Citizens Memorial Hospital

“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: 48359 Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#31 and #44) of 44 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital failed to follow its policies and procedures when they failed to provide an appropriate transfer for four patients (#13, #32, #42 and #43) out of 44 ED records reviewed from 01/01/25 through 06/30/25. The hospital’s average monthly census over the past six months was 1,445, and the average monthly transfer of patients over the past six months was 115. Findings included: Review of the hospital’s policy titled, “Transfer of Patients/Residents,” approved 08/2024, showed no patient/resident shall be arbitrarily transferred. Transferring a patient to another medical facility will be appropriate in those cases in which the patient requires medical treatment, that is not within Citizens Memorial Hospital ability or scope of service. Review of the hospital’s policy titled, “Admission, ED,” reviewed 04/2026, showed an EMC is a medical condition manifesting itself by acute (sudden onset) systems of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. If the provider determines the patient has an EMC, the patient shall receive within the capabilities of the staff and facilities, further medical examination and treatment as required to stabilize the medical condition and admission to Citizens Memorial Hospital; or transfer of the patient to another medical facility. Review of the hospital’s document titled “Medical Staff By-Laws,” dated 07/2023, showed: - An active staff member must consult with other staff members consistent with his or her scope of practice and clinical privileges and accept the care and treatment of patients who present at the ED that do not have an assigned physician. - The active medical staff shall consist of physicians, both medical and osteopathic, who assume all the functions and responsibilities of membership including, appropriate care of patients, emergency service care and consultation assignments. - Active medical staff shall accept the follow-up care and treatment of patients who present at the emergency room that do not have an assigned physician through the episode of treatment. Review of the hospital’s document titled, “Rules and Regulations of the Medical Staff of Citizens Memorial Hospital,” reviewed 11/03/20, showed: - If a staff physician is on call to provide emergency services or to consult with an emergency room physician in the area of his/her expertise, that physician will be considered to be available by phone for consultation or to come in to physically assess the patient in the ED. - The determination as to whether the on-call physician must physically assess the patient in the ED is the decision of the treating emergency physician. - Consultations shall show evidence of a review of the patient’s record by the consultant, pertinent findings on examination of the patient, the consultant’s opinion and recommendations. - Any qualified practitioner with clinical privileges in the hospital can be called for consultation within his area of expertise. - If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor who in turn may refer the matter to the director of the nursing service. If warranted, the director of nursing may bring the matter to the attention of the physician advisor of the service wherein the practitioner has clinical privileges.”

“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: 48359 Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#31 and #44) of 44 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Admission, ED,” reviewed 04/2026, showed an EMC is a medical condition manifesting itself by acute (sudden onset) systems of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. If the provider determines the patient has an EMC, the patient shall receive: within the capabilities of the staff and facilities, further medical examination and treatment as required to stabilize the medical condition and admission to Citizens Memorial Hospital; or transfer of the patient to another medical facility. Review of the hospital’s document titled, “Rules and Regulations of the Medical Staff of Citizens Memorial Hospital,” reviewed 11/03/20, showed: - The determination as to whether the on-call physician must physically assess the patient in the ED is the decision of the treating emergency physician. - If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor who in turn may refer the matter to the director of the nursing service. - If warranted, the director of nursing may bring the matter to the attention of the physician advisor of the service wherein the practitioner has clinical privileges. Review of the hospital’s document titled, “Privileges - Standard,” dated 11/21/23 through 11/21/25, showed: - Staff K, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), had internal medicine core privileges: Evaluate, diagnose, treat, and provide consultation (including medical history and physical examination) to patients 18 years of age and older with common and complex illnesses, diseases, and functional disorders of the circulatory (the system that contains the heart and the blood vessels and moves blood throughout the body), respiratory (your body’s breathing system), endocrine (a system of glands that make hormones to control moods, growth and development), metabolic (the process when your body converts food and drinks into energy to keep you alive and functioning), musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement), hematopoietic (anything related to the process of making blood cells), gastrointestinal (GI, stomach and intestines), and genitourinary (the body parts involved in making and removing urine and the body parts involved in reproduction) systems. - May provide care to patients in the intensive care setting in conformance with unit policies. - Assess, stabilize, and determine disposition of inpatients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. Review of Patient #31’s medical record, dated 02/11/25, showed: - At 12:01 PM, a 44-year-old female presented to the ED with a chief complaint of abdominal pain. - Her past medical history included gastritis (inflammation of the stomach) and alcohol abuse. - Her past surgical history included cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food). - The course narrative indicated she drank multiple drinks of alcohol every day, with her last drink of alcohol the previous day at 12:00 PM. - Her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was 10. - Her physical examination showed abdominal tenderness with some guarding (tightening of muscles to prevent further harm or discomfort), rebound tenderness (pain that increases when pressure is relieved) and hypoactive bowel sounds. - From 10/02/24 through 10/06/24, she was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for the same symptoms. - The ED was not able to get her pain-free and planned to discuss admission with Staff K, Hospitalist. - At 12:19 PM, her blood work showed her potassium (mineral in the blood or body fluid, normal is 3.5-5.0) was 2.8, carbon dioxide (CO2, a gas produced by exhaling, normal is 22-30) was 35, lactic acid (an acid produced in muscle tissues during strenuous exercise, normal is 0.5-1.9) was 6.3, total bilirubin (yellowish pigment that is made during the breakdown of red blood cells, normal is 0.5-1.3) was 2.6, aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal is 8-39) was 259, alanine transaminase (ALT, an enzyme found mostly in the liver, normal is 0-35) was 76, alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 38-126) was 203 and lipase (an enzyme produced by the pancreas which the body uses to break down fats, normal is 23-300) was 1,074. - Her liver function tests were chronically (long term, ongoing) elevated due to her alcoholism. - At 12:28 PM, her urinalysis (UA, a laboratory examination of a person’s urine) showed color interference, red blood cells (RBC, oxygen carrying cells, normal is none) were five to nine, white blood cells (WBC, infection-fighting cells, normal is none) were three to four, squamous epithelial cells (skin cells that show contamination of the urine sample, normal is none) were 51-100, many mucus and was unacceptable for a culture and sensitivity (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection). - At 1:09 PM and 4:12 PM, she was given intravenous (in the vein) medication for nausea (feeling of sickness, with an urge to vomit). - At 1:10 PM, she was given IV medication to treat alcohol withdrawal (symptoms that occur when the intake of a substance such as alcohol or drugs is reduced or stopped). - At 1:11 PM, 2:46 PM and 4:39 PM, she was given IV pain medication. - At 1:18 PM and 2:46 PM, she was given one liter (L) of IV fluids for her elevated lactic acid. - At 1:45 PM, an abdominal and pelvic computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed mild acute uncomplicated pancreatitis (inflammation of the pancreas), thrombosis (blood clot formation in a deep vein) of right gonadal vein (a blood vessel that carries blood away from the organs that produce sex cells) and fatty infiltration of the liver (fat build up on the liver cells). - At 2:07 PM, she was given IV potassium. - At 3:21 PM, an abdominal ultrasound (a test that uses sound waves to create images of structures within the body) showed a common bile duct (tiny canals that connect some of the organs in your digestive system) measuring 0.8 centimeters (cm) and an enlarged liver. - The Radiologist (a medical doctor who uses imaging technology to look inside the body to figure what is wrong) recommended clinical correlation of symptoms for the common bile duct dilation. - Staff R, ED Medical Director, did not clinically believe the patient had a bile duct stone, she was comfortable with right upper quadrant abdominal pain, the pain was more generalized throughout the entire abdomen. - Staff K’s, Hospitalist, evaluation showed she was admission appropriate. A Magnetic Resonance Cholangiopancreatography (MRCP, a test to examine your pancreas and bile duct systems) was recommended because the common bile duct had doubled in size since 11/2024, her alkaline phosphatase elevation was new, and the elevated total bilirubin raised concerns for a common bile duct stone. - The hospital was unable to perform the MRCP due to scheduling conflicts. - Staff R requested Staff K admit the patient, pending the MRCP in the morning, but was declined. Staff K indicated the patient needed to remain in the ED or be transferred until a confirmatory MRCP showed no evidence of a common bile duct stone. - Staff K advised Staff R to hold the patient until the follow morning for the MRCP, if the MRCP was negative the Hospitalist team would admit the patient. - Staff R believed the patient could have been admitted having her pain appropriately managed and then transferred from the medical floor “just as easily” as she could from the ED, which would have benefited the patient’s care. - The patient refused transfer and declined to stay in the ED all night for the MRCP in the morning. - Staff R expressed his concerns to Staff K and asked him to admit the patient for medical management. He informed Staff K the patient planned to sign out against medical advice (AMA) due to the ED constraints and the admission request was again declined. Staff K was aware the patient planned to sign out AMA which was less than ideal for the patient’s medical condition. - At 4:45 PM, Patient #31 signed a refusal to permit treatment or test form because she would have had to stay in a hall bed all night due to the ED’s capacity constraints. - She planned to return at 7:00 AM for the MRCP. Review of Patient #31’s medical record dated 02/12/25, showed: - At 8:52 AM, she presented to the ED for cardiac arrest (when the heart suddenly and unexpectedly stops pumping). - Her electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed sinus tachycardia (an increased heart rate [HR] that exceeds 100 beats per minute [bpm]) with a HR of 122, marked ST depression (a level below baseline on one part of the EKG) indicating myocardial ischemia (the heart muscle is not getting enough blood and oxygen) and heart attack. - At 8:40 AM, her blood work showed her WBCs were 13.3 (normal is 4.8-10.8). - At 9:48 AM, her blood work showed her sodium (a mineral in the blood or body fluid, normal is 137-145) was 138, CO2 was 13, anion gap (a measure for electrolyte imbalances and acid-base imbalances in your blood, normal is 6-18) was 24.8, lactic acid was 18.3, calcium (a mineral in the blood or body fluid, normal is 8-10.2) was 7.7, phosphate (a mineral in the blood or body fluid, normal is 2.5-4.5) was 6.7, total bilirubin was 3.3, AST was 743, ALT was 145, troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) was high and brain natriuretic peptide (BNP, blood tests that measures levels of protein made by the heart and blood vessels that indicate heart failure, normal is 0-95.3) was 1,560. - At 8:55 AM, she had a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) that showed normal anatomy. - At 10:30 AM, she was admitted to the ICU, started on antibiotics for possible septic thrombophlebitis (infection of a thrombosis) in the setting of acute pancreatitis, and developed tonic-clonic seizure (a type of seizure that causes the loss of consciousness and violent muscle contractions) activity of greater than 10 episodes in six hours. - At 8:05 PM, she was transferred to Hospital B per the family’s request to continue aggressive cares. Review of Patient #31’s Hospital B medical record dated 02/12/25, showed: - At 9:04 PM, she was directly admitted to the ICU. - On 03/12/25, she was terminally extubated (withdrawal of a ventilator [a machine that supports breathing] from critically ill patients who are not expected to survive without respiratory support). - On 03/14/25, she was transferred to the medical floor for comfort care (a patient care plan that is focused on symptom control, pain relief, and quality of life at the end of life). During a telephone interview on 07/10/25, at 3:00 PM, Staff R, ED Medical Director, stated that the hospital had the capability and capacity to care for Patient #31 on her 02/11/25 visit. She was not stable for transfer because she was in “profound withdrawal.” The patient stated that she was transferred the last time she presented to the hospital for a MRCP, and she did not have a common bile duct stone. She was discharged the day after she arrived at the receiving hospital, and it took her three days to find a ride home. If a patient refused to transfer, the Hospitalists convinced them to leave AMA. Staff K, Hospitalist, created an uncomfortable environment for Patient #31, by remaining in the ED hallway, which encouraged her to leave AMA. A repeat potassium level would have been completed on the inpatient side if she had been admitted. An EKG order was not triggered with a potassium of 2.8, but would be ordered at the Physician’s discretion. A potassium of 2.8 met the hospital’s Utilization Review (UR, staff who review documentation as a safeguard against unnecessary and inappropriate medical care) guideline for an observation service (assessment, treatment, and reassessment, to determine whether a patient will require further inpatient treatment or could be safely discharged) admission. He suspected Patient #31 died from a withdrawal seizure. During a telephone interview on 07/09/25, at 1:45 PM, Staff K, Hospitalist, stated that he physically evaluated Patient #31 in ED room four. She had severe abdominal pain with a history of pancreatitis and alcohol abuse. He was concerned with the increased dilation of her common bile duct and laboratory findings compared to her previous results. He was aware Staff R, ED Medical Director, did not believe the patient had a common bile duct stone, he spoke with the Surgeon on-call and the decision was made to keep the patient in the ED until the MRCP was completed. If the MRCP showed a common bile duct stone the hospital was not capable of performing an endoscopic retrograde cholangiopancreatography (ERCP, a procedure to diagnosis and treat problems in the digestive system) procedure because there was no GI provider available. He planned to provide co-management of the patient and wrote orders for her care while she remained in the ED, “that way he did not have to worry about transferring her anywhere as an in-patient.” It was “very challenging to transfer inpatients to a higher level of care, all hospitals were busy.” He was not aware the patient was in a hallway bed, that knowledge would not have changed his recommendation to hold her in the ED pending the MRCP. If Staff R believed Patient #31 needed to be admitted right then, she should have been transferred. He was not aware the patient refused to be transferred. There were no treatment guidelines for a gonadal vein thrombosis, and it was not an emergent condition. “In an ideal world an EKG would have been done due to her low potassium. She did not have chest pain, and her low potassium level was related to her vomiting.” Her diagnosis was “pretty slam dunk.” He expected a repeat potassium level if the patient had not left AMA. He did not know what transpired between Staff R and the patient, it was her choice to leave AMA. During a telephone interview on 07/09/25, at 3:50 PM, Staff L, Surgeon, stated that he vaguely remembered speaking with Staff K, Hospitalist, regarding Patient #31. He did not recall speaking with Staff M, ED Medical Director. He was familiar with the patient, he performed surgery on her the year before. The patient had to quit drinking alcohol before he was able to perform the surgery. Unfortunately, she began drinking again and there was concern for pancreatitis versus common bile duct stone. The work-up was incomplete without a MRCP, therefore the patient should have remained in the ED. During a telephone interview on 07/10/25, at 10:30 AM, Staff T, Chief Operating Officer (COO), stated that he was not aware of Patient #31’s hospital experience and that was concerning to him. In his personal opinion admitting the patient rather than boarding in the ED hallway made the most sense over allowing her to leave AMA. She could have been transferred as an inpatient if that became necessary. This patient was managed as a “what if scenario. In spite of the challenges the hospital faced the patient needed care.” He was not aware of delays the hospital faced when transferring patients from an inpatient status. Review of the hospital’s document titled, “Tiger Text,” dated 07/10/25, showed at 10:39 PM, Staff V, ED Physician, wrote, that hall bed (Patient #44) that we were going to send back to the nursing home was standing but with 50%-75% assist, I think he will get sent right back if we discharge him. At 10:45 PM, Staff S, Hospitalist, replied, he does not have a diagnosis that would meet criteria for admission. If he is weak, they can do PT and OT at the nursing home. Review of Patient #44’s medical record dated 07/10/25, showed: - At 6:02 PM, he was a 62-year-old who presented to the ED for a chief complaint of altered mental status (AMS, mental functioning ranging from slight confusion to coma). - His past medical history included a stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), memory problems, Traumatic Brain Injury (TBI, an injury in how the brain works). and chronic kidney disease (CKD, ongoing, gradual loss of kidney function). - The course narrative showed he had AMS and lethargy (weak, sluggish). He had a new oxygen requirement that appeared to be related to obstruction due to sleeping. His blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) improved with IV fluids and the plan was to discharge home. - The history of present illness showed he was poorly responsive and unable to provide a coherent history. The nurse obtained additional history from the patient’s nursing home (NH). He had slipped while he attempted to sit on a chair and landed on his bottom. He did not strike his head, but did not seem able to get up on his own. He was awake and alert today. - At 6:12 PM, his BP was 95/72. - At 6:30 PM, his WBC’s were 4.4, hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal is 9-20) was 11.2, platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal is 150-400) were 147, sodium (a mineral in the blood or body fluid, normal is 137-145) was 135, blood urea nitrogen (BUN, blood test that specifies kidney function normal is 9-20) was 25, creatinine (blood test that shows how the kidney is functioning, normal is 0.8-1.5) was 1.53 and lactic acid was 1.3. - At 7:38 PM, 2,400 milliliters (mls) of IV fluids were administered - At 8:10 PM, a brain Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) showed no abnormality. - At 8:17 PM, a head CT showed no abnormality. - At 8:30 PM, Staff S, Hospitalist, was consulted and stated there was no indication for admission if the patient’s BP improved, he could be discharged. - At 8:31 PM, a pelvis x-ray showed osteoarthritis (when the flexible tissue at the end of bones wears down and cause pain). - At 8:34 PM, a chest x-ray showed atelectasis (collapse of part or all of a lung) of both lungs. - At 8:45 PM, Staff S, was contacted again and stated there was no admission criteria and recommended going back to the NH with physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) and occupational therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) consults. - The nurse reported she did not think the patient was able to go back to his NH at that time, he was not able to stand. He was normally able to walk without assistance. - At 8:46 PM, his UA showed urobilinogen (a substance formed in the intestines when bacteria break down bilirubin [yellowish pigment that is made during the breakdown of red blood cells], normal is 0.2-1) was 6. - At 8:49 PM, IV antibiotics were administered. - At 10:04 PM, IV antibiotics were administered. - At 11:15 PM, his BP was 107/85. - The patient was discharged home. Review of Patient #44’s medical record dated 07/11/25, showed: - At 12:19 AM, he presented to the ED after a fall and AMS. - The course narrative showed he was seen previously and discharged from the ED, although at the time of the discharge there was still concern about the patient’s AMS and instability with walking. Shortly after he arrived at the NH he was found down on the ground. He had no signs of trauma but was confused and lethargic. - At 2:40 AM, his WBCs were 7.8, hgb was 13.3, platelets were 132 and BUN was 24. - At 3:06 AM, a venous blood gas (VBGs, blood that is low in oxygen content and is carried through blood vessels from the body back to the heart) showed a pH (measurement of acidity and alkalinity of blood, normal is 7.33-7.43) was 7.35, partial pressure of carbon dioxide (PCO2, measurement of how much carbon dioxide is in your blood and how well your lungs are removing it, normal is 35-48) was 54.7, partial pressure of oxygen (pO2, amount of oxygen dissolved in blood, normal is 38-50) was 28.2 and base excess (a measurement of acid base balance, normal is -3.2-1.8) was 4.3. - At 3:34 AM, his UA showed ketones (when a type of sugar is present in the urine, may indicate high blood sugar levels in the body, normal is zero) was trace, leukocyte esterase (substance that suggests there are white blood cells in the urine, normal is zero) was 75, WBCs were 15-19 urobilinogen was 2, bacteria was trace (normal is zero) and a urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for marijuana. - At 7:05 AM, IV antibiotics were administered. - At 2:10 PM, one L of IV fluids were administered. - Staff G, Hospitalist suspected some sort of marijuana edible spread among the patients at the NH. - The nursing home called to the hospital and informed them the patient exceeded their ability to provide safe care, he was not allowed to return and required placement. - Staff S, Hospitalist, was consulted and the patient was admitted for polypharmacy (taking too many medications at the same time), marijuana abuse and potential urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). During a telephone interview on 07/16/25, at 10:30 AM, Staff V, ED Physician, stated that he was employed at the hospital since 2022 on an as needed basis. He was credentialled as an ED Physician at 11 other hospitals. Patient #44 was “definitely not” at his baseline when he was discharged from the ED, his mentation (mental activity) improved but his gait (a person’s manner of walking) had not. He walked independently at his baseline, and he was a two person assist to stand at the end of his first ED visit. He consulted Staff S, Hospitalist, and his admission request was denied. Patient #44 was to discharge back to the NH with PT and OT consults. Staff V felt he could try the discharge to the NH but believed the patient would “bounce back” to the ED. In his experience with other hospitals, Patient #44 would have been admitted. He felt Patient #44’s discharge to the NH did not meet the standard of care and he was not surprised he returned to the ED. He was “disappointed” with the “push back” from the Hospitalists to the ED Physicians. There was more push back at this hospital than any other hospital he worked at. In his experience, other hospitals had a more collaborative approach with a focus on what was in the best interest of the patient. He sometimes experienced a lot of resistance from the Hospitalist and felt the patient’s quality of care and safety were impacted. He felt that he had to pick his battles. The hospital was not patient centered, and he had to worry about maintaining relationships with the Hospitalists. The Hospitalists focused on UR and payment; “this was 100% the issue. It was a huge issue” that the hospitalists were so concerned about the recommendations of UR and patient payments. During a telephone interview on 07/15/25, at 12:00 PM, Staff S, Hospitalist, stated that the ED Physician consulted him because “he did not know what to do with the guy.” The patient was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), he was “just different.” It was “hard to get Patient #44 to talk,” he thought maybe there was a physiological condition (the condition or state of the body or bodily function). There was no focal deficit. He was aware the nurse was concerned the patient was too weak to walk. The patient “did not necessarily meet criteria for admission without a specific cause for his weakness.” He could have had a PT and OT consult in the ED but would have had to stay longer. When Patient #44 returned to the ED it was clear he had marijuana intoxication (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs). He was placed in observation because he fell “again”, and he wanted to observe Patient #44 until the morning so he could “sleep it off.” He felt the first discharge was safe and it was unfortunate he fell the second time. During a telephone interview on 07/11/25, at 2:00 PM, Staff R, ED Medical Director, stated that Staff S, Hospitalist, refused to admit Patient #44 after a UR review. Staff S was “notorious for wallet biopsies and chart surfing.” The patient had AMS and generalized weakness. He was normally independent and was not at his normal function at discharge due to weakness. Staff V, ED Physician, wanted to admit but was denied by Staff S because the patient “did not meet UR’s admission criteria.” Two hours later Patient #44 was found on the floor, returned to the ED and was admitted. During a telephone interview on 07/15/25 at 1:30 PM, Staff T, Registered Nurse (RN), stated that she assumed care of Patient #44 prior to his discharge from the ED. She tried to dress him and felt he was “not appropriate” for an assisted living home. She communicated her concerns to Staff V, ED Physician, a couple of times and knew he communicated her concerns to Staff S, Hospitalist. She thought “the home will return him and hoped the Hospitalist would have a shift change and he would be admitted.” She felt the discharge was not safe. When Patient #44 returned to the ED, Staff G, Hospitalist, tried again to have the patient admitted. It turned out the patient had marijuana intoxication, but it could have been something else. Staff T stated that there seemed to be “patterns of animosity between the ED Physicians and the Hospitalists.” The conflict affected patient care. Recent changes had taken place in response to the “fighting” between the ED Physicians and the Hospitalists. When the patient was accepted for admission, the patient was “held in the ED” until the Hospitalists informed the floor staff, they were able to call the ED for report. Quick admissions from the ED benefited the patients, there were beds available, but the ED was not allowed to transfer the patient until the Hospitalists “decided it was okay.” That process resulted in “delays in care” and back up in the ED. The ED was “so small with a high census.” During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that the Hospitalists referred to UR before patients were admitted. This was screening patients for their ability to pay for care. If the patient was not a “slam dunk” admission the Hospitalists requested the ED Physician review the patient with UR. That meant Physicians were being told how to manage patients by non-clinically educated staff. The UR department stated the final decision to admit was up to the Physician but called the Hospitalist to inform them the patient did not meet admission criteria, and the Hospitalist refused to admit the patient based on the UR recommendation. When he requested the Hospitalist to evaluate patients face-to-face, he was told there was “nothing they had to offer” the patient and did not perform the face-face evaluation.”

“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: 48359 Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide an appropriate transfer for four patients (#13, #32, #42 and #43) out of 44 Emergency Department (ED) records reviewed from 01/01/25 through 06/30/25. The hospital’s average monthly census over the past six months was 1,445, and the average monthly transfer of patients over the past six months was 115. Findings included: Review of the hospital’s policy titled, “Transfer of Patients/Residents,” approved 08/2024, showed no patient/resident shall be arbitrarily transferred. Transferring a patient to another medical facility will be appropriate in those cases in which the patient requires medical treatment, that is not within Citizens Memorial Hospital ability or scope of service. Review of the hospital’s document titled, “Medical Staff By-Laws,” dated 07/2023, showed: - An active staff member must consult with other staff members consistent with his or her scope of practice and clinical privileges and accept the care and treatment of patients who present at the ED that do not have an assigned physician. - The active medical staff shall consist of physicians, both medical and osteopathic, who assume all the functions and responsibilities of membership including, appropriate care of patients, emergency service care and consultation assignments. - Active medical staff shall accept the follow-up care and treatment of patients who present at the emergency room that do not have an assigned physician through the episode of treatment. Review of the hospital’s document titled, “Rules and Regulations of the Medical Staff of Citizens Memorial Hospital,” reviewed 11/03/20, showed: - If a staff physician is on call to provide emergency services or to consult with an emergency room physician in the area of his/her expertise, that physician will be considered to be available by phone for consultation or to come in to physically assess the patient in the ED. - The determination as to whether the on-call physician must physically assess the patient in the ED is the decision of the treating emergency physician. - Consultations shall show evidence of a review of the patient’s record by the consultant, pertinent findings on examination of the patient, the consultant’s opinion and recommendations. - Any qualified practitioner with clinical privileges in the hospital can be called for consultation within his area of expertise. - If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor who in turn may refer the matter to the director of the nursing service. If warranted, the director of nursing may bring the matter to the attention of the physician advisor of the service wherein the practitioner has clinical privileges. Review of the hospital’s document titled, “Physician Resource Optimization Meeting,” dated 06/18/25, showed: - From 04/04/25 through 05/31/25, 77 Hospitalist consults from ED Physicians resulted in 44 transfers. - In 2021, 5.8% of ED patients were transferred; - In 2022, 6.2% of ED patients were transferred; - In 2023, 6.7% of ED patients were transferred; - In 2024, 7.6% of ED patients were transferred; and - In 2025, 8.2% of ED patients were transferred. Review of the hospital’s document titled, “Privileges - Standard,” dated 05/21/24 through 05/21/26, showed Staff E, Orthopedic (medical specialty dealing with bones) Surgeon, had orthopedic surgery core privileges to: - Evaluate, diagnose, consult, and provide non-surgical and surgical care to patients of all ages; - Correct or treat various conditions, illnesses, and injuries of the musculoskeletal system, including the provision of consultation; and - Including specific processes such as intermedullary rods (femur, tibia), total knee replacements, and revisions of total knee. Review of the hospital’s document titled, “Privileges - Standard,” dated 04/23/24 through 04/23/26, showed Staff J, Hospitalist, had internal medicine core privileges to: - Evaluate, diagnose, treat, and provide consultation (including medical history and physical examination) to patients 18 years of age and older with common and complex illnesses, diseases, and functional disorders of the circulatory (the system that contains the heart and the blood vessels and moves blood throughout the body), respiratory (your body’s breathing system), endocrine system (a system of glands that make hormones to control moods, growth and development), metabolism (the process when your body converts food and drinks into energy to keep you alive and functioning), musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement), hematopoietic (anything related to the process of making blood cells), gastrointestinal (GI, stomach and intestines), and genitourinary (the body parts involved in making and removing urine and the body parts involved in reproduction) systems. - Provide care to patients in the intensive care setting in conformance with unit policies. - Assess, stabilize, and determine disposition of inpatients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services. Review of the hospital’s untitled electronic mail (email) dated 07/08/25, showed: - On 06/25/25, there were no telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) boxes available; - Medical-telemetry patients needed transfer; and - Boarding Progressive Care Unit (PCU, a telemetry monitored unit that provides care for adult patients requiring continuous cardiac monitoring) in the ED was appropriate as cardiac monitoring was possible with their mobile or in room monitors. Review of the hospital’s document titled, “Department: Cardiology (a physician that specializes in the care of your heart and blood vessels),” dated 03/2025, showed a Cardiologist was on call every day in 06/2025. Review of Patient #32’s medical record dated 06/24/25, showed: - At 10:07 PM, he was a 60-year-old who presented to the ED for a chief complaint of left sided pain and altered mental status (AMS, mental functioning ranging from slight confusion to coma). - His past medical history included alcohol abuse. - His past surgical history included a thoracotomy (a surgical incision through the chest wall, used to visualize and treat illnesses within the chest) and heart bypass surgery of five vessels. - The course narrative showed he had a slow heart rate (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) enroute to the ED per Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and atropine (an emergency medication used to treat a slow HR) was administered. He was lethargic (weak, sluggish) but would awaken to verbal and physical stimulation. He complained of abdominal pain and was tender in the left lower abdomen. He had phimosis (the foreskin of the penis is too tight to be fully pulled back over the head of the penis) with associated urinary retention (when the bladder doesn’t empty completely or at all) with greater than 600 milliliters (ml). - Staff G, ED Physician, suspected his AMS was caused by a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) and the kidney injury was in part due to the phimosis which was addressed. - A rectal exam was negative for blood. - At 10:11 PM, his blood work showed his blood urea nitrogen (BUN, blood test that specifies kidney function, normal is 9-20) was 46, creatinine (blood test that shows how the kidney is functioning, normal is 0.8-1.5) was 2.08 and magnesium (mineral in the blood or body fluid, normal is 1.6-2.3) was 3.1. - From 10:12 PM through 06/25/25 at 12:03 PM, his HR ranged from 25 to 130 beats per minute (BPM), his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) ranged from 96/59 to 139/62 and his oxygen saturation (SpO2, measure of how much oxygen is in blood. A normal is between 95% and 100%) ranged from 93% to 99% on room air (not receiving supplemental oxygen). - At 11:00 PM, one-liter (L) of intravenous (IV, in the vein) fluids was administered. - At 11:03 PM, he had a three-beat run of ventricular tachycardia (V-tach, a condition in which the lower chambers of the heart [ventricles] beat very quickly). - At 11:18 PM, his EKG showed a first-degree AV block (a heart condition where the electrical signals that travels from the heart’s upper chambers [atria] to the lower chambers are delayed) and frequent premature ventricular contractions (PVCs, a type of abnormal heartbeat). - On 06/25/25 at 12:05 AM, his urinalysis (UA, a laboratory examination of a person’s urine) showed leukocyte esterase (substance that suggests there are white blood cells [WBC, infection-fighting cells] in the urine, normal is negative) were 500, red blood cells (RBC, cells that carry oxygen throughout the body, normal is negative) were five to nine and WBCs were too numerous to count (normal is zero). - At 1:41 AM, IV antibiotics were administered. - At 2:52 AM, Staff J, Hospitalist, was consulted for admission for hepatic encephalopathy (inflammation of the brain brought on by severe liver disease) due to UTI. Staff J felt the patient required an Intensive Care Unit (ICU, a unit where critically ill patients are cared for) level of care related to the episode of V-tach and episodic slow HR. - Staff J, did not perform a bedside assessment. - The patient was transferred to Hospital B. Review of Patient #32’s Hospital B medical record dated 06/25/25, showed: - At 10:12 AM, he was directly admitted to the Cardiac-Medical Unit. - His treatment plan included a brain Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body), blood and urine laboratories, Cardiologist consult, echocardiogram (ECHO, a test that makes images of the heart and surrounding structures), telemetry monitoring, medication administrations and adjustments and rib and hip x-rays (test that creates pictures of the structures inside the body-particularly bones). - His code status (refers to whether or not a patient wants medical intervention if their heart or breathing stops) was Do Not Resuscitate (DNR, written instructions from a physician telling health care providers not to perform CPR). - On 06/28/25 at 2:14 PM, Patient #32 was discharged home. During a telephone interview on 07/09/24 at 12:00 PM, Staff G, ED Physician, stated that the transfer of Patient #32 “was ridiculous.” He had metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood) from the UTI, not hepatic encephalopathy. “The voice to dictation made an error.” The patient was not symptomatic with the slow HR. Staff G believed “low voltage of his QRS complex (electrical impulse as it travels through the ventricles of the heart) with frequent PVCs was why the telemetry monitor showed a slow HR. The three-beat run of V-tach was actually three PVCs in a row and the telemetry monitor “called it V-tach.” Staff J, Hospitalist, “threw up roadblocks to admissions.” He requested a surgical consult for this patient for possible bleeding varices (expanded blood vessels that develop most commonly in the esophagus [a muscular tube that food travels through from the throat to reach the stomach] and stomach). To overcome the gastrointestinal (GI) bleed (excessive bleeding that starts in the intestinal tract) obstacle, Staff G performed a rectal examination, and the patient was guaiac (a test that checks for hidden blood in stool, normal is negative) negative. Staff G believed the surgery consult was requested because Staff J knew the on-call surgeon would request the patient was transferred because the hospital was not capable of performing esophageal varices banding (a procedure where tight elastic band are placed around a bulging vein to stop it from bursting and bleeding). Patient #32 needed antibiotics to treat the UTI. Staff J, called the House Supervisor and her perspective was the patient needed an ICU level of care, but there were no ICU beds available. “We sent this guy out for a three-beat run of V-tach!” The ED was unable to determine the patient’s code status, he was confused. Staff G believed the patient required telemetry monitoring. It was not uncommon for patient’s to be held in the ED for telemetry monitoring if bed and telemetry availability was limited. Boarding patients happened on a regular basis. Patients appropriately transferred for telemetry needs were on medication drips and intubated (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) or those with critical care needs. Staff J, “found reasons patients could not be admitted.” During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that a diagnosis of V-tach required six beats. Patient #32 had a wide complex ventricular beat (irregular HR rhythm). “At the most,” the patient needed a Cardiology consult. The hospital had a Cardiologist provider available that was capable of caring for Patient #32. The working process in the ED was to board up to two ICU patients before transferring. Patient #32 could have boarded in the ED until an ICU bed was available. During a telephone interview on 07/09/25 at 5:00 PM, Staff J, Hospitalist, stated that Patient #32’s UA results “were not impressive” for a UTI. His goal was to always keep patients local, if possible. No ICU beds were available, and Staff J needed to be sure he could care for the patient. He collaborated with the House Supervisor, and due to the patient’s “persistent” low HR and episode of V-tach it was recommended the patient needed an ICU level of care. He was looking to work with the House Supervisor to determine if the patient was able to be cared for locally, the decision to transfer was not unilateral. He had a “very close relationship with the House Supervisors and was instrumental in developing their program to support consistency with available resources.” He recalled reviewing the patient’s EKG’s but not his telemetry monitoring. He was not informed of Staff G’s suspicions for a low voltage QRS and PVC run interpreted as V-tach which would have potentially changed his decision to transfer. It would have prompted further review. He depended on the ED Physician to provide details of the patient’s situation. He was surprised the patient was not directly admitted to an ICU at the receiving hospital and stated different hospitals have different capabilities in their units. During a telephone interview on 07/10/25 at 7:45 AM, Staff M, House Supervisor, stated that no ICU beds were available for Patient #32. The ED had the only hemodynamic monitoring (a procedure that checks your blood circulation and evaluates how well your heart is working) available in the hospital. As the House Supervisor she tried not to hold ICU level of care patients in the ED. Review of Patient #42’s medical record dated 07/05/25, showed: - At 9:54 PM, he was a 64-year-old who presented to the ED with a chief complaint of shortness of breath with concerns for sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) and pneumonia (infection in the lungs). - His past medical history included sarcoidosis (a disease that causes small patches of swollen tissue to develop in the organs of the body), chronic hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) requiring three (Ls) of oxygen, chronic urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) for urinary retention and long-term anticoagulant (medications used to prevent blood clots) therapy. - His past surgical history included a permanent pacemaker (small device that’s placed in the chest or abdomen to help control abnormal heart rhythms). - The course narrative showed he had a peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) and received IV antibiotics at home for a recurrent UTI bacteremia (bacteria in the bloodstream). He was confused, had a labored cough, had a high HR and respiration rate (RR, normal breaths per minute for an adult at rest ranges from 12 to 20) and was placed on bi-level positive airway pressure (Bi-PAP, type of ventilator that is used to treat conditions in which a person is able to breathe on their own but needs assistance). - At 10:10 PM, arterial blood gases (ABGs, a blood test that measures the amount of oxygen and carbon dioxide in the blood) showed the arterial pH (measurement of acidity and alkalinity of blood, normal is 7.35-7.45) was 7.35 and partial pressure of carbon dioxide (PCO2, measurement of how much carbon dioxide is in your blood and how well your lungs are removing it, normal is 35-48) was 69.1. Staff G, ED physician, suspected a venous blood gas (VBGs, blood that is low in oxygen content and is carried through blood vessels from the body back to the heart) was obtained. - At 10:15 PM, his blood work showed WBCs were 29.3, RBCs were 1.25 and hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal is 14-18) was 4. Staff G suspected a laboratory error. His platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal is 150-400) were 141. - At 10:15 PM, he was administered an albuterol nebulizer (bronchodilator medication used to relax muscles in the airways and increase airflow to the lungs). - At 10:46 PM, he was given IV antibiotics. - At 11:21 PM, his blood work showed WBCs were 15.7, RBCs were 2.63 and Hgb was 8.2. - At 11:39 PM, he was given IV antibiotics. - On 07/06/25 at 1:48 AM, he was given an IV medication to treat a yeast infection. - At 3:51 AM, he was administered an albuterol nebulizer. - At 3:53 AM, his UA, after the urinary catheter was exchanged, showed brown colored urine, urine blood was greater than 1 (normal is negative), leukocyte esterase (substance that suggests there are white blood cells in the urine, normal is zero) were 500, WBCs were too numerous to count, and yeast was observed. Blood work showed his lactic acid was 2.1. VBGs showed an arterial pH of 7.43 and his PCO2 was 52.4. - At 6:21 AM, his lactic acid was 1.9. - At 8:56 AM, a chest x-ray showed increased infiltrates (accumulation of a foreign substance, typically within the lungs)/atelectasis (collapse of part or all of a lung) of his left lower lobe without other changes. - At 9:01 AM, he was given IV antibiotics. - Staff J, Hospitalist, was consulted for admission and responded that he was “uncomfortable caring for him locally due to lack of supportive services, chiefly Pulmonology-critical care (a physician who specialized in lung issues), Infectious Disease (a doctor who specializes in diagnosing, treating, and preventing illnesses caused by infections), Hematology (a doctor who specializes in diagnosing and treating disease of the blood, bone marrow and lymphatic system [the tissues and organs that produce, store, and carry WBCs that fight infections and other diseases]) and Rheumatology (medical specialty concerned with disorders of the joints, muscles and ligaments).” During his recent admissions, he failed three antibiotic treatments. “There was a recent concern for hemolytic anemia (a condition where the body’s RBCs are destroyed faster than your bone marrow can create new ones). Given his multiple comorbidities, to include chronic immunosuppression (the body’s immune system is unable to fight infections and other diseases), he required transfer to a higher level of care.” - Staff J, did not perform a bedside assessment. - After several hours of Bi-PAP his VBG showed his pCO2 improved. He was uncomfortable with the BiPAP and was transitioned to a nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) and was able to maintain his SpO2 on four L of oxygen per NC while he boarded in the ED waiting for EMS shift change for transport. - He was transferred to Hospital F. Review of Patient #42’s Hospital F medical record dated 07/06/25, showed at 12:35 AM, he was directly admitted to the ICU and transferred to the medical floor for continued diuresis (increase urine production) with improved breathing and his infection workup was unremarkable. His treatment plan included physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) and occupational therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) consults, chest x-ray, NC during daytime hours and BiPAP at night, medication adjustments and administrations and blood laboratories. During a telephone interview on 07/09/25 at 12:00 PM, Staff G, ED Physician, stated that Patient #42 was previously treated at the hospital for bacteremia and came into the ED with sepsis. He expected the patient would be admitted and treated with broad spectrum antibiotics (an antibiotic that is effective against many different types of bacteria). He believed the patient did not require the care of a critical care Pulmonologist; he was stable in the ED “all night long and his VBGs improved.” He agreed the patient may need to see an Infectious Disease physician, but that need was not emergent. When Staff G was asked about the need for the patient to see a Rheumatologist he responded, “come on!” When Staff G was asked about Staff J’s, Hospitalist, concern for Hemolytic Anemia he responded, he had no idea what Staff J referred to, he makes “shit” up when he decided he did not want to do “stuff.” Staff G stated that Staff J “sat in his office and dug through the chart, he never saw the patient.” Staff G asked, why transfer a patient emergently with improved VBGs? Historically, Staff J argued against consults, requested unneeded testing and still wanted to transfer patients. During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that a Rheumatology consult was “never” emergent. The hospital had an Infectious Disease Physician available by phone consult. That provider was available 24 hours a day seven days a week in an unofficial capacity. During a telephone interview on 07/09/25 at 5:00 PM, Staff J, Hospitalist, stated that he knew Patient #42 well. He had cared for him on “a couple of occasions.” He was an “incredibly complicated and debilitated patient.” He had two hospitalizations within a few weeks and was treated with three different antibiotics, which he failed. He was difficult to treat in regard to an infectious disease standpoint. He returned to the ED five days after his previous discharge having failed the third antibiotic. The concern for hemolytic anemia was related to the patient’s use of Dapsone (medication used to treat a bacterial infection and reduce inflammation). The patient presented to the ED on a holiday weekend and the hospital lacked supportive services to care for a patient that required multidisciplinary care with a worsening condition. Staff J did not have higher level of care support without a Pulmonologist or Infectious Disease Provider. “What was he to do, the patient failed third level antibiotics and there was not access to an Infectious Disease provider.” What he knew of the patient before was his respiratory status at baseline was “marginal” with pulmonary sarcoidosis, steroid (drugs used to relieve swelling and inflammation) dependence and chronic immunosuppression. The patient was on and off of BiPAP and he had no access to a Pulmonologist to manage acute respiratory failure. Review of Patient #43’s medical record dated 07/07/25, showed: - At 8:50 PM, he was 73-year-old who presented to the ED with a chief complaint of fall. - His past surgical history included a right knee replacement in 03/2024. - The course narrative showed he had chest pain with palpation (using one’s hands to assess the body) and a laceration (a deep cut or tear in skin) to his right knee. He maintained his SpO2 levels. He worked with Hospital E’s orthopedics (medical specialty dealing with bones) and planned a revision of his right knee replacement. The patient refused to follow up with his previous Orthopedic Surgeon. The wound was irrigated, and a sterile (completely clean and free from germs) dressing was applied. - At 9:00 PM, his WBCs were 13.1. - On 07/08/25 at 7:14 AM, a right knee x-ray showed a total right knee replacement and no evidence of hardware failure. - Staff E, Orthopedic Surgeon, was consulted and recommended wound care, he “advised that given the nature of the wound the knee was likely infected.” He recommended a wound culture (a test to identify bacteria that may cause an infection), one dose of IV antibiotics and a referral back to the patient’s previous Orthopedic Surgeon. - An outside Orthopedic Surgeon was consulted and recommended the patient was transferred to Hospital E’s ED. - At 7:19 AM, a rib x-ray showed no disease or break. - The patient was transferred to Hospital E. Review of Patient #43’s Hospital E medical record dated 07/08/25, showed: - At 12:15 AM, he arrived at the ED. - His knee laceration was repaired in the ED. - His treatment plan included a head, cervical spine (neck region of the back), chest, abdomen and pelvis CT scan. - He was admitted to the surgical floor with a diagnosis of rib fracture (a break in a bone), two middle back and one lower back compression fractures (a type of break in a bone caused by pressure and in which the bone collapses) and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness). During a telephone interview on 07/09/25 at 12:00 PM, Staff G, ED Physician, stated that Patient #43 presented after a fall with a laceration to his knee over previous hardware. He consulted Staff E, Orthopedic Surgeon, but did not push for him to come in to see the patient. Historically, Staff E was a difficult consult, if he was made to come in, he got “pissy.” Staff G texted pictures of the wound to Staff E and the recommendation was for wound care. Staff E responded to the text with “probably infected, do not care to inherit.” Which was a “really unhelpful consult, stating he did not want to be involved.” Staff G did not think the wound was infected, it was too fresh. The antibiotic recommended required multiple doses to be effective, the plan was “useless.” The patient had previously met with an outside orthopedic group at Hospital E and Staff G contacted their on-call provider to discuss the patient’s care and needs. The outside Orthopedic Surgeon stated that “the current plan to clean the wound and follow up outpatient made no sense,” and he requested the patient was transferred to his care. Staff G, suspected the receiving provider took the patient to the operating room for a formal wash out, which was “pretty standard.” Staff G “absolutely” needed to ensure the patient had a short term follow up plan, that was why he consulted the outside Orthopedic Surgeon, looking for a safe plan. He could not confirm a solid and quick follow up plan with a doctor who said he did not want to inherit the patient. Staff G “could have pushed harder with Staff E who did not want to take care of the patient.” Staff G stated that “he could not in good conscience send the patient to a doctor who did not want to take care of him. Telling me he did not want to get involved.” Why subject a patient to a doctor with “crappy recommendations and refused follow-up?” The hospital was capable of performing a washout out with a physical evaluation from the Orthopedic Surgeon. The patient was transferred for an orthopedic evaluation. Staff G did not challenge Staff E because “he was not the most pleasant person and he had to continue working with him, and he was not receptive to consults.” During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that there was no formal process for Physicians to escalate patient care concerns to department Medical Directors. He felt Staff E, Orthopedic Surgeon, should have come in to evaluate the patient and followed up with the patient as an outpatient. It was a standard of care if a patient was greater than six weeks post operative, they were to be cared for by the available Physician, not the operating Physician. Staff E had the capability to care for Patient #43. During a telephone interview on 07/10/25 at 9:55 AM, Staff E, Orthopedic Surgeon, stated that Patient #43’s wound looked like a knee infection. He did not perform knee replacements and did not want to “inherit” an infected knee. He stated that the ED Physician wanted to “sew the knee”, he felt it was better to leave it open and have the patient return to his personal Orthopedic Surgeon. He was not informed the patient refused to return to the provider who performed the knee replacement or why the ED Physician consulted the Orthopedic Surgeon at Hospital E. He stated that it did not seem to him there was any reason for an emergent wash out. There was no purulent (pus) drainage. It looked like a wound dehiscence (separation of previously approximated wound edge, due to a failure of proper wound healing) of an older surgical site. During a telephone interview on 07/10/25 at 7:45 AM, Staff M, House Supervisor, stated that she reviewed Patient #43’s transfer paperwork. She did not know how much detail was provided to Staff E, Orthopedic Surgeon from Staff G, ED Physician. She did not understand why the patient was transferred when the specialist recommended a plan of care. If the ED Physician was not satisfied with the plan, he could have requested Staff E evaluate the patient face-to-face. Staff E did not come into the ED as often as other providers. The hospital had the capability of performing a formal wash out of the wound. Review of Patient #13’s ambulance report, dated 06/16/25, showed: - At 1:58 PM, EMS was dispatched to a motor vehicle accident (MVA). - The patient breathed normal and answered questions. - The patient had no loss of consciousness and did not have life threatening blood loss. - The patient was taken to the ED and report was given. Review of Patient #13’s medical record, dated 06/16/25, showed: - At 2:50 PM, he was a 21-year-old who arrived at the ED by EMS after an MVA where he suffered a deformed, left leg fracture. - The course narrative showed Patient #13 was a restrained driver of a vehicle that sideswiped a trailer going approximately 60 miles per hour, lost control of the vehicle and ended up in the ditch. - His left lower leg had an intact pulse, motor function and sensation, he had swelling to his right ankle without deformity, lip pain and cuts to both arms. - He had no acute (sudden onset) distress, was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time), was slow to answer some questions and his vital signs (VS, measurements of the body’s most basic functions) were normal. - At 3:18 PM, an x-ray of both ankles showed left mild to moderate tibia and fibula (lower leg bones) fractures. - At 3:39 PM, chest, abdomen, pelvis, cervical spine (, thoracic spine (middle portion of the spine), lumbar spine (lower back) and brain CT scans were negative. - At 4:00 PM, Staff E, Orthopedic Surgeon, was consulted and recommended to transfer the patient to a higher level of care. - At 4:08 PM, Staff E, ordered an inpatient admission, scheduled surgery, surgery consent form for intermediary nail placement (a surgical procedure used to stabilize and promote healing of long bone fractures) of the left tibia, no food or drink, social service consult for discharge planning, medications and blood laboratories - At 6:20 PM, the orders were cancelled due to discharge. - The patient was transferred to Hospital G. Review of Patient #13’s medical record from hospital B, dated 06/16/25, showed: - At 7:00 PM, he arrived at the ED. - He was admitted to the medical-surgical unit. - On 06/17/25 at 1:00 PM, he had a nail fixation of his left tibia. - On 06/18/25, he was discharged home. During an interview on 07/01/25 at 12:15 PM, Staff D, ED Physician, stated that he consulted Staff E, Orthopedic Surgeon, via text message for patient admission with photographs of Patient #13’s injury for review. Staff E requested a transfer to Springfield, MO, though Staff E did not provide an explanation in regard to the requested destination. Staff D stated historically, Staff E’s reasoning was the patient needed a traumatologist (surgeon who specializes in the treatment of severe, acute physical injuries caused by accidents or violence). He explained to Staff E, Springfield was not accepting transfers throughout the day and the patient may have to go to Kansas City. He then proceeded with locating an accepting facility. Hospital G, in Springfield, accepted the patient, because he was a trauma, and transfer paperwork was initiated. Moments later, he was notified the operating room personnel were prepared to take the patient for surgery. He reached out to Staff E for clarification and notified him of the patient’s transfer acceptance to Hospital G, in Springfield. Staff E told him to continue with the transfer and cancelled the surgery. During a telephone interview on 07/01/25 at 12:45 PM, Staff E, Orthopedic Surgeon, stated that the patient needed a tibial nail, and he had not performed that procedure in three to four years. He was told Springfield did not have any beds and he did not think the patient should have to travel all the way to Kansas City for the procedure. He felt it was in the best interests of the patient to transfer to Hospital G where surgeons performed that type of procedure multiple times a day. He did not speak to the patient to discuss the options available. During an interview on 07/02/25 at 8:20 AM, Staff G, ED Physician, stated that sometimes they transferred patients they could keep depending on “dynamics.” The Hospitalists justified transfers because the patient might get worse. The ED physicians were blocked from admitting patients that could be cared for in the hospital and were given barriers to jump through to get patients admitted. During a telephone interview on 07/10/25 at 2:00 PM, Staff Q, Chief Executive Officer (CEO), stated that he was aware of the admission process conflict between the ED Physicians and the Hospitalists. His thoughts were the ED had a significantly increased volume over recent years. The ED capacity was 12 beds and saw over 20,000 patients annually. The ED worked “really hard” with patient movement from the ED. They were pressed for time and space and looked for quick patient transitions. The Hospitalist program had grown in complexity over the previous 10 years. The Hospitalists had different opinions regarding patient admissions which resulted in push back to the ED Physicians. The question was what “was the hospital looking at, and did they have the capability to meet the patient’s needs.” He thought the hospitalists tried to think of too many “what ifs,” and were reluctant to admit “in case” the patient required a higher level of care once admitted. The concerns had been elevated to him and a transfer meeting was established to review the transfers and determine if the hospital was capable of caring for the transferred patient. He believed transferring patients was a “real problem.” Patients and their families were inconvenienced by transfers. He expected the medical staff to follow the By-Laws and perform a physical evaluation if requested by the ED Physician. He expected support from specialist when the ED Physicians requested support. He expected all staff to do what was best for the patient. He was not surprised that was not the consistent practice. He felt the hospital had very good Physicians with a broken process and trust that needed rebuilt. He expected event reports (a staff report of an unexpected occurrence) were created when an ED Physician felt there was an Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition) violation. The event report was reviewed, possibly leading to a Root Cause Analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) that allowed the hospital to identify opportunities for improvement. He was concerned the Physicians needed education on the reporting process. He believed there was fault with both the ED Physicians and the Hospitalists, they tried to accomplish different goals. The hospital needed a way to manage disputes in real time, “not what should have been done.” During a telephone interview on 07/10/25, at 3:00 PM, Staff R, ED Medical Director, stated that he felt the hospital had an “epidemic” of EMTALA violations. He had exchanged multiple emails with administration regarding the violations. The Chief Operating Officer (COO) was aware for over one year and had “chosen to do nothing.” The medical staff did not receive “real” EMTALA education. They played a game of “Jeopardy” every year. He believed there were “probably” 40 EMTALA violations over the last six months. Patients were transferred 10 times more then they needed to be. Staff J, Hospitalist, averaged two transfer EMTALA violations per day. He believed the gravity of the situation would not hit home unless the Centers for Medicare & Medicaid Services (CMS) issued fines. If Physicians were not going to meet their privileges expectations the hospital needed to correct their privileges and establish transfer agreements for those diagnosis/treatments not included in the actual care Physicians provided. He had “many” discussions with the COO in regard to conflicting opinions for patients plans of care and was told to direct the Physicians to contact the COO, 24 hours a day seven days a week. After one week the COO instructed the Physician’s to stop calling and quit answering the phone because he received too many calls. During a telephone interview on 07/09/25, at 12:00 PM, Staff G, ED Physician, stated that his practice was to forward EMTALA concerns to the ED Medical Director. He did not know who the Compliance Officer was. The situation at the hospital was “exhausting, every time he went to work with Staff J, Hospitalist.” He was a single provider in a busy ED, he could have up to 20 patients and did not have time to spar with a consultant who did not want to take care of patients and refused. Administration did not feel empowered to tell doctors to care for patients. If doctors refuse, administration did not challenge. That was a recurring theme. During a telephone interview on 07/10/25, at 10:30 AM, Staff T, COO, stated that he believed there were a couple of “dynamics” in play at the hospital. The ED had seen considerable increase in volume and acuity in recent months. A lot of ED patients were boarded for extended periods of time due to a number of different reasons. There was not enough supply to meet the demand, not enough beds available for admissions. The ED Physicians felt pressure to move patients through the hospital to a disposition location. The Hospitalists had a mind set of “how it was a long time ago” without specialist support, the question was could the hospital care for patients if a critical issue arose. In spite of adding specialist in the fields of Pulmonology, Nephrology (the branch of medicine that deals with the kidneys, especially their functions or diseases) and Cardiac Intervention (a heart doctor who specializes in fixing the heart and blood vessels), which increased the capability of the hospital. The Hospitalists were “still very protective and concerned the hospital could not ultimately care for the patient.” Administration informed the Hospitalists they wanted what was best for the patient but could not operate on the “what ifs.” The relationship between the ED Physicians and the Hospitalists had deteriorated “to the principle of the thing. The Physicians were going to make a point.” Administration had multiple meetings with Physicians, reviewed transfer decisions to find “common ground” and created a new House Supervisor position in the ED for improved bed availability communication. The ED Physicians felt the Hospitalists would not admit patients, and the Hospitalists felt the ED Physicians wanted to admit every patient. He agreed with the CNO’s opinion that Physician’s egos played a part in the Physician’s decision making. The two Physician groups were not receptive to solutions. The message from administration to the Hospitalists was if he/she disagreed with the ED Physician’s plan for admission, the Hospitalist was to perform a face-to-face assessment of the patient. That expectation was written in the By-Laws. He was not aware those face-to-face assessments were not consistently performed. He expected the ED Physician to consult the Chief Medical Officer (CMO) or the specialty Medical Director if he/she had a conflict with the on-call specialist’s plan of care. Administration asked the Physician’s to look at what was the immediate problem, the right now, not what could happen, and take care of the patient. He felt administration was “empowered” to direct Physicians but there was an issue with the Physician’s receptiveness. He stated that he saw improvement after the meetings, but the improvement deteriorated over time. Obviously, administration was not successful with their attempted approaches to get the two Physicians groups together. A consulting group was scheduled to assist in hopes that administration was “missing something.” During a telephone interview on 07/10/25, at 9:00 AM, Staff N, CNO, stated that she was “very aware” of the conflict between the ED Physicians and the Hospitalists. She was not directly involved but worked closely with the Medical Executive Committee (MEC) and the CEO. The hospital recently established a “transfer committee” to meet monthly for ED transfer reviews. The hospital had a 15% ED transfer rate and 1% was related to the lack of ICU bed availability. She believed the issue came down to “poor communication and egos. Egos were getting in the way of the process.” Some of the concerns brought up at the meeting were sent to peer review. The hospital had a “robust” internal process with an engaged MEC and CMO for concerns. There was a “very streamlined” peer review process for physician concerns. The hospital worked to improve the ED patient’s transitions through the hospital. A day House Supervisor position was recently created to improve physician awareness of bed availability. The hospital acquired an Intensivist (a doctor who specializes in caring for patients with severe or life-threatening illnesses or injuries) in 04/2025, who provided daytime coverage. Without the intensivist coverage the Hospitalists recommended increased testing for ED patients to assist with making the correct decision for admission versus transfer. The patient’s disposition decision was based on firsthand information regarding if the hospital could provide the level of care the patient required. She believed most of the ED Physicians came from trauma centers and were new to the limitations of rural healthcare. Conflict resolution took time. She believed the Physician’s felt the hospital was not moving fast enough, and a complaint was filed with the State Office. She did not feel the hospital had any EMTALA violations. She believed citations from this survey were going to fuel the egos of one of the sides of the conflict. During a telephone interview on 07/10/25, at 9:30 AM, Staff O, ED Manager, stated that there was conflict between the ED Physicians and the Hospitalists. The ED Physicians report the patient’s information to the Hospitalists and there was conflict if the hospital had the capability and capacity to manage the patient as an inpatient. The ED Physicians believed the patient could be admitted and the Hospitalists believed the patient needed to be transferred to a higher level of care. There once was a loud verbal exchange in the ED between an ED Physician and a Hospitalist, administration had to get involved to mitigate the situation. The hospital had no “clear cut” written admission and/or transfer criteria. The ED nursing staff’s main focus was to immediately stabilize patients, and the nurses trust the ED Physicians and Hospitalist to make the correct disposition decisions. The nurses advocated for patient’s and the ED Medical Director provided his opinion on the transfers. It was not “uncommon” for the ED to board patients until a room became available. Sometimes, patients were boarded for a longer period of time based on the acuity of patients in the ICU. 51509”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 39840 Based on observation, interview and policy review, the hospital failed to ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients and failed to perform daily checks on the crash cart (mobile cart which contains emergency medical supplies and medication). This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 11/20/24, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were educated on telemetry monitoring and the need for constant observation. All remaining staff were educated prior to the start of their next shift. Please refer to A-0144.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 39354 Based on observation, interview and policy review, the hospital failed to ensure designated continuous telemetry (remote observation of a person’s heart rhythm, using signals that are transmitted from the patient to a computer screen) monitoring observation for all telemetry monitored patients and failed to perform daily checks on the crash cart (mobile cart which contains emergency medical supplies and medication). Findings included: 1. Review of the hospital’s policy titled, “Guidelines for Care in Intensive Care (ICU, a unit where critically ill patients are cared for)/Telemetry Unit,” dated 01/2024, showed cardiac rhythm will be monitored continuously. Observation on 11/18/24 at 2:12 PM, in the ICU and Telemetry Unit, showed eleven patients (#1, #2, #11, #12, #13, #14, #15, #16, #17, #18, and #20) on the telemetry monitor with no staff present to observe the monitor. During an interview on 11/18/24 at 2:15 PM, Staff B, Physician, seated alone at the nurses’ station, stated that he was not responsible for watching the telemetry monitors. During an interview on 11/18/24 at 2:13 PM, Staff A, ICU/Telemetry Director, stated that the Unit Clerk or Patient Care Technician (PCT) should constantly watch the telemetry monitors. During an interview on 11/18/24 at 2:25 PM, Staff C, Unit Clerk/PCT, stated that she was responsible for watching the telemetry monitors and there was always someone to relieve her. During an interview on 11/19/24 at 12:12 PM, Staff AA, Professional Excellence Coordinator, stated that the ICU watched the telemetry for the medical/surgical (Med/Surg) unit. There was no specific person to monitor the telemetry, it was just monitored by whoever was at the nurses’ desk. During an interview on 11/9/24 at 2:35 PM, Staff Y, Chief Nursing Officer (CNO), stated that the hospital no longer had telemetry monitor technicians. They had not had monitor technicians for about six years. In the ICU and on the telemetry floor/space, there was central monitoring at the nurses’ station. The ICU could see all patients on telemetry. There was no dedicated person to monitor telemetry, everyone was responsible for monitoring it. The PCTs and the unit clerks were trained to notify the nurse if the telemetry alarmed. The RNs and LPNs went through basic and advanced telemetry arrhythmia (irregular heartbeat) training. 2. Review of the hospital’s policy titled, “Code/Procedure Carts and Airway Boxes,” dated 09/2024, showed the crash cart check was to be completed daily. Review of the hospital’s document titled, “Adult Code Cart Checklist,” dated 11/2024, showed missing daily checks on 11/03, 11/05, 11/10, 11/14, 11/15 and 11/16. Review of the hospital’s pediatric code cart document titled, “Broselow Checklist,” dated 11/2024, showed missing daily checks on 11/03, 11/05, 11/10, 11/14, 11/15 and 11/16. During an interview on 11/18/24 at 2:00 PM, Staff W, Med/Surg Director, stated that crash carts were to be checked daily. During an interview on 11/20/24 at 10:04 AM, Staff Y, CNO, stated that the crash carts were to be checked daily. 39840 51509”

“INFECTION CONTROL PROGRAM CFR(s): 482.42(a)(1) The hospital infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the hospital and between the hospital and other institutions and settings; This Standard is not met as evidenced by: 39354 Based on observation, interview and policy review, the hospital failed to: label the intravenous (IV, in the vein) site for 11 patients (#1, #2, #3, #7, #10, #21, #22, #23, #24, #25, and #26) of 12 patients observed and label the IV tubing for 11 patients (#1, #2, #3, #7, #10, #19, #22, #23, #24, #25, and #26) of 12 patients observed. Findings included: 1. Review of the hospital’s policy titled, “IV Venipuncture, Initiation of IV Fluids,” dated 10/2022, showed the dressing should be labeled and include the date and time of the IV insertion, gauge, and nurse’s initials. Observation on 11/18/24 at 2:17 PM, showed no label on the IV dressing for Patient #1. Observation on 11/18/24 at 2:30 PM, showed no labels on two IV dressings for Patient #2. Observation on 11/18/24 at 3:10 PM, showed no label on the IV dressing for Patient #3. Observation on 11/19/24 at 8:30 AM, showed no label on the IV dressing for Patient #7. Observation on 11/18/24 at 3:08 PM, showed no label on the IV dressing for Patient #10. Observation on 11/19/24 at 9:10 AM, showed no labels on two IV dressings for Patient #21. Observation on 11/19/24 at 9:45 AM, showed no labels on two IV dressings for Patient #22. Observation on 11/19/24 at 8:45 AM, showed no label on the IV dressing for Patient #23. Observation on 11/19/24 at 10:23 AM, showed no labels on two IV dressings for Patient #24. Observation on 11/19/24 at 10:00 AM, showed no labels on two IV dressings for Patient #25. Observation on 11/19/24 at 12:05 PM, showed no labels on two IV dressings for Patient #26. During an interview on 11/18/24 at 3:18 PM, Staff M, Registered Nurse (RN), stated that IV dressings should be labeled with date, time and initials. During an interview on 11/20/24 at 10:04 AM, Staff Y, Chief Nursing Officer (CNO), stated that she expected IV dressings to be labeled according to hospital policy. 2. Review of the hospital’s policy titled, “IV Therapy Guidelines,” dated 11/2022, showed the IV tubing should be labeled with the date and time of change and the initials of the nursing personnel that changed the tubing. Observation on 11/18/24 at 2:17 PM, showed no label on the IV tubing for Patient #1. Observation on 11/18/24 at 2:30 PM, showed no labels on two IV tubing for Patient #2. Observation on 11/18/24 at 3:10 PM, showed no label on the IV tubing for Patient #3. Observation on 11/19/24 at 8:50 AM, showed no label on the IV tubing for Patient #7. Observation on 11/19/24 at 9:00 AM, showed no label on the IV tubing for Patient #10. Observation on 11/19/24 at 9:30 AM, showed no label on the IV tubing for Patient #19. Observation on 11/19/24 at 9:45 AM, showed no label on the IV tubing for Patient #22. Observation on 11/19/24 at 8:45 AM, showed no labels on three IV tubing for Patient #23. Observation on 11/19/24 at 10:23 AM, showed no labels on two IV tubing for Patient #24. Observation on 11/19/24 at 10:00 AM, showed no labels on two IV tubing for Patient #25. Observation on 11/19/24 at 12:05 PM, showed no labels on two IV tubing for Patient #26. During an interview at 9:55 AM, Staff N, Licensed Practical Nurse (LPN), stated that the IV tubing should always be labeled. During an interview on 11/20/24 at 10:04 AM, Staff Y, CNO, stated that she expected IV tubing to be labeled according to hospital policy. 39840 51509”

“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: 41865 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 24 Emergency Department (ED) records reviewed from 10/01/23 through 05/19/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC). Findings included: Review of hospital policy, “Medical Screening Exam,” dated 04/2021, showed once a patient enters a Citizen’s Memorial Hospital (CMH)-owned ambulance, the patient is considered as presented to hospital property and should be transported to CMH’s ED, provided a MSE and stabilizing treatment within the hospital’s capability and capacity. The hospital is obligated to provide an MSE so the presence of an EMC, or lack thereof, can be identified. Review of hospital policy, “Ambulance Medical Control,” dated 12/2022, showed whenever medical control of patient care is required during an emergency, it should be provided by the Emergency Room physician at the receiving hospital. Review of the hospital’s online Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) protocol, “Trauma Arrest,” revised 03/19/23, showed that for the adult trauma patient, with a narrow complex pulseless electrical activity (PEA, where the electrocardiogram [record of the electrical signal from the heart] shows a heart rhythm that should produce a pulse, but does not) rhythm, resuscitation efforts should not be terminated in the field. Review of Patient #23’s EMS Trip Ticket, dated 04/14/24 showed the following: - At 10:40 PM, EMS was dispatched to the scene of a gunshot wound (GSW) to the head in cardiac arrest (when the heart suddenly and unexpectedly stops pumping). - At 10:55 PM, EMS arrived on scene. - At 10:59 PM, intubation (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) was attempted but unsuccessful. He lost his pulse and cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) was initiated. - At 11:08 PM, he was successfully intubated. - At 11:16 PM, CPR was stopped. Patient #23 was in a sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) with a heart rate of 127 bpm. - At 11:21 PM, transport to CMH ED began. - At 11:27 PM, he went into cardiac arrest again and CPR was initiated. - The patient did not receive defibrillation (Delivers an electric shock to the heart to allow it to get out of a potentially fatal abnormal heart rhythm). - At 11:32 PM, Patient #23 was in ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden cardiac death). Resuscitation was terminated and patient’s time of death was 11:32 PM. - A non-timed narrative entered by Staff R, Paramedic, showed Staff H, EMS Regional Manager, rode in the ambulance with the patient. During transport, Staff H called CMH for report. During Staff H’s call to the ED, Patient #23 lost pulses and CPR was restarted. Staff H ended the call. Staff H then called the ED back and requested to speak to Medical Control. During this call, the patient was in PEA without a pulse. Staff H informed the EMS crew to stop CPR as directed by Medical Control. CPR was discontinued approximately one minute before the ambulance arrived at the ED. After CPR was discontinued, Staff R felt she could feel a thready pulse and found the patient was in a bradycardic (slow heart rate) rhythm. When EMS arrived at the ED, Staff H entered the ED to speak with the physician. It was requested that the physician come out and evaluate the patient. Staff H then returned to the ambulance and stated Staff M, Physician, and Staff L, Charge Registered Nurse (RN) refused to allow the patient in the ED since he had already died. The patient remained in the ambulance until the Polk County coroner arrived on scene.”

“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: 50151 Based on interview, record review and policy review, the hospital failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#23) of 24 Emergency Department (ED) records reviewed from 10/01/23 through 05/19/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC). Findings included: Review of hospital policy, “Medical Screening Exam,” dated 04/2021, showed once a patient enters a Citizen’s Memorial Hospital (CMH)-owned ambulance, the patient is considered as presented to hospital property and should be transported to CMH’s ED, provided a MSE and stabilizing treatment within the hospital’s capability and capacity. The hospital is obligated to provide an MSE so the presence of an EMC, or lack thereof, can be identified. Review of hospital policy, “Ambulance Medical Control,” dated 12/2022, showed whenever medical control of patient care is required during an emergency, it should be provided by the Emergency Room physician at the receiving hospital. Review of the hospital’s online Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) protocol, “Trauma Arrest,” revised 03/19/23, showed that for the adult trauma patient, with a narrow complex pulseless electrical activity (PEA, where the electrocardiogram [record of the electrical signal from the heart] shows a heart rhythm that should produce a pulse, but does not) rhythm, resuscitation efforts should not be terminated in the field. Review of Patient #23’s EMS Trip Ticket, dated 04/14/24 showed: - At 10:40 PM, EMS was dispatched to the scene of a gunshot wound (GSW) to the head in cardiac arrest (when the heart suddenly and unexpectedly stops pumping). CMH ED activated their trauma team. - At 10:55 PM, EMS arrived on scene. - At 10:59 PM, intubation (process where a healthcare provider inserts a tube through a person’s mouth or nose down into their windpipe when a person is not breathing on their own) was attempted but unsuccessful. He lost his pulse and cardiopulmonary resuscitation (CPR, emergency life-saving procedure performed when a person’s breathing or heartbeat has stopped) was initiated. - At 11:05 PM, intubation was attempted again, but unsuccessful. CPR continued. - At 11:08 PM, he was successfully intubated. - At 11:14 PM, 1 milligram (mg) epinephrine (a hormone and medication used along with emergency medical treatment to treat life-threatening conditions) was administered. - At 11:16 PM, CPR was stopped. Patient #23 was in a sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) with a heart rate of 127 bpm. - At 11:21 PM, transport to CMH ED began. - At 11:27 PM, he went into cardiac arrest and CPR was initiated. - The patient did not receive defibrillation (Delivers an electric shock to the heart to allow it to get out of a potentially fatal abnormal heart rhythm). - At 11:32 PM, Patient #23 was in ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden cardiac death). Resuscitation was terminated and patient’s time of death was 11:32 PM. - A non-timed narrative entered by Staff R, Paramedic, showed Staff H, EMS Regional Manager, rode in the ambulance with the patient. During transport, Staff H called CMH for report. During Staff H’s call to the ED, Patient #23 lost pulses and CPR was restarted. Staff H ended the call. Staff H then called the ED back and requested to speak to Medical Control. During this call, the patient was in PEA without a pulse. Staff H informed the EMS crew to stop CPR as directed by Medical Control. CPR was discontinued approximately one minute before the ambulance arrived at the ED. After CPR was discontinued, Staff R felt she could feel a thready pulse and found the patient was in a bradycardic (slow heart rate) rhythm. When EMS arrived at the ED, Staff H entered the ED to speak with the physician. It was requested that the physician come out and evaluate the patient. Staff H then returned to the ambulance and stated Staff M, Physician, and Staff L, Charge Registered Nurse (RN) refused to allow the patient in the ED since he had already died. The patient remained in the ambulance until the Polk County coroner arrived on scene. Although requested, Staff P, Trauma Surgeon, was out of the country and could not be reached for an interview. During an interview on 05/22/24 at 11:30 AM, Staff R, Paramedic, stated that Staff H, EMS Regional Manager called the ED for report while Patient #23 was being transported. The first call ended prematurely because Patient #23 had lost his pulse and resuscitation efforts had to be restarted. At some point during resuscitation efforts, Staff H made a second call to the ED and requested to speak to Medical Control. Staff H informed them that per Medical Control and the trauma surgeon on-call, resuscitation efforts needed to be stopped. CPR was stopped and was not being performed when they arrived at the hospital. Staff H entered the hospital when they arrived and when he returned to the ambulance, he informed them that the ED would not take the patient. She stated that she instructed Staff H to go back into the ED and request the physician come out to have the patient evaluated. When Staff H returned to the ambulance for the second time, he stated that they would not take the patient. She felt Patient #23 was denied entry into the ED, but she did not go into the ED herself and make a request for Patient #23 to be evaluated. She had no direct communication with the ED staff or physician about the patient, during transport or when they arrived at the ED. During an interview on 05/21/24 at 10:45 AM, Staff H, EMS Regional Manager, stated that during transport, he called the ED to give report on the patient. At that time the patient had a pulse. While he was still on the phone, the patient lost his pulse and CPR was restarted, so he abruptly ended the call to tend to the patient. Once he felt the other EMS crew had the situation under control, he called the ED back and requested to speak to Medical Control. During the second call, it was decided by Staff M, Physician, in consultation with the on-call trauma surgeon, to have resuscitation efforts terminated. When they arrived at the ED, he stated that Staff L, Charge RN, instructed him to not bring Patient #23 into the ED as they did not want to complete paperwork associated with a patient death. During a telephone interview on 05/21/24 at 2:45 PM, Staff L, Charge RN, stated that she received two phone calls from EMS about Patient #23. During the first call, EMS provided her with a patient report, but the call was prematurely ended. During the second call, Staff H requested to speak with Medical Control, so she connected Staff H to Staff M, Physician. Shortly after that call, Staff H entered the ED and asked, “What do you want us to do with the dead body?” Staff L stated that it was never mentioned that Patient #23 had achieved return of spontaneous circulation (ROSC) or had any signs of life. During a telephone interview on 05/21/24 at 3:10 PM, Staff M, Physician, stated that he received a call for Medical Control of Patient #23. When he spoke with Staff H, he was informed that the patient had a GSW to the head, in PEA, and that resuscitation efforts had been underway for 30 minutes. He consulted Staff P, Trauma Surgeon, who instructed him to have resuscitation efforts terminated. When the ambulance arrived at the ED, Staff H entered and asked, “What do you want us to do with the body?” Staff M was not informed that the patient was not deceased, that the patient had a pulse, or any signs of life. He was under the impression that resuscitation efforts were discontinued while en route and Patient #23 had died prior to his arrival at the ED. No paramedics came into the ED and requested that he go out to the ambulance to assess the patient for potential signs of life. He stated that EMS did not typically leave a patient in the ambulance to enter the ED and request a physician come out to the ambulance and perform a MSE. EMS brought patients into the ED, so an MSE could be performed, and stabilizing treatment provided, if applicable. Staff M stated that if it had been requested, he would have gone out to the ambulance and evaluated the patient.”

“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: 49404 Based on interview, record review, and policy review, the hospital failed to ensure that emergency medical conditions (EMC) were stabilized for two patients (#23 and #24) out of 24 Emergency Department (ED) sample cases reviewed from 10/01/23 through 05/19/24, when they were discharged or transferred with unstable medical conditions. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for and Emergency Medical Condition (EMC). Findings included: Review of the hospital’s policy titled, “Ambulance Medical Control,” dated 12/2022, showed that whenever medical control of patient care was required during an emergency, it should be provided by the ED physician at the receiving hospital. Review of the hospital’s online Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) protocol titled, “Trauma Arrest,” revised 03/19/23, showed that for the adult trauma patient, with a narrow complex pulseless electrical activity (PEA, where the electrocardiogram [record of the electrical signal from the heart] shows a heart rhythm that should produce a pulse, but does not) rhythm, resuscitation efforts should not be terminated in the field. Review of the hospital’s online EMS Protocol, “Cardiac Arrest,” revised 04/27/23, showed for victims of trauma with no signs of life, field termination of resuscitation efforts may be requested from Medical Control. Field termination of resuscitation efforts may be requested regardless of how long resuscitation efforts have been underway. Review of Patient #23’s EMS Trip Ticket, dated 04/14/24 showed: - At 11:16 PM, Patient #23 was in a sinus tachycardia (an increased heart rate that exceeds 100 beats per minute [bpm]) with a heart rate of 127 bpm with a pulse. The patient was prepared and moved to the ambulance. - At 11:21 PM, Patient #23 was secured in the ambulance and transported to Citizens Memorial Hospital’s (CMH) ED. - At 11:27 PM, Patient #23 went into cardiac arrest and CPR was initiated. - The patient did not receive defibrillation (delivers an electric shock to the heart to allow it to get out of a potentially fatal abnormal heart rhythm). - At 11:32 PM, Patient #23 was in ventricular fibrillation (V-Fib, an abnormal heart rhythm that can lead to sudden cardiac death). Resuscitation was terminated and patient’s time of death was 11:32 PM. - A non-timed narrative entered by Staff R, Paramedic, showed Staff H, EMS Regional Manager, rode in the ambulance with the patient. During transport, Staff H called CMH for report. During Staff H’s call to the ED, Patient #23 lost pulses and CPR was restarted, so Staff H ended the call. Staff H then called the ED back and requested to speak to Medical Control. During this call, the patient was in PEA without a pulse. Staff H informed the EMS crew to stop CPR as directed by Medical Control. CPR was discontinued approximately one minute before the ambulance arrived at the ED. After CPR was discontinued, Staff R felt she could feel a thready pulse and found the patient was in a bradycardic (slow heart rate) rhythm. When EMS arrived at the ED, Staff H entered the ED to speak with the physician. It was requested that the physician come out and evaluate the patient. Staff H then returned to the ambulance and stated Staff M, Physician, and Staff L, Charge Registered Nurse (RN) refused to allow the patient in the ED since he had already died. The patient remained in the ambulance until the Polk County coroner arrived on scene. Although requested, Staff P, Trauma Surgeon, was out of the country and could not be reached for an interview. During an interview on 05/22/24 at 11:30 AM, Staff R, Paramedic, stated that Staff H, EMS Regional Manager called the ED for report while Patient #23 was being transported. The first call ended prematurely because Patient #23 had lost his pulse and resuscitation efforts had to be restarted. At some point during resuscitation efforts, Staff H made a second call to the ED and requested to speak to Medical Control. Staff H informed them that per Medical Control and the trauma surgeon on-call, resuscitation efforts needed to be stopped. CPR was stopped and was not being performed when they arrived at the hospital. Staff H entered the hospital when they arrived and when he returned to the ambulance, he informed them that the ED would not take the patient. She stated that she instructed Staff H to go back into the ED and request the physician come out to have the patient evaluated. When Staff H returned to the ambulance for the second time, he stated that they would not take the patient. She felt Patient #23 was denied entry into the ED, but she did not go into the ED herself and make a request for Patient #23 to be evaluated. She had no direct communication with the ED staff or physician about the patient, during transport or when they arrived at the ED. During an interview on 05/21/24 at 10:45 AM, Staff H, EMS Regional Manager, stated that during transport, he called the ED to give report on the patient. At that time the patient had a pulse. While he was still on the phone, the patient lost his pulse and CPR was restarted, so he abruptly ended the call to tend to the patient. Once he felt the other EMS crew had the situation under control, he called the ED back and requested to speak to Medical Control. During the second call, it was decided by Staff M, Physician, in consultation with the on-call trauma surgeon, to have resuscitation efforts terminated. When they arrived at the ED, he stated that Staff L, Charge RN, instructed him to not bring Patient #23 into the ED as they did not want to complete paperwork associated with a patient death. During a telephone interview on 05/21/24 at 2:45 PM, Staff L, Charge RN, stated that she received two phone calls from EMS about Patient #23. During the first call, EMS provided her with a patient report, but the call was prematurely ended. During the second call, Staff H requested to speak with Medical Control, so she connected Staff H to Staff M, Physician. Shortly after that call, Staff H entered the ED and asked, “What do you want us to do with the dead body?” Staff L stated that it was never mentioned that Patient #23 had achieved return of spontaneous circulation (ROSC) or had any signs of life. During a telephone interview on 05/21/24 at 3:10 PM, Staff M, Physician, stated that he received a call for Medical Control of Patient #23. When he spoke with Staff H, he was informed that the patient had a GSW to the head, in PEA, and that resuscitation efforts had been underway for 30 minutes. He consulted Staff P, Trauma Surgeon, who instructed him to have resuscitation efforts terminated. When the ambulance arrived at the ED, Staff H entered and asked, “What do you want us to do with the body?” Staff M was not informed that the patient was not deceased, that the patient had a pulse, or any signs of life. He was under the impression that resuscitation efforts were discontinued while en route and Patient #23 had died prior to his arrival at the ED. No paramedics came into the ED and requested that he go out to the ambulance to assess the patient for potential signs of life. He stated that EMS did not typically leave a patient in the ambulance to enter the ED and request a physician come out to the ambulance and perform a MSE. EMS brought patients into the ED, so an MSE could be performed, and stabilizing treatment provided, if applicable. Staff M stated that if it had been requested, he would have gone out to the ambulance and evaluated the patient. Review of Patient #24’s medical record from Hospital B, dated 10/07/24, showed: - She was an 81-year-old female with a history of dementia (a loss of thinking abilities and memory) who was brought to the ED by police, on 10/06/23, for a psychiatric (relating to mental illness) evaluation after exhibiting erratic behavior. She was placed on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others). - The patient was medically cleared for transfer to a psychiatric facility. - Hospital B contacted CMH and the patient was accepted for admission to the geriatric psychiatric (Geropsych, a unit that focuses on treating mental health and psychiatric disorders in older adults) unit and given a room assignment. Transport was scheduled with the Vernon County Ambulance District (VCAD). - VCAD picked up the patient at approximately 9:00 AM. At 10:09 AM Hospital B was notified that a physician at CMH refused the transfer. VCAD returned with the patient to Hospital B where she was re-evaluated in the ED and held for placement in another facility. Review of Patient #24’s VCAD’s Patient Care Report, dated 10/07/24, showed the patient was picked up from Hospital B at 9:19 AM and transported to CMH. Upon arrival they were informed by hospital staff that the patient would not be accepted. VCAD staff waited while the ED physician contacted Hospital B. They were instructed by Hospital B to return with the patient. The patient’s vital signs were recorded at regular intervals throughout the trip. During an interview on 05/21/24 at 3:05 PM, Staff N, VCAD Emergency Medical Technician (EMT), stated he transported the patient from Hospital B to CMH. He stated that upon arrival the hospital wouldn’t accept the patient and they were instructed by Hospital B to return with the patient. He stated that the patient’s condition remained unchanged during the trip and didn’t require medical intervention. The patient remained in the ambulance. Review of Patient #24’s medical record, dated 10/07/23, showed only the patient’s registration information including address, allergies, diagnosis, insurance information and family contacts. During an interview on 05/22/24 at 9:30 AM, Staff D, Nursing Operations Director, stated that the hospital’s review of Patient #24’s transfer request showed: - Hospital B requested a transfer to CMH’s geropsych unit on 10/06/24. - The hospital accepted the patient at approximately 3:00 AM on 10/07/24 and began completing registration information in the hospital’s electronic medical record. - The acceptance was not communicated to the oncoming shift. - EMS arrived at the hospital’s ambulance bay with the patient at approximately 10:00 AM on 10/07/24. The geropsych unit was unaware of the transfer and refused to accept the patient. The ED physician was notified of the patient’s presence but with no knowledge of the transfer was concerned it could be patient dumping. - The ED physician consulted with hospital administration and decided to contact Hospital B to discuss placement. If a solution had not been reached with Hospital B the patient would have been evaluated by CMH’s ED staff. Hospital B was contacted and agreed to have the patient returned by EMS. - The patient was transported by EMS back to Hospital B.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 49404 Based on interview, policy review and record review, the hospital failed to accept one patient (#24) from another hospital out of 24 Emergency Department (ED) records reviewed. The hospital’s ED average monthly census over the past six months was 1,269. Findings included: Review of Patient #24’s medical record from Hospital B, dated 10/07/24, showed: - She was an 81-year-old female with a history of dementia (a loss of thinking abilities and memory) who was brought to the ED by police on 10/06/23 for a psychiatric (relating to mental illness) evaluation after exhibiting erratic behavior. She was placed on a 96-hour hold (court-ordered evaluation by behavioral specialists to determine if a person is safe to themselves and others). - The ED physician completed a medical screening examination (MSE) and recommended placement in a geriatric facility and her guardian agreed. - The patient was medically cleared for transfer to a psychiatric facility. - Hospital B contacted several facilities for placement and the patient was accepted for admission to Citizen’s Memorial Hospital’s (CMH) geropsych unit on 10/07/24 at 2:30 AM and given a room assignment. Her RN called CMH and gave a report to the receiving nurse and scheduled transportation with the Vernon County Ambulance District (VCAD). - VCAD picked up the patient at approximately 9:00 AM. At 10:09 AM, Hospital B was notified that a physician at CMH had refused the transfer. VCAD returned with the patient to Hospital B where she was re-evaluated in the ED and held for placement in another facility. Review of Patient #24’s CMH medical record, dated 10/07/23, showed only the patient’s registration information including address, allergies, diagnosis, insurance information and family contacts. Review of Patient #24’s VCAD’s Patient Care Report, dated 10/07/24, showed the patient was picked up from Hospital B by EMS at 9:19 AM and transported to CMH. Upon arrival they were informed by CMH staff that the patient would not be accepted. VCAD staff waited while the ED physician contacted Hospital B. They were then instructed by Hospital B to return with the patient. During an interview on 05/21/24 at 3:05 PM, Staff N, VCAD EMT, stated that he transported the patient from Hospital B to CMH. He stated that upon arrival, CMH wouldn’t accept the patient due to a problem with the patient’s legal guardianship and that they were instructed by Hospital B to return with the patient. During an interview on 05/22/24 at 9:30 AM, Staff D, Nursing Operations Director, stated that the hospital’s review of Patient #24’s transfer request showed: - Hospital B requested a transfer to CMH’s geropsych unit on 10/06/24. - The hospital accepted the patient at approximately 3:00 AM on 10/07/24 and began completing registration information in the hospital’s electronic medical record. It was unclear if all admission requirements were met, including the hospital speaking with the patient’s legal guardian to obtain consent to admit her. The hospital did not have documentation of the patient’s legal guardianship. - The acceptance was not communicated to the oncoming shift. - EMS arrived at the hospital’s ambulance bay with the patient at approximately 10:00 AM on 10/07/24. The geropsych unit was unaware of the transfer and refused to accept the patient. The ED physician was notified of the patient’s presence but with no knowledge of the transfer was concerned it could be patient dumping. - Staff present overnight when the transfer was requested were not contacted for clarification. - The ED physician consulted with hospital administration and decided to contact Hospital B to discuss placement. Hospital B was contacted and agreed to have the patient returned by EMS. - The patient was transported by EMS back to Hospital B. During an interview on 05/21/24 at 11:15 AM, Staff G, Geriatric Psychiatry Department Supervisor, stated that she did not recall patient #24. During a telephone interview on 05/21/24 at 11:00 AM, Staff I, Physician, stated that he did not recall Patient #24. Patients that had been medically cleared were admitted directly to the geriatric psychiatric unit. During an interview on 05/20/24 at 3:35 PM, Staff D, Nursing Operations Director, stated that transfer patients that are medically cleared prior to arrival were admitted directly to the geriatric psychiatric unit. During an interview on 05/21/24 at 3:35 PM, Staff O, former Quality Director, stated that she spoke with Hospital B concerning the transfer and reviewed the circumstances of the transfer. She stated that the requirement for guardianship documentation and consent were not met.”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 41865 Based on interview, record review, policy review and video review, the hospital failed to properly observe one patient (#10) who was ordered to be on one to one (1:1, continuous visual contact with close physical proximity) observation status, was protected from self-harm, when he was able to remove the drawstring from his pants and tie it around his neck. (A-0144) The hospital also failed to complete a thorough investigation and recognize failures to prevent future reoccurrences, following incidents of self-harm. (A-0145) This failed practice resulted in a systemic failure and noncompliance with 42 CFR 482.13 Condition of Participation: Patient’s Rights. The hospital census was 26. The severity and cumulative effect of this practice had the potential to place all patients at risk for their health and safety, also known as Immediate Jeopardy (IJ). As of 11/30/23, the hospital had provided an immediate action plan sufficient to remove the IJ when the hospital implemented corrective actions that included all current and oncoming nursing staff were educated on the suicide (to cause one’s own death) precaution procedures, physical assessment after a self-harm event, and the behavioral assessment and care of psychiatric (relating to mental illness) patients. All remaining staff were educated prior to the start of their next shift. Please refer to A-0144 and A-0145”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 44536 Based on observation, interview, record review, policy review and video review, the hospital failed to ensure staff properly observed and protected from harm one patient (#10) who was ordered to be on one to one (1:1, continuous visual contact with close physical proximity) observation status, when they were able to remove the drawstring from their pants and tie it around their neck. Findings included: Review of the hospital’s policy titled, “Behavioral Assessment and Care of Psychiatric (relating to mental illness) Patients in the Emergency Department (ED)”, reviewed 09/2023, showed that a suicide risk screening will be completed with initial screening in triage utilizing the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life). Suicide precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) were implemented as outlined. Level I Suicide/Behavior Precautions requires constant observation (sitter) and should be considered when the patient has scored High Risk on the C-SSRS screening. If physician orders Level I SP, a sitter is placed at bedside. If a sitter is not immediately available, evaluate staffing options and consider modifying assignments to provide direct observation of patient. Public safety is notified of patient arrival and, if available, Public Safety to assist with monitoring the cameras of psychiatric preferred rooms. If a patient attempts suicide, remove hazard, assess patient, provide appropriate care, and notify the ED provider. Nursing responsibilities are to provide appropriate level of observation for the suicidal patient in accordance to the physician’s order. Review of Patient #10’s medical record showed they were a 50-year-old brought to the ED by a law enforcement officer (LEO) on 11/03/23 at 8:25 PM. The ED provider note showed the patient was brought to the hospital for a fit for confinement (patient is medically and psychiatrically stable to go to jail) evaluation after they reported chest pain. A triage (process of determining the priority of a patient’s treatment based on the severity of their condition) assessment was completed at 8:31 PM with a C-SSRS result of High Risk. The patient reported suicidal ideation (SI, thoughts of causing one’s own death) with a plan to overdose on fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use). An order for suicide and behavior precautions every 15 minutes with a SP Level I was entered at 8:57 PM. The ED provider note showed that at 9:32 PM, Patient #10 wrapped the draw string from their hospital pants around their neck and the string was immediately removed by nursing staff. The provider note showed the patient did not have any pressure markings on their neck after the event and x-rays were not indicated. Late entry suicide and behavior precaution observations were documented by nursing on 11/04/23 at 2:37 AM, for 11/03/23 at 9:00 PM, 9:15 PM and 9:30 PM and showed observation status as SP 1:1, continuous and Level I. Hand-written constant 1:1 observation documentation began at 9:45 PM. Review of the video recording of ED Room #6 dated 11/03/23 showed: - At 9:28 PM, hospital staff stand in the hallway and appear to talk with the patient. Hospital staff exit doorway. - At 9:30 PM, the patient moves to the floor in front of doorway, removes the mattress from bed and covers body from view of the camera. Then lays on top of mattress on floor with head at doorway. - At 9:31 PM, Patient #10 on floor with head at doorway. Pulls and breaks a portion of the drawstring from paper scrub pants, holds it to their neck (appears to be checking length). - At 9:32 PM, pulls and breaks another portion of drawstring from the paper scrubs and ties it in several knots to the previous portion of string. Continues to lay on mattress on floor with head in doorway. Changes position in room so head is no longer at doorway. Lays on back on mattress and wraps knotted drawstring around their neck. - At 9:33 PM, Patient #10 cinches the string around neck and pulls on opposite ends to tighten. An end portion of the string breaks away. Patient #10 fidgets and inspects paper scrubs. - At 9:34 PM, Patient #10 pulls and tears at paper scrubs, then pulls more drawstring from paper scrub pants and ties it to the string remaining around neck. - At 9:35 PM, Patient #10 wraps the additional string around neck and continues to pull and tighten the string around neck. - At 9:36 PM, Patient #10 continues to pull on the string around neck and kick legs. Patient appears to be coughing and removes grip from string. Staff J, ED Charge Registered Nurse (RN), walks into the room and Patient #10 re-grabs the string around neck. Staff J walks towards Patient #10’s head, places hand under the string wrapped around patient’s neck. The patient released the string, pulled their head away from Staff J and begins to kick legs. Staff J removes scissors from pants pocket and cuts the string away from Patient #10’s neck and holds it up while the patient kicks legs. Patient Care Technician (PCT) and Staff K, Security Officer, viewed in doorway. - At 9:37 PM, all staff exit ED Room #6. The patient lays on the floor thrashing and appears to be coughing. Although requested, video surveillance from the hallway outside of ED Room #6 during Patient #10’s ED visit on 11/03/23 was not provided by the hospital. Observation in the ED on 11/27/23 at 11:33 AM, showed the monitor utilized for video observation of ED patients in the psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) was in the nursing station on a swing-out mount about four feet above the desk area utilized by the ED charge nurse. When the monitor mount was pushed flat against the wall, the chair at the desk area was directly underneath the monitor. The monitor could not be visualized while seated at the charge nurse area unless the chair was moved away from the desk and the observer looked straight up. The windows for the ED nursing station were tinted to prevent visualization of staff within the nursing station and hindered clear observation to areas outside of the nursing station. Observation in the ED on 11/29/23 at 12:05 PM, showed the area marked “Hall Bed D” was located in the hall directly in front of the window of the ED nursing station and between the nursing station and rooms utilized as psychiatric safe rooms (ED rooms #6 and #7). When the privacy curtain for Hall Bed D was pulled closed, visualization of the psychiatric safe rooms from inside the nursing station was blocked. During an interview on 11/28/23 at 3:15 PM, Staff J, ED Charge RN, stated that at the time Patient #10 came to the ED, the technician assigned as a 1:1 sitter in the ED was already observing two other patients who had SI and homicidal ideation (HI, thoughts or attempts to cause another’s death). Staff J called the house supervisor and told them there were three psychiatric patients in the ED and no one “extra” to perform 1:1 duties. SI and HI patients in the ED were assigned Level I or Level II observation precautions based on their assessed risk. Patient #10 had orders for Level I observation, which involved a 1:1 sitter. Because the patient had voiced a plan to overdose on fentanyl and did not have access to the drug immediately, Staff J felt that observation through the window of the nurses’ station and video surveillance were adequate until a sitter became available. During an interview on 11/28/23 at 8:30 AM, Staff K, Security Officer, stated that he was working with another security officer and they were monitoring all of the video surveillance in the hospital. They noticed on the camera for ED Room #6 that Patient #10 was trying to tie something around their neck and attempted to call the nursing station in the ED and notify them. No one in the ED answered the phone, so Staff K went to the ED while the other security officer continued to attempt to contact ED staff. Staff K walked into the ED and yelled “He’s trying to tie something around his neck.” Staff J, ED Charge RN, was walking out of the nurses’ station just as Staff K walked into the ED and they both went to ED Room #6 and the charge nurse cut the string away from the patient’s neck. During an interview on 11/27/23 at 11:30 AM, Staff E, ED Director, stated that the hospital’s policy regarding SP showed that Level I SI patients expressed a plan, were at higher risk of suicide and had 1:1 observation. Patient #10 was not placed on 1:1 observation immediately, but the charge nurse requested a sitter be sent to the ED. Nursing staff were unable to sit with the patient. The LEO left and patient was under camera observation. Security was watching from their department and the charge nurse was observing from monitor in the nursing station. The charge nurse was quick to arrive to the patient’s room and cut the string. Patient #10’s circulation and breathing were assessed, the charge nurse insured the patient was stable and increased surveillance. During an interview on 11/29/23 at 12:33 PM, Staff T, ED Physician, stated that they performed an assessment of Patient #10 after the drawstring was removed from their neck and the patient had no identified airway or vascular concerns. Staff T ordered Level 1 SP and expected that Patient #10 had a 1:1 sitter for constant observation. They were not aware that the patient did not have a constant observer until they were told the patient had tied the drawstring from the paper scrubs around their neck.”

“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: 44536 Based on interview, record review, policy review and video review, the hospital failed to recognize failures and conduct a complete and thorough investigation to prevent future reoccurrences following incidents of self-harm when one patient (#10) removed the drawstring from their pants and wrapped it around their neck while ordered to be on one to one (1:1, continuous visual contact with close physical proximity) observation status. Findings included: Review of the hospital’s policy titled, “Event Reporting”, reviewed 08/2021, showed the Incident Reporting System will be used to report possible errors, untoward events, and near misses to management and administration. The purpose is to promptly document information to investigate causes and develop appropriate measures to minimize risk of injury and adverse occurrences. A sentinel event (actual events that could or did cause patient harm) was outlined as an unexpected occurrence which involved death or physical injury, or the risk thereof. Staff were directed that the supervisor, charge nurse, or their designee will assess the event. The supervisor will review the report to determine the need for follow-up or corrective action and add investigative actions that have been completed. The risk manager will review, investigate further if need, and provide follow-up as indicated. In addition to the completion of an Incident Report, a root cause analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) may be conducted involving the employees involved in the event and a member of the Quality Service and Innovation Department. RCA will focus primarily on systems and processes, not individual performance and will be utilized to identify potential improvement in processes that would tend to decrease the likelihood of such events in the future or determine after analysis that no such improvement opportunities exist. When an action plan is indicated it will be based on the RCA and will identify changes to be made in systems and processes. Changes may be through redesign or development of new systems of processes to reduce the risk of such event occurring in the future. The plan will be implemented and evaluated for effectiveness. Although requested, the hospital did not provide a policy which guided staff on how to conduct an investigation following a serious patient event. Review of the hospital’s policy titled, “Behavioral Assessment and Care of Psychiatric (relating to mental illness) Patients in the Emergency Department (ED)”, reviewed 09/2023, showed Level I Suicide/Behavior Precautions (SP, precautions taken to ensure patients are safe and free of self-injury or self-harm) requires constant observation (1:1 sitter) and should be considered when the patient has scored High Risk on the Columbia Suicide Severity Rating Scale (C-SSRS, scale to evaluate a person’s risk to self-inflicted harm and desire to end one’s life). If physician orders Level I SP, a sitter is placed at bedside. If a sitter is not immediately available, evaluate staffing options and consider modifying assignments to provide direct observation of patient. If a patient attempts suicide (to cause one’s own death), remove hazards, assess patient, provide appropriate care, and notify the ED provider. Nursing responsibilities are to provide appropriate level of observation for the suicidal (SI, thoughts of causing one’s own death) patient in accordance to the physician’s order. Review of Patient #10’s medical record showed they were a 50-year-old brought to the ED by a law enforcement officer (LEO) on 11/03/23 at 8:25 PM. A triage (process of determining the priority of a patient’s treatment based on the severity of their condition) assessment was completed at 8:31 PM with a C-SSRS result of High Risk. The patient reported SI with a plan to overdose on fentanyl (a medication used to treat severe pain, and is a high risk drug for theft and personal use). An order for SP Level I was entered at 8:57 PM. The ED provider note showed that at 9:32 PM, Patient #10 wrapped the draw string from their hospital pants around their neck and the string was immediately removed by nursing staff. Nursing documented assessment of the patient at 9:40 PM. Late entry suicide and behavior precaution observations were documented by nursing on 11/04/23 at 2:37 AM for 11/03/23 at 9:00 PM, 9:15 PM and 9:30 PM and showed observation status as SP 1:1, continuous and Level I. Hand-written constant 1:1 observation documentation began 9:45 PM. Review of the video recording of ED Room #6 dated 11/03/23 showed: - At 9:30 PM, the patient moves to the floor in front of doorway, removes the mattress from bed and covers body from view of the camera. Then lays on top of mattress on floor with head at doorway. - At 9:31 PM, Patient #10 on floor with head at doorway. Pulls and breaks a portion of the drawstring from paper scrub pants, holds it to their neck (appears to be checking length). - At 9:32 PM, Patient #10 pulls and breaks another portion of drawstring from the paper scrubs and ties it in several knots to the previous portion of string. Continues to lay on mattress on floor with head in doorway. Changes position in room so head no longer at doorway. Lays on back on mattress and wraps knotted drawstring around their neck. - At 9:33 PM, Patient #10 cinches the string around neck and pulls on opposite ends to tighten. An end portion of the string breaks away. Patient #10 fidgets and inspects paper scrubs. - At 9:34 PM, Patient #10 pulls and tears at paper scrubs, then pulls more drawstring from paper scrub pants and ties it to the string remaining around neck. - At 9:35 PM, Patient #10 wraps the additional string around neck and continues to pull and tighten the string around neck. - At 9:36 PM, Patient #10 continues to pull on the string around neck and kick legs. Patient appears to be coughing and removes grip from string. Staff J, ED Charge Registered Nurse (RN), walks into the room and Patient #10 grabs the string around neck. Staff J walks towards Patient #10’s head, places hand under the string wrapped around patient’s neck. The patient released the string, pulled their head away from Staff J and begins to kick legs. Staff J removes scissors from pants pocket and cuts the string away from Patient #10’s neck and holds it up while the patient kicks legs. Patient Care Technician (PCT) and Staff K, Security Officer, viewed in doorway. Review of the hospital’s undated document titled, “RCA Framework,” showed review of an event which occurred on 11/03/23 at approximately 9:35 PM in the ED where a patient attempted self-harm by removing the drawstring from their paper scrubs and pulled it tightly around their neck. The RCA showed policies were followed and absence of a 1:1 sitter was not identified as a root cause with no opportunity for improvement. Opportunities for improvement with action plans identified were moving the video surveillance monitor in the ED nurses’ station, reviewing the placement and use of the privacy curtain for Hall Bed D, the psychiatric safe paper scrubs did not perform as expected, enlisting security assistance with camera monitoring when a 1:1 sitter cannot be allocated, notification of security when psychiatric or patient with LEO arrived in ED, potentially placing additional cameras for monitoring rooms from a different angle and removal of the tint from the nurses’ station windows. Review of the hospital’s document titled, “ED/Intensive Care Unit (ICU, a unit where critically ill patients are cared for) Staff Meeting Minutes,” dated 11/17/23, showed that staff were informed that the hospital’s investigation of Patient #10’s event identified that staff acted in accordance to policy based on the patient’s initial chief complaint. Due to their swift actions to intervene, the patient did not harm himself. During an interview on 11/28/23 at 12:35 PM, Staff L, Chief Nursing Officer (CNO) stated that the hospital had not implemented changes in their 1:1 policy as a result of the incident with Patient #10 on 11/03/23. The hospital had identified potential areas of improvement as a result of the RCA, and the challenges were being addressed, but other hospital projects involving their maintenance team held higher priority. Staff L did not view the video surveillance of the event, but knew that other staff had reviewed it as a part of the investigation of the event and the development of a RCA. They were unaware that the patient exhibited intent of self-harm by removing the drawstring from their paper scrub pants and wrapping it around their neck the first time, approximately five minutes prior to the charge nurse and security officer responding to Patient #10’s room. Had they been aware of that time lapse in the sequence of events, the action plan involved with the RCA would have been addressed differently. During an interview on 11/29/23 at 10:10 AM, Staff P, Risk Manager, stated that because this incident was not identified as a sentinel event, their role involved coordinating with the staff performing the investigation, ensuring that someone involved in the investigation took the lead and providing guidance to the RCA process. She asked the department manager to advise who was involved and who they wanted to invite to the RCA meeting. They recognized issues with the paper scrubs, lack of sitter, hall bed curtains, and monitor location during their investigation. It was expected that any education needed or any action plan items were started very soon after they were identified. They viewed the video of Patient #10’s incident in the ED on 11/06/23 and “other than needing a sitter” for the patient, there were no concerns. The RCA was initiated on 11/14/23 and sent to involved parties for suggested action plans on 11/16/23. Staff P stated they believed the hospital’s process in the investigation and RCA was good and the staff did everything they could for the patient involved. During an interview on 11/27/23 at 11:30 AM and follow-up on 11/28/23 at 12:30 PM, Staff E, ED Director, stated that a staff meeting was held for ED staff on 11/17/23 where staff were educated regarding the event investigation results, the importance of every 15 minute documentation for psychiatric patients and that documentation would be carried out on a written form, rather than in the electronic health record (EHR). During a follow-up interview on 11/30/23 at 8:15 AM, Staff E, ED Director, stated an investigation into the events of Patient #10 on 11/03/23 was started immediately after they were notified of the incident. They instantly gathered statements from all staff involved. The video surveillance was viewed on 11/06/23. They received guidance from Staff N, Hospital Nursing Director, on what to include in reviewing the incident and conducting the investigation, but Staff E completed the bulk of the investigation. They were then contacted by Staff P in Risk Management about gathering individuals to meet and complete the RCA. During an interview on 11/28/23 at 3:15 PM, Staff J, ED Charge RN, stated that they were present in the meeting with hospital administrative staff and the other ED and security personnel involved in Patient #10’s 11/03/23 event. They understood it was determined through the investigation of the incident that there was nothing identified for improvement other than staffing support within the ED and challenges identified with direct visualization of the psychiatric safe rooms (a room that has been cleared of any objects a patient might use to harm themselves or others) from the nursing station due to privacy curtains, tinted windows and the placement of the video surveillance monitor. During an interview on 11/28/23 at 8:30 AM, Staff K, Security Officer, stated they attended a “debriefing” meeting a few days after the incident where administration and the hospital staff involved in the incident reviewed the events of that evening. The only change in hospital procedure since the incident involving Patient #10 was that ED registration staff now informed security that a psychiatric patient had presented to the ED, in case ED staff did not have time to contact security.”