Ellett 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: 41865 Based on interview, record review and policy review, the Critical Access Hospital (CAH, a small facility that gives limited outpatient and inpatient hospital services to people in rural areas) failed to follow its policies and provide within its capability and capacity, an appropriate medical screening examination (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC), and failed to ensure that an EMC was stabilized prior to being discharged, for one patient (#20) of 20 Emergency Department (ED) records reviewed from 10/28/23 through 04/28/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of hospital policy titled, “EMTALA,” dated 02/22/24, showed in order to comply with special responsibilities of Medicare hospitals in emergency cases, hospitals must perform an appropriate MSE to any individual that comes to the ED seeking care. All testing and on-call services, within the hospital’s capabilities, will be provided as part of the MSE. A patient experiencing an EMC, who may be at reasonable risk to deteriorate from the natural progression of their EMC, are considered unstable and must be stabilized, prior to being transferred or being discharged. Review of the hospital’s undated document titled, “Medical Staff Bylaws: Restated Rules and Regulations,” showed any individual who presents to the hospital, even if they presented at a location other than the hospital’s ED, and makes a request for examination or treatment of an EMC, will be provided a MSE within the capability of the hospital’s ED to determine whether that individual is experiencing an EMC. An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part. Ancillary services routinely available to ED patients shall be included, even if not located directly in the ED. When a MSE has determined that an EMC does not exist or has resolved, the individual is considered stabilized and may be transferred (if further care is needed) or be discharged. Review of Patient #20’s medical record from Ellett Memorial Hospital, dated 01/16/24, showed: - He presented to the ED, from Facility C, on 01/16/24 at 6:00 PM, after falling and striking his head. - The patient complained of arm pain and had abrasions (an area of skin damaged by scraping) to both arms and elbows. - His oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower.) at the time of arrival was 91% on room air. His oxygen saturation was 97% on room air at the time of discharge. - A CT scan of the head, performed on 01/16/24 at 7:34 PM, showed an acute subdural hematoma (SDH, a pool of blood between the brain and it’s outermost covering) with maximal thickness of 8.5 millimeters (mm) without compression on the cerebral hemispheres (pertaining to a side of the brain). A one cm intracranial (within the skull) hemorrhage (excessive bleeding) was also identified. - Patient #20 was transferred to Hospital B on 01/16/24 at 8:25 PM. Review of Patient #20’s medical record, from Ellett Memorial Hospital’s ED, dated 01/27/24, showed: - He presented to the ED after being struck in the head with a lightweight back scratcher by another resident at Facility C. The patient sustained an abrasion to his scalp and skin tears to both arms. He denied headache or neck pain. - He had acute hypoxia (not enough oxygen reaching the cells and tissues in the body) upon arrival with oxygen saturation of 85% on room air. - Staff D noted that Patient #20’s overall physical and mental health had been declining for some time and he had experienced multiple falls and reported memory impairment. There was no evidence of increased confusion beyond his baseline. - Staff B documented that she placed steri-strips (also known as “butterfly band-aids,” sticky paper bands placed across a wound to help hold the skin edges together) to the right upper arm, back of the right upper arm and back of the left upper arm skin tears. The three cm superficial laceration on the top of his head required no skin closure devices. All wounds were cleaned with sterile normal saline. - Patient #20 was discharged back to Facility C. Please refer to 2406 and 2407 for further details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 41865 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 (#20) out of 20 Emergency Department (ED) records reviewed from 10/28/23 to 04/28/24. This failed practice had the potential to cause harm to all patients who presented to Ellett Memorial Hospital seeking care for an EMC. Findings included: Review of hospital policy titled, “EMTALA,” dated 02/22/24, showed in order to comply with special responsibilities of Medicare hospitals in emergency cases, hospitals must perform an appropriate MSE to any individual that comes to the ED seeking care. All testing and on-call services, within the hospital’s capabilities, will be provided as part of the MSE. Review of the hospital’s undated document titled, “Medical Staff Bylaws: Restated Rules and Regulations,” showed any individual who presents to the hospital, even if they presented at a location other than the hospital’s ED, and makes a request for examination or treatment of an EMC, will be provided a MSE within the capability of the hospital’s ED to determine whether that individual is experiencing an EMC. An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part. Ancillary services routinely available to ED patients shall be included, even if not located directly in the ED. When a MSE has determined that an EMC does not exist or has resolved, the individual is considered stabilized and may be transferred (if further care is needed) or be discharged. Review of Patient #20’s medical record from Ellett Memorial Hospital, dated 01/16/24, showed: - He presented to the ED, from Facility C, on 01/16/24 at 6:00 PM, after falling and striking his head. - The patient complained of arm pain and had abrasions (an area of skin damaged by scraping) to both arms and elbows. - His oxygen saturation (measure of how much oxygen is in blood. Normal is between 95% and 100%) at the time of arrival was 91% on room air. His oxygen saturation was 97% on room air at the time of discharge. - A CT scan of the head, performed on 01/16/24 at 7:34 PM, showed an acute subdural hematoma (SDH, a pool of blood between the brain and it’s outermost covering) with maximal thickness of 8.5 millimeters (mm) without compression on the cerebral hemispheres (pertaining to a side of the brain). A one cm intracranial (within the skull) hemorrhage (excessive bleeding) was also identified. - Patient #20 was transferred to Hospital B on 01/16/24 at 8:25 PM. Review of Patient #20’s medical record, from Ellett Memorial Hospital’s ED, dated 01/27/24, showed: - He presented to the ED after being struck in the head with a lightweight back scratcher by another resident at Facility C. The patient sustained an abrasion to his scalp and skin tears to both arms. He denied headache or neck pain. - He had acute hypoxia (not enough oxygen reaching the cells and tissues in the body) upon arrival with an oxygen saturation of 85% on room air. - His physical work up, including his lung exam, were unremarkable, however no further work-up was completed to evaluate the hypoxia. - Staff D noted that Patient #20’s overall physical and mental health had been declining for some time and he had experienced multiple falls and reported memory impairment. There was no evidence of increased confusion beyond his baseline. - Staff B documented that she placed steri-strips (also known as “butterfly band-aids,” sticky paper bands placed across a wound to help hold the skin edges together) to the right upper arm, back of the right upper arm and back of the left upper arm skin tears. The three cm superficial laceration on the top of his head required no skin closure devices. All wounds were cleaned with sterile normal saline. - Patient #20 was discharged back to Facility C.”

“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: 41865 Based on interview, record review and policy review, the hospital failed to follow its policies and ensure an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment) was stabilized when one patient (#20) of 20 sampled cases from 10/28/23 through 04/28/24, was discharged with an unstable medical condition. Findings included: Review of hospital policy titled, “EMTALA,” dated 02/22/24, showed in order to comply with special responsibilities of Medicare hospitals in emergency cases, hospitals must perform an appropriate MSE to any individual that comes to the ED seeking care. All testing and on-call services, within the hospital’s capabilities, will be provided as part of the MSE. A patient experiencing an EMC, who may be at reasonable risk to deteriorate from the natural progression of their EMC, are considered unstable and must be stabilized, prior to being transferred or being discharged. Review of the hospital’s undated document titled, “Medical Staff Bylaws: Restated Rules and Regulations,” showed any individual who presents to the hospital, even if they presented at a location other than the hospital’s ED, and makes a request for examination or treatment of an EMC, will be provided a MSE within the capability of the hospital’s ED to determine whether that individual is experiencing an EMC. An EMC is defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in: placing the health of the individual in serious jeopardy, serious impairment to any bodily function, or serious dysfunction of any bodily organ or part. Ancillary services routinely available to ED patients shall be included, even if not located directly in the ED. When a MSE has determined that an EMC does not exist or has resolved, the individual is considered stabilized and may be transferred (if further care is needed) or be discharged. Review of Patient #20’s medical record from Ellett Memorial Hospital, dated 01/16/24, showed: - He presented to the ED, from Facility C, on 01/16/24 at 6:00 PM, after falling and striking his head. - The patient complained of arm pain and had abrasions (an area of skin damaged by scraping) to both arms and elbows. - His oxygen saturation (measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower.) at the time of arrival was 91% on room air. His oxygen saturation was 97% on room air at the time of discharge. - A CT scan of the head, performed on 01/16/24 at 7:34 PM, showed an acute subdural hematoma (SDH, a pool of blood between the brain and it’s outermost covering) with maximal thickness of 8.5 millimeters (mm) without compression on the cerebral hemispheres (pertaining to a side of the brain). A one cm intracranial (within the skull) hemorrhage (excessive bleeding) was also identified. - Patient #20 was transferred to Hospital B on 01/16/24 at 8:25 PM. Review of Patient #20’s medical record, from Ellett Memorial Hospital’s ED, dated 01/27/24, showed: - He presented to the ED after being struck in the head with a lightweight back scratcher by another resident at Facility C. The patient sustained an abrasion to his scalp and skin tears to both arms. He denied headache or neck pain. - He had acute hypoxia (not enough oxygen reaching the cells and tissues in the body) upon arrival with an oxygen saturation of 85% on room air. This was a significant difference from his oxygen saturation at his previous visit, 11 days prior, which ranged from 91% to 97%. - His physical work up, including his lung exam, were unremarkable, however no further work-up was completed to evaluate the acute hypoxia. - No supplemental oxygen was provided during his ED visit. - Staff D noted that Patient #20’s overall physical and mental health had been declining for some time and he had experienced multiple falls and reported memory impairment. There was no evidence of increased confusion beyond his baseline. - Staff B documented that she placed steri-strips (also known as “butterfly band-aids,” sticky paper bands placed across a wound to help hold the skin edges together) to the right upper arm, back of the right upper arm and back of the left upper arm skin tears. The three cm superficial laceration on the top of his head required no skin closure devices. All wounds were cleaned with sterile normal saline. - Patient #20 was discharged back to Facility C.”