided P1’s scenario and questioned on facility expectations in such a presentation, “This is me. I am your person for this one.” RN-A explained EMS called and informed her they were bringing P1 in related to COPD exacerbation. She confirmed the information and ability to take P1: however, about 30 seconds after that, they found another patient in the entrance way seizing in the vestibule with a helmet on. She stated the ED was not busy that night; however, the trauma patient and P1 would have divided our resources too much. It would have taken too much of our resources. RN-A verbalized she asked EMS personnel if P1 was stable enough to be transported to the nearest hospital, and EMS personnel confirmed this. Thus, she asked them to take P1 there as she felt P1 would get faster and more one-on-one care there versus at the facility. RN-A identified she did not lay eyes on P1 to assess his situation and expressed the paramedics were very well equipped to manage respiratory concerns in the ambulance. RN-A was unable to recollect if she passed this situation on to facility management. An EMTALA Assessment and Transfer Compliance policy, revised 3/31/25, identified its purpose was to provide guidelines to ensure patients who presented to the ED received a MSE by a qualified medical professional and that patients were stabilized and transferred in accordance with the law. The policy identified an MSE was outside the scope of practice for an RN and described an “Emergency medical condition” as one manifesting symptoms, including “cardiac, respiratory ...that in the absence of immediate medical attention was likely to cause serious dysfunction ...or serious jeopardy to the health of the individual ...” The policy directed all individuals, who presented anywhere on facility property, and who sought emergency care, were to be triaged and evaluated to an RN and then provided a MSE by the provider to determine if an emergency medical condition exited, if the facility was not on a diversionary status.”