Progress West 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 observation, interview, record review and policy review, the hospital failed to provide within its capability and capacity, an appropriate medical screening examination (MSE) for one patient (#14) and failed to ensure stabilization for one patient (#26) of 27 Emergency Department (ED) records reviewed from 09/2023 through 07/2024. The hospital failed to conspicuously post signs in the Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions, and information indicating whether or not the hospital participated in the Medicaid program in the Labor and Delivery Unit. These failed practices had the potential to cause harm to all patients who presented to the ED and Labor and Delivery Unit seeking care for an emergency medical condition (EMC). The hospital’s average monthly ED census over the past six months was 2,213. The hospital’s Labor and Delivery average monthly triage (process of determining the priority of a patient’s treatment based on the severity of their condition) census over the past six months was 564. Findings included: Review of the hospital’s undated policy titled, “EMTALA,” showed: - It is the hospital policy to provide patients with emergency medical care that meets or exceeds the requirements of EMTALA. - Individuals who come to the ED and request an examination, or treatment will receive an appropriate MSE. - It is unacceptable to transfer or discharge a patient with an EMC to a physician’s office for evaluation and/or treatment. - When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital. - The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether an EMC exists. The use of such ancillary services will be based on the qualified personnel’s clinical assessment of the patient and the need for those ancillary services, including specialty consults. - Once the determination is made that the individual has an EMC, the hospital must provider further examination or treatment as may be required to stabilize the medical condition or transfer the individual to another medical facility. Review of the hospital’s undated policy titled, “Assessment of the Obstetrical (relating to childbirth and the processes associated with it) Triage Patient,” showed all patients shall receive a MSE that includes providing necessary testing and services within the capability of the hospital to reach a diagnosis. Federal law requires that all necessary definitive treatment will be given to the patient and only maintenance care can be referred to a physician office or clinic. Review of the hospital’s undated policy titled, “Radiology (a variety of medical imaging/x-ray [test that creates pictures of the structures inside the body-particularly bones] techniques used to diagnose or treat diseases)/ED Discrepancy Policy,” showed: - A Radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) will interpret films between the hours of 7:00 AM and 6:00 PM Monday through Friday, 7:00 AM to 2:00 PM on Saturdays and 7:00 AM to 12:00 PM on Sundays. For procedures performed outside of coverage hours or when a radiologist is unavailable, the following procedure will be followed. - The Attending (a medical doctor who is responsible for the overall care of a patient in a hospital) ED physician will review x-rays and leave preliminary treatment notes in the electronic medical system (EMR). - If they agree, the report will be dictated. - If there is a discrepancy in the interpretation, the radiologist will notify the ED staff/physician to follow-up with the patient appropriately. - The Radiologist will then dictate the report and include the ED staff member’s name and when he/she spoke with this staff member. - The ED physician will review the patient’s chart and determine whether the discrepancy impacted the patient’s care; if so, the appropriate action (notify patient, notify primary physician, modify treatment, etc.) will take place and be noted in the EMR. Please refer to 2402, 2406 and 2407 for further details. 50321”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 48359 Based on observations and interview, the hospital failed to conspicuously post signs in the Labor and Delivery Unit specifying the rights of individuals with respect to examination and treatment for emergency medical conditions (EMCs), and information indicating whether the hospital participated in the Medicaid program. These failures had the potential to affect all patients that presented to the Labor and Delivery unit for emergency medical treatment. The hospital’s Labor and Delivery Unit average monthly triage (process of determining the priority of a patient’s treatment based on the severity of their condition) census over the past six months was 564. Findings included: Observation on 07/01/24 at 11:30 AM, in the Labor and Delivery Unit, showed no Emergency Medical Treatment and Labor Act (EMTALA) signage at the registration desk, waiting room or patient rooms. The one triage room had two EMTALA signs. During an interview on 07/01/24 at 11:30 AM, Staff B, Women’s and Pediatrics Program Director, stated that patients were examined and treated for EMCs in the Labor and Delivery Unit patient rooms in addition to the one triage room. She agreed there was no EMTALA signage in the registration area, waiting room or patient rooms.”

“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: 48359 Based on interview, record review, and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#14) out of 27 Emergency Department (ED) records reviewed from 09/2023 to 07/2024. This failed practice had the potential to cause harm to all patients who presented to Progress West Hospital seeking care for an EMC. Review of the hospital’s undated policy titled, “EMTALA,” showed: - It is the hospital policy to provide patients with emergency medical care that meets or exceeds the requirements of EMTALA. - Individuals who come to the ED and request an examination, or treatment will receive an appropriate MSE. - When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital. - The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether an EMC exists. The use of such ancillary services will be based on the qualified personnel’s clinical assessment of the patient and the need for those ancillary services, including specialty consults. - Once the determination is made that the individual has an EMC, the hospital must provide further examination or treatment as may be required to stabilize the medical condition or transfer the individual to another medical facility. Review of the hospital’s undated policy titled, “Radiology (a variety of medical imaging/x-ray [test that creates pictures of the structures inside the body-particularly bones) techniques used to diagnose or treat diseases]/ED Discrepancy Policy,” showed: - A Radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) will interpret films between the hours of 7:00 AM and 6:00 PM Monday through Friday, 7:00 AM to 2:00 PM on Saturdays and 7:00 AM to 12:00 PM on Sundays. For procedures performed outside of coverage hours or when a radiologist is unavailable, the following procedure will be followed. - The Attending (a medical doctor who is responsible for the overall care of a patient in a hospital) ED physician will review x-rays and leave preliminary treatment notes in the electronic medical system (EMR). - If they agree, the report will be dictated. - If there is a discrepancy in the interpretation, the radiologist will notify the ED staff/physician to follow-up with the patient appropriately. - The Radiologist will then dictate the report and include the ED staff member’s name and when he/she spoke with this staff member. - The ED physician will review the patient’s chart and determine whether the discrepancy impacted the patient’s care; if so, the appropriate action (notify patient, notify primary physician, modify treatment, etc.) will take place and be noted in the EMR. Review of Patient #14’s medical record, dated 01/01/24, showed: - At 12:16 PM, he was an 87-year-old male who arrived at the ED and reported, right sided chest and epigastric (the upper part of the abdomen just below the rib cage) abdominal pain. - His past medical history was aortic stenosis (narrowing of the valve in the large blood vessel branched off the heart), asthma (a chronic lung disease which makes breathing difficult), bladder cancer, dementia (a loss of thinking abilities and memory), high cholesterol and high blood pressure. He was seen in the ED on 12/30/23 and diagnosed with a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) and given a prescription for antibiotics. - At 12:28 PM, his vital signs (VS, measurements of the body’s most basic functions: blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats (HR) normal 60 to 100 per minute and respiration rate (RR) normal 12 to 20 breaths per minute) were HR-112, RR-20, BP 161/97. His oxygen saturation (SAO2, measure of how much oxygen is in blood, normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 93%. - At 1:01 PM, his electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed an irregular heartbeat. - At 1:18 PM, his blood work showed sodium (a mineral in the blood or body fluid, normal is 135-145) was 126, his chloride (a type of electrolyte in the blood, normal is 97-110) was 86, blood urea nitrogen (BUN, blood test that specifies kidney function, normal is 6-25) was 33, alanine transaminase (ALT, an enzyme found mostly in the liver, normal is 7-55) was 6, lipase (an enzyme the body uses to break down fats, normal is 10-99) was 124, troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 22) was 39 and white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 3.8-9.9) was 8.6. - At 2:07 PM, he was seen by a provider. His assessment showed he presented with epigastric discomfort and was spitting up bile (fluid in the digestive system) like fluid. - At 2:15 PM, his VS were SAO2-96% and HR-95. - At 2:24 PM, Intravenous (IV, in the vein) fluids were administered for hyponatremia (a condition when low salt levels in the blood cause an abnormally low level of body fluids). - At 2:53 PM, his repeat troponin was 32. - At 3:00 PM, his VS were HR-109, RR-26, BP-141/96 and SAO2-92%. - At 3:35 PM, his disposition was set to discharge. His discharge diagnosis was adverse drug reaction (ADR, unwanted or harmful reaction after the administration of a drug) to the antibiotic (Bactrim) prescribed for the UTI, drug induced acute pancreatitis (inflammation of the pancreas) and hyponatremia. - At 3:51 PM, IV antibiotics were given. - At 4:00 PM, his VS were HR-104, BP-147/103 and SAO2-96%. - At 4:30 PM, he was discharged home with instructions to follow up with his primary care doctor as needed. - At home his family witnessed him fall and found a large amount of coffee ground vomit (indicates old blood in the gastrointestinal tract) around the patient. - On 01/01/24, at 11:56 PM, he arrived at the ED in cardiac arrest (when the heart suddenly and unexpectedly stops pumping). There was dark red blood vomit in his throat. - On 01/02/24, at 12:06 AM, Patient #14 was pronounced dead. During an interview on 07/08/24 at 1:52 PM, Staff KK, ED Medical Director, stated that symptoms of pancreatitis were epigastric pain, nausea and vomiting. Any level of increased lipase indicated pancreatitis. Lipase was also increased with diet and alcohol intake. He only considered imaging when he suspected pancreatitis was related to an infectious source. Suspicion of an infectious source was if a patient had a “significantly increased white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) with a left side shift (an increased number of immature cells in the blood). During an interview on 07/03/24 at 8:56 AM, Staff U, Registered Nurse (RN), stated that Patient #14 complained of right sided epigastric pain. He was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation). The decision to order imaging was provider driven. Pancreatitis was treatable at home. She was not present when Patient #25 came into the ED for cardiac arrest. 50321”

“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 emergency medical conditions (EMC) were stabilized for one patient (#26) out of 27 Emergency Department (ED) records reviewed from 09/2023 through 07/2024, when they were discharged 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). Review of the hospital’s undated policy titled, “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),” showed: - The MSE must be within the capacity of the ED and include ancillary services routinely available to determine whether an EMC exists. The use of such ancillary services will be based on the qualified personnel’s clinical assessment of the patient and the need for those ancillary services, including specialty consults. - When an individual is determined to have an EMC, the hospital will provide necessary examination and treatment to stabilize the patient within the capabilities of staff and facilities available at the hospital. - Once the determination is made that the individual has an EMC, the hospital must provide further examination or treatment as may be required to stabilize the medical condition or transfer the individual to another medical facility. Review of the hospital’s undated policy titled, “Radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases)/ED Discrepancy Policy,” showed: - A Radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) will interpret films between the hours of 7:00 AM and 6:00 PM Monday through Friday, 7:00 AM to 2:00 PM on Saturdays and 7:00 AM to 12:00 PM on Sundays. For procedures performed outside of coverage hours or when a radiologist is unavailable, the following procedure will be followed. - The Attending (a medical doctor who is responsible for the overall care of a patient in a hospital) ED physician will review x-rays (test that creates pictures of the structures inside the body-particularly bones) and leave preliminary treatment notes in the electronic medical system (EMR). - If they agree, the report will be dictated. - If there is a discrepancy in the interpretation, the radiologist will notify the ED staff/physician to follow-up with the patient appropriately. - The Radiologist will then dictate the report and include the ED staff member’s name and when he/she spoke with this staff member. - The ED physician will review the patient’s chart and determine whether the discrepancy impacted the patient’s care; if so, the appropriate action (notify patient, notify primary physician, modify treatment, etc.) will take place and be noted in the EMR. Review of Patient #26’s medical record, dated 01/12/24, showed: - At 1:27 AM, he was a 55-year-old male who arrived at the ED and reported, “abdominal pain that started a couple of hours ago, nausea and vomiting.” - At 1:47 AM, his pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was eight out of ten. - At 2:01 AM white blood cell count (normal is 3.8-9.9) was 14.2. - At 3:06 AM and 4:07 AM, he was given IV Zofran (medication for the treatment of nausea). - At 3:42 AM, the abdominal and pelvis CT scan results per ED physician was “clinically correlates to presenting symptoms of gastroenteritis.” - At 4:09 AM, he was given IV Pepcid (a medication that treats excess stomach acid or heartburn) and oral Bentyl (medication to treat irritable bowel syndrome [IBS, ongoing disorder of the colon which includes diarrhea, cramping and abdominal pain]. - At 5:04:26 AM, he was seen by the ED provider. his review of systems was positive for fever, chills and nausea. - At 5:04:40 AM, his disposition was set to discharge. - At 5:16 AM, his pain scale assessment was seven out of ten. - At 5:34 AM, he was given oral Zofran. - At 5:47 AM, he was discharged home with instructions to return to the ED if he developed focal abdominal pain or was unable to tolerate oral intake. - At 10:39 AM, A Radiologist called the ED Provider to report an abdominal and pelvis CT report discrepancy of suspected acute appendicitis (inflammation of the appendix [a small tube-shaped part that is joined to the intestines on the right side of the intestines]). - At 2:42 PM, he returned to the ED and reported he was seen 12 hours ago and received a call to come back in for re-evaluation for possible appendicitis. - At 7:00 PM, Patient #26 underwent an appendectomy (surgical removal of the appendix). Although requested the hospital did not provide an interview with Staff NN, Physician. She provided care to Patient #26 during his initial visit on 01/12/24. During an interview on 07/09/24 at 10:15 AM, Staff MM, RN, stated that Patient #26 continued with pain at discharge. He performed a pain assessment, and the patient stated seven out of ten. “Two minutes later” an order was written to discharge the patient home. He informed the provider of the patient’s continued pain. During an interview on 07/03/24 at 2:11 PM, Staff LL, Physician, stated that a critical discrepancy was when the radiologist (medical doctor that specialize in diagnosing and treating injuries and diseases using medical imaging) believed the patient needed to be notified as soon as possible of the discrepancy to prevent a negative outcome. In the case of a critical discrepancy the radiologist who noted the discrepancy called the patient directly. A discrepancy that was not considered to be “critical” was placed on the discrepancy tracker and the ED provider was responsible to contact the patient. 50321”