Children’s Hospitals & Clinics of MN

“USE OF RESTRAINT OR SECLUSION CFR(s): 482.13(e) Patient Rights: Restraint or Seclusion. All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. This Standard is not met as evidenced by: 49618 Based on interview and record review, the facility failed to assess a patient for injuries after restraints had been discontinued for one of one patient (P1) reviewed. Nursing staff did not assess P1 for injuries after the restraint had been discontinued. Findings include: P1’s medical records indicated his first visit to the partial hospitalization program (PHP) was on 3/3/26. P1’s diagnoses included attention deficit hyperactivity disorder (ADHD), anxiety, autism spectrum disorder, and obsessive-compulsive disorder (OCD). P1’s medical records indicated P1 received an order for violent or self-destructive behavior restraints on 3/3/26. The order indicated the reason the restraints were ordered was due to high risk of injury to self. P1’s code green/violent restraint evaluation dated 3/3/26 indicated P1 had a new restraint application and the face-to-face was completed. P1 had been a danger to himself by running around the milieu, pushing on exit doors, screaming, “headbutted” walls, kicking walls, punching walls, “headbutted” and kicked windows to break them, “headbutted” and punched TV, and broke a clipboard. Staff attempted verbal de-escalation, gave choices/options, a break in the gym, break in with staff, comfort items from home, reduced stimuli, and removed objects prior to the restraint application. P1’s medical record nursing assistant (NA) note dated 3/3/26 indicated NA responded to a staff assist alert involving P1. NA observed P1 had escalated and was pacing around the room, kicking the window, and throwing markers at the window while repeatedly stating he wanted to call his mom. The therapist offered coping strategies such as deep breathing, engaging with games available in the room, and watching calming videos. P1 did not respond to those interventions. NA observed P1 pacing around the room, kicking the window several times, and punching the protective screen of the TV. Therapist continued de-escalation by providing verbal support, redirection, and distraction techniques but P1 did not respond to those interventions. P1’s medical record NA note dated 3/3/26 indicated NA observed P1 pacing around the unit, attempting to elope out of the door, and stated he wanted to leave and see his mom. Staff offered verbal re-direction, offered active listening, and talked in a calm voice. P1 was not receptive to interventions offered. NA offered verbal re-direction by stating “we can call your mom, but we need to be able to calm down first and show safe behaviors”. NA observed P1 kicking the door to the lobby, the door that leads to behind the desk, as well as “head banging” against the wall. Due to increased dysregulation, NA initiated a staff assist alert. P1’s medical record provider note dated 3/3/26 indicated at approximately 9:50 a.m., P1 had escalated in the milieu while attempting to elope, kicked doors, and hitting his head on the wall “multiple times”. P1 was brought back to a group room to contain his behaviors. Therapist and NA were in the group room with P1 while his agitation continued. Staff observed P1 throwing markers and a clipboard at the window, injuring his finger while kicking the window and door. P1 was yelling and demanding to speak with his mom. This interaction lasted about 10 minutes. P1’s medical record provider note dated 3/3/26 indicated the therapist and the registered nurse (RN) brought P1 back to the office to speak with P1’s mom and calm down. P1 was able to speak with his mom. Therapist and RN spoke with P1’s mom about what had happened. P1’s medical record provider note dated 3/3/26 indicated therapist received a call from P1’s mom and reported P1 having “broken blood vessels” and “bruises”. Therapist had recommended P1 be brought to the nearest emergency department if she was concerned for P1. P1’s mom stated P1 would not be returning to PHP. P1’s medical record nursing note dated 3/3/36 indicated RN responded to a staff assist alert in the milieu at 9:30 a.m. P1 was screaming in the milieu stating he needed his mom. P1 was pushing against security to reach the exit door and was kicking walls and doors. Security, NA, and therapist were present and attempted to de-escalated P1 when RN arrived. Staff attempted verbal de-escalation, gave choices, offered breaks, offered body sock, or weighted vest. P1 did not respond to those interventions as P1 was frantic, screaming, and hyperventilating. P1 stated he wanted to call his mom. RN offered to call P1’s mom but asked P1 to sit or get some energy out in the gym while RN called P1’s mom. P1 attempted to sit but immediately got up and started shouting and pushing against staff to get to the door. P1 hit head against the wall once and then ran around the milieu. RN told P1 that he was going to call P1’s mom but to do that RN needed to know P1 could be safe while he was calling. P1 went into a group room with staff where he was pushing against staff to leave. While in the group room, P1 was still escalating, and he was offered and as needed medication but P1 refused. P1 punched walls while in the group room, RN noticed blood on P1’s knuckles, and staff reported it was due to P1 punching the TV. RN informed P1 he attempted to call P1’s mom but he could not get ahold of her. RN provided verbal limits and if P1 continued to harm himself then a physical intervention may be needed to keep him safe. RN offered P1’s stuffed dog from home. P1 shattered a clipboard and ran and punched the TV, ran into the wall and “headbanged” it twice, ran into the window, kicked the window, punched the window, and “headbanged” the window. P1 was placed in a four-point manual hold to keep him from harming himself and breaking the window at 10:02 a.m. and was released at 10:07 a.m. After P1 was released from the restraint, P1 sat in the group room with stuffed dog and went to the therapist’s office to call his mom. P1’s medical records from another hospital stated P1 had superficial scratches or pressure marks of unclear etiology to bilateral upper extremities. P1 had visible marks on his right side, under both armpits, on left side of back, on right side of his arms, on his back near the right rib sage, broken blood vessels on right side of neck that was visible on both sides of his neck. During an interview on 4/14/26 at 9:15 a.m., family member (FM)-A stated she was informed of the restraint hold during a phone call with P1 and the therapist on 3/3/26. When FM-A brought P1 home that day, she saw red “pinpoint” dots on his body. FM-A saw bruises across his body. FM-A brought P1 to a different emergency room for evaluation. During an interview on 4/14/26 at 1:17 p.m., RN-A stated he responded to the staff assist alert and saw P1 pushing on an exit door. RN-A attempted to talk to P1, offered for P1 to color or go to the gym but it did not de-escalate the situation. RN-A stated P1 kept repeating he wanted to call his mom, but she did not answer. P1 was throwing himself against doors. RN-A stated to P1 he would attempt to call P1’s mom. While in the office, P1 was punching and kicking doors. When RN-A came out of the office, he saw P1 in a group room with the therapist and the NA. P1 hit his head against the wall and had blood on his knuckles. RN-A brought him his stuffed dog but that did not de-escalate the situation. P1 was banging his head on the TV, walls, and window. That is when RN-A decided to put him in the restraint because RN-A did not know if P1 was going to punch through the wall and hurt himself. RN-A did the two-arm small body restraint hold where RN-A crossed P1’s arms in front of him as RN-A stood behind P1. That is when P1 dropped his weight to the door. That is when RN-A restrained P1 on the floor using the capture wrap method. This method is where P1 was on his side and crossed legs and RN-A held P1’s shoulders and NA-A held P1’s legs. RN-A stated P1 was never on his back during the restraint. After the restraint, the therapist brought P1 to her office and called P1’s mom. RN-A did not see P1 the rest of the day besides when he took P1’s vitals around 1:30 p.m., when he does his vital signs rounding on all of his patients. RN-A stated he did not assess P1 for injuries after the restraints had been discontinued. During an interview on 4/14/26 at 2:34 p.m., RN-B stated he was present during the physical hold but was not hands on with P1. RN-B stated RN-A and NA-A restrained P1 after P1 had been screaming, punching the TV, and hitting his head against the wall. P1 also had a bloody knuckle from punching the TV. RN-B stated the staff initiated the restraints because P1 was hitting his head against the wall and was unsafe to himself. RN-B stated RN-A put P1 into a two-arm small body hold restraint where RN-A crossed P1’s arms and RN-A held P1’s forearms. P1 dropped to the floor. That is when RN-A guided him down to the ground to continue the restraint. RN-B stated his restraint lasted five to six minutes. Afterwards, P1 was still emotionally dysregulated but could talk to staff. RN-B, P1, and the therapist went back to the office to call P1’s mom. RN-B informed P1’s mom of the restraint incident. After the restraint had been discontinued, RN-B stated he did not assess P1 for injuries. During an interview on 4/15/26 at 3:04 p.m., RN-A stated he did not assess P1 for injuries after the restraints had been discontinued. During an interview on 4/16/26 at 8:48 a.m., Supervisor (S)-A stated he would have expected staff to assess a patient for injuries immediately following a restraint incident. During an interview on 4/16/26 at 10:40 a.m., S-B stated after a patient had a restraint incident, staff would immediately assess the patient’s skin, circulation, and breathing. That would be documented in the patient’s medical records in the nursing narrative note. The facility’s Restraints and Seclusion policy dated 8/9/23 indicated the RN would complete a standard assessment based on the patient’s condition, behavior, and environmental considerations. The RN would document in the patient’s medical record if the patient obtained any injuries.”

“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: 43080 Based on interview, document review, and policy review, the hospital failed to maintain compliance with 42 CFR 489.24 with respect to the Emergency Medical Treatment and Labor Act (EMTALA) for 1 of 20 patients (P1) reviewed. Findings include: The hospital failed to ensure a comprehensive medical screening examination (MSE) was completed for P1, based on standards of practice, to ensure a potentially life-threatening emergency medical condition (EMC) did not exist or worsen. See A-2406. The hospital failed to ensure a certification of transfer form was completed by a qualified physician, and provided to the receiving hospital, to certify the expected transfer benefits outweighed the risks for P1. See A-2409.”

“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: 43080 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) unconscious (a life-threatening pathology) with a suspected drug overdose and required intubation (insertion of a tube into airway to assist with breathing) for decreased respiratory effort. P1 was not provided an appropriate medical screening examination, based on standards of practice, to ensure a potentially life-threatening emergency medical condition (EMC) did not exist or worsen. Findings include: P1’s medical record identified on 3/19/25 at approximately 10:40 a.m., P1, suspected to be 26 years old, was dropped off in the emergency department parking lot, unresponsive with a suspected drug overdose, by an unknown female who was unable to provide any details related to P1. P1 was immediately brought to the resuscitation room where he was intubated at 10:52 a.m., after an adult code blue was called. P1 was provided two doses of Narcan (over the counter medication that rapidly reverses the effects of opioid type medications) without effect, along with intravenous (IV) fluids. Additionally, the following point-of-care testing labs (blood work drawn and tested at the bedside) were completed: glucose (elevated), calcium (within normal limits - WNL), sodium (WNL), potassium (low), venous blood gases (elevated). At 10:56 a.m., approximately 16 minutes after arrival, P1 was transferred via ambulance, with advanced cardiovascular life support (ACLS), to another hospital in critical condition. P1’s ED Report, dated 3/19/25 and completed by medical doctor (MD)-A, identified P1’s case details were unclear due to the circumstances surrounding P1’s ED presentation, and other then the person who brought him to the ED indicating she administered “2 separate doses of Narcan at home prior to arrival with no relief of symptoms,” MD-A had no additional information related to P1 other than a suspected overdose. In response, P1 was brought to the resuscitation room and intubated due to “some spontaneous” “very shallow” breathing effort and the need for airway protection, where P1 demonstrated “good color change on CO2 detector and clear breath sounds bilaterally on auscultation of the chest after intubation;” however, the note indicated, P1’s case “was moving rapidly and transfer was required in a rapid manner, post intubation x-ray was unable to be completed to confirm ET (endotracheal) tube placement. At the time it was not felt that any further work-up could be completed prior to transfer including potential for head imaging.” Despite this, the report identified “It [did] not sound as if there was any history of trauma but again this could not be elicited further as acquaintance did not provide any further information.” P1’s medical record lacked evidence of some degree of imaging, which included a chest x-ray to confirm ET tube placement or a head CT to look for emergent causes of P1’s condition. Additionally, P1’s record lacked an ECG (electrocardiogram - testing to detect heart problems), or a full set of labs beyond point-of-care testing. When interviewed on 4/2/25 at 10:41 a.m., the compliance manager (CM)-A stated the facility lacked concerns with P1’s case and thus no follow-up was conducted. During an interview on 4/2/25 at 12:34 p.m., MD-A was able to identify the need for an MSE before the patient was transferred to another hospital for continued care to determine appropriate treatment and transfer needs. He explained P1’s care and treatment moved very quickly, and in such situations, like P1’s, when they need to be moved, they need to be moved quickly, especially when he thought something else might be going on with P1. MD-A explained that typically the ambulance was not at the hospital, as they were when P1 arrived, and thus it was not typically such a rush for transfer. MD-A identified P1 was unstable; however, was as stable as could be. MD-A stated they maybe could have done a chest x-ray to ensure tube placement; however, “things moved too quick to get it done,” and maybe if EMS had not already been there, and he was required to wait for transport, this would have been completed but “globally [he] may have done the same process.” MD-A identified facility management had yet to talk to him about any potential concerns related to P1’s care. When interviewed on 4/2/25 at 1:11 p.m., MD-B, who identified himself as the system medical director, stated he expected an unresponsive patient to promptly be evaluated with a focus on “ABCs (airway, breathing circulation)” and to attend to life-threatening issues first and foremost. After that, trauma care was provided if deemed necessary. MD-B explained once a patient was intubated, he expected a chest x-ray to be completed to ensure placement; however, with P1, “EMS was chomping at the bit to go,” and he felt staff did enough to demonstrate P1’s airway was secured and “likely to be in a proper position.” MD-B identified he had reviewed P1’s medical record; however, no concerns were identified. An Emergency Medical Treatment and Active Labor Act (EMTALA) policy, version date 8/10/23, identified a MSE was an exam reasonably calculated to identify critical medical conditions uniformly provided to all patients who present with substantially similar signs, symptoms, and/or complaints; performed by qualified medical personnel. If the MSE revealed that the patient had an EMC, stabilizing treatment must be provided if Children’s has the capacity and capability to do so. The policy did not identify any specific MSE components were expected, other than “an exam.” A Plan for Provision of Patient Care, revised 10/24/23, identified Children’s existed so serve children; however, a Patient Care and Patient Support Services section indicated “any patient, regardless of race, color, ...or age will be assessed at Children’s.” Patient needs were assessed to determine appropriate care, treatment, and services which were dependent on collecting data, analyzing information to understand the patients’ needs for care, treatment, and services and to identify the need for additional data, along with making care, treatment, and service decisions based on the analysis of information collected. A Code Blue Emergency policy, version date 12/20/24, identified all individuals, which included adults, who presented to the ED, were required to have an MSE completed.”

“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: 43080 Based on interview and document review, the facility failed to ensure a certification of transfer form was completed by a qualified physician, and provided to the receiving hospital, to certify the expected transfer benefits outweighed the risks for 1 of 4 (P1) patients reviewed for hospital-to-hospital transfers. Findings include: P1’s medical record identified on 3/19/25 at approximately 10:40 a.m., P1, suspected to be 26 years old, was dropped off in the emergency department parking lot, unresponsive with a suspected drug overdose, by an unknown female who was unable to provide any details related to P1. P1 was immediately brought to the resuscitation room where he was intubated at 10:52 a.m., after an adult code blue was called. P1 was provided two doses of Narcan (over the counter medication that rapidly reverses the effects of opioid type medications) without effect. P1’s medical doctor (MD)-A dictated progress note identified, P1’s case “was moving rapidly and transfer was required in a rapid manner ...” At 10:56 a.m., P1 was transferred via ambulance, with advanced cardiovascular life support (ACLS), to another hospital in critical condition. P1’s medical record lacked evidence a certification of transfer was completed and sent to the receiving hospital. P1’s receiving hospital medical record, obtained on 4/1/25, lacked evidence a certification of transfer was received from Children’s Hospital. When interviewed on 4/2/25 at 10:41 a.m., the compliance manager (CM)-A stated the facility lacked concerns with P1’s case and thus no follow-up was conducted. During an interview on 4/2/25 at 12:34 p.m., MD-A stated when a patient was transferred to another hospital, he was expected to complete a transfer form, which was then expected to be sent to the receiving hospital with the rest of the required paperwork. Despite this expectation, MD-A stated he did not complete one for P1 as “[P1] was already gone [transferred]. What was done was done.” MD-A explained P1’s care and treatment moved very quickly, and in such situations, like P1’s, when they need to be moved, they need to be moved quickly. MD-A explained that typically the ambulance was not at the hospital, as they were when P1 arrived, and thus it was not typically such a rush for transfer, and he was able to be more cognizant of the requirements to complete the transfer form before the transfer. MD-A identified facility management had yet to talk to him about any potential transfer concerns related to P1. When interviewed on 4/2/25 at 1:11 p.m., MD-B, who identified himself as the system medical director, stated he expected providers to transfer patients appropriately. This included contacting the receiving hospital and obtaining a provider acceptance of care. Once this was completed, a transfer form was then to be completed which would identify the acceptance details, and the appropriate level of transport required. MD-B identified he had reviewed P1’s medical record; however, no concerns were identified. MD-B was unaware the transfer form was not completed. During a telephone call on 4/3/25 at 2:27 p.m., the receiving hospital’s release of information staff (ROI)-A reviewed P1’s medical record related to his 3/19/25 admission. ROI-A verified the hospital received paperwork from Children’s on 3/19/25; however, she was unable to locate a certification of transfer. On 4/4/25 at 12:07 p.m., QM-A reviewed P1’s medical record and verified the record lacked a certification of transfer. An Emergency Medical Treatment and Active Labor Act (EMTALA) policy, version date 8/10/23, directed Children’s may not transfer an unstable patient unless a physician certified the medical benefits expected from the transfer, and from the provision of appropriate medical treatment at another medical facility, outweigh the increased risks to the patient, and a copy of the completed certification (Children’s Transfer Form) must be provided to the receiving facility.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49337 Based on interview and document review, the facility failed to report an injury of unknown origin to the State Agency (SA) for 1 of 1 (P1) patient reviewed for injuries of unknown origin. Findings include: P1’s progress note dated 10/28/24 at 8:00 a.m., indicated P1 had an abrasion to the left forearm which was visible, dry, maroon/purple, no drainage. P1 also had an abrasion on the left arm which was visible, dry, maroon/purple, no drainage. The Midwest Children’s Resource Center (MCRC) consultation from medical doctor (MD)-A dated 10/31/24, indicated P1 was a 2-month-old baby who was born at 31 weeks’ gestation. P1’s diagnoses included infant of a diabetic mother syndrome, preterm, delivered via cesarean section and slow feeding. P1 had never left the hospital and had unexplained bruising. The bruising was first documented the morning of 10/28/24 by registered nurse (RN)-A. MD-A summarized, “The bruising is patterned and most consistent with a squeeze injury. There is no history of any medical interventions, such as blood draws that would require significant holding of her left arm in the days preceding the bruising. She has no laboratory evidence of underlying coagulopathy. Her injury is most consistent with an abusive injury, where excessive force was applied to her left arm, resulting in patterned bruising. This would not be expected in the course of routine care of an infant. Plan: risk is involved, will make reports to law enforcement.” On 11/5/24 at 12:36 p.m., RN-A stated she noticed the bruising on P1 the morning of 10/28/24 at around 8 a.m. She reported it to the charge nurse about 3 to 4 hours after discovery. On 11/5/24 at 1:09 pm., the director of risk and compliance (DRC)-A stated an internal investigation substantiated something happened to cause P1’s bruising, but they were unable to determine what happened or by who. Within 18 hours of the bruise being identified, it was brought to the attention of risk management. Risk management determined what agencies to report to. The concern was reported to MCRC and the police. The police would usually report to the SA; they (police) would determine if a concern should be reported to the SA after the police conducted their own investigation. The facility policy Patient Safety and Adverse Health Events dated 7/15/22, directed the Patient Safety Executive Committee determines if an event is reportable under any applicable statutory, regulatory, or accrediting agency requirements.”

“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: 50873 Based on interview and record review, the facility failed to comply with the requirements at 42 CFR 489.24 and 42 CFR 489.20. Findings included: The facility failed to have adequate Emergency Medical Treatment and Labor Act (EMTALA) signage, as required by 42 CFR 489.20(q) (see citation at A-2402). The facility failed to provide stabilizing treatment, as ordered by the provider, as required by 42 CFR 489.24(d) (see citation at A-2407).”

“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: 50873 Based on observation, interview, and facility policy review, the facility failed to conspicuously post signage specifying the rights of individuals under the Emergency Medical Treatment and Labor Act (EMTALA) in a place or places likely to be noticed by all individuals for 2 of 2 hospital campuses reviewed for EMTALA. Findings included: A facility policy titled, “Emergency Medical Treatment and Active Labor Act (EMTALA)” dated 08/10/2023, revealed, “Signage: [Facility name] will maintain appropriate signage to notify patients of their rights when presenting with emergency conditions and woman in labor, who present to the hospital for care and treatment.” During a facility tour of the Minneapolis emergency department on 06/25/2024 at 11:05 AM, the facility failed to have EMTALA signage posted in the main areas of the emergency department that would be visible to individuals seeking medical treatment at the facility. During a tour of the Saint Paul emergency department on 06/27/2024 at 1:36 PM, the facility failed to have EMTALA signage posted in the Emergency Department (ED) waiting room. During an interview on 06/25/2024 at 12:02 PM, Senior Director Compliance Officer #1, stated they thought signage in the emergency department entrance was sufficient. The facility policy Emergency Medical Treatment and Active Labor Act dated 8/10/23 directed Children’s will maintain appropriate signage to notify patients of their rights when presenting with emergency conditions and women in labor, who present to the hospital for care and treatment.”

“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: 50873 Based on interview and record review, the facility failed to provide stabilizing treatment per the providers orders for 1 (Patient #8) of 21 patients reviewed for Emergency Medical Treatment and Active Labor Act (EMTALA). Findings included: A “Face Sheet” revealed the facility registered Patient #8 on 04/01/2024 at 4:18 PM with the symptom/diagnosis of vomiting. An “ED [Emergency Department] Report - House Staff” document revealed Patient #8 presented to the emergency department with a chief complaint of vomiting. The report revealed the date and time of the evaluation was 04/01/2024 at 5:55 PM. The report indicated the ED course plan was to check the patient’s renal function and glucose levels, and to provide stabilizing treatment that included fluids and an anti-emetic. The report revealed the “Plan” section indicated the patient and family left against medical advice before the workup could be completed. The report was electronically signed by the provider on 04/01/2024 at 8:16 PM. Patient #8’s “Orders” sheet revealed an order for sodium chloride 0.9 percent (%) normal saline bolus “Give 110 mL [milliliter] IV [intravenous] once, bag, STAT [statim; immediately]” with an order start date/time of 04/01/2024 at 6:39 PM. The Orders sheet revealed an order for ondansetron (anti-emetic) “Give 1.5 mg [milligram] = 0.75 ml IV push once” to infuse over five minutes STAT with an order start date/time of 04/01/2024 at 6:47 PM. The Order sheet revealed an order for a Basic Metabolic Panel (BMP) to be drawn by the nurse “ASAP [as soon as possible]” with an order start date/time of 04/01/2024 at 6:40 PM. Patient #8’s “ED Discharge Assessment” revealed a note dated 04/01/2024 at 8:15 PM that indicated the patient had left before treatment was completed. The note revealed, “pt [patient] LBTC [left before treatment completed] @ [at] 2001 [8:01 PM], RN [registered nurse] got back from transferring another pt to find empty room.” During a telephone interview on 06/27/2024 at 11:05 AM, RN #15 stated that STAT medications were to be given right away and that if a nurse were with another patient, another nurse would then give the STAT medication. She reported generally that was done within 15 minutes or so with exceptions such as if there was a delay obtaining the medication from the pharmacy or difficulty obtaining IV access. She said that if STAT fluids were ordered, they were available on the floor, and nursing staff would not have to wait for the pharmacy to verify the order prior to administering. During a telephone interview on 06/27/2024 at 2:37 PM, RN #16 stated the expectation for STAT medications was for them to be given within 15 to 30 minutes but that could depend on circumstances such as if there was difficulty obtaining IV access, if the medication was not in the medication storage and dispensing device and nursing staff had to wait for the medication to come from the pharmacy, or if the patient were off the unit for imaging orders. She also reported that nursing staff would not wait on pharmacy verification to administer STAT IV fluid orders. During an interview on 06/28/2024 at 10:32 AM, Medical Doctor (MD) #20, stated that when STAT orders were placed the hope was that they would be given as soon as possible but said that it would be hard to give an exact expected guideline for administration timeframes because there could be other things such as trauma going on in the ED. During an interview on 06/28/2024 at 9:05 AM, Pharmacy Clinical Coordinator (PCC) #11 stated the facility’s medication administration policy did not outline timeframes for the administration of STAT medications. PCC #11 said for ASAP and STAT orders they would drop everything and get the medication to the patient as quickly as possible. The facility policy Emergency Medical Treatment and Active Labor Act dated 8/10/23 directed if the patient is determined to have an emergency medical condition, necessary stabilizing treatment will be provided.”