Macon County Samaritan 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: 50321 Based on interview, document review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#12) of 22 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, “Consolidated Omnibus Budget Reconciliation Act (COBRA)/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),” reviewed 01/2025, showed: - An EMC was a condition that manifested 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 person in serious jeopardy, serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part. - A MSE was the initial, and on-going, evaluation of the presenting patient conducted by a physician, to include history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient, within the capabilities of the hospital utilizing the facilities routinely available to the ED to determine whether a patient did or did not have an EMC. - The patient was considered stable in a condition in which no material deterioration was likely to occur from or during transfer, discharge or referral. - Patients should not be denied evaluation, screening, treatment or stabilization on the basis of their presenting complaint, condition or lack of a physician on the medical staff of the hospital. Please refer to A-2406 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: 50321 Based on interview, document review and policy review, the hospital failed to provide, within its capability and capacity, an appropriate medical screening exam (MSE) sufficient to determine the presence of an emergency medical condition (EMC) for one patient (#12) of 22 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, “Consolidated Omnibus Budget Reconciliation Act (COBRA)/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),” reviewed 01/2025, showed: - An EMC was a condition that manifested 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 person in serious jeopardy, serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part. - A MSE was the initial, and on-going, evaluation of the presenting patient conducted by a physician, to include history, physical examination, appropriate testing, completion of appropriate documentation and evaluation of the patient, within the capabilities of the hospital utilizing the facilities routinely available to the ED to determine whether a patient did or did not have an EMC. - The patient was considered stable in a condition in which no material deterioration was likely to occur from or during transfer, discharge or referral. - Patients should not be denied evaluation, screening, treatment or stabilization on the basis of their presenting complaint, condition or lack of a physician on the medical staff of the hospital. Review of Patient #12’s medical record showed: - On 08/05/25 at 3:11 PM, he was a 63-year-old who arrived at the ED with a chief complaint of a potential infection. - Triage documentation showed he had received radiation (the use of energy waves to diagnose or treat disease) treatment that morning, and since then he had chills and a fever of 102 to 103 degrees Fahrenheit (F). He had spoken to his Oncologist’s (a physician who diagnoses and treats cancer) office. The nurse he spoke to instructed him to go to the ED. His VS were obtained and showed a temperature (normal 97.8 to 99 degrees) of 99.8 F, a blood pressure (BP, normal between 90/60 to 120/80) of 150/72 and a HR of 127. - Lab work was obtained and showed a white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood) of 10.9, a carbon dioxide (CO2, a gas produced by exhaling) of 10, anion gap (a test that checks the acid-base balance of your blood) of 23, blood urea nitrogen (BUN, blood test that specifies kidney function) of 41, and creatinine (a test that measure how well your kidneys are working) of 1.42. Urine and blood cultures (a laboratory test to check for bacteria or other germs in a blood sample) were obtained. A urinalysis (a laboratory examination of a person’s urine) obtained from his nephrostomy tube (a small, flexible tube inserted directly into a kidney to drain urine) showed he had bacteria and blood present in his urine. - Physician documentation showed he had chemotherapy (a drug treatment that uses powerful chemicals to kill fast growing cells or cancer in the body) and radiation treatment earlier in the day for bladder cancer that metastasized (the spread of cancer cells from the place where they first formed to another part of the body) to his tailbone. Physician and nursing assessments showed he had a nephrostomy tube in place. - At 5:00 PM, an antibiotic was administered. - Discharge instructions showed he was diagnosed with a catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) associated urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra). He was discharged with a prescription for oral antibiotics and advised that urine and blood cultures would be checked daily for three days. The results would be sent to his Oncologist for further follow up. His Oncologist’s on-call provider reviewed the ED findings and was comfortable with him taking antibiotics from home. He was also advised to change his leg bag (a smaller-capacity bag worn on the thigh or calf to collect urine from a urinary catheter) and keep it below his hips to avoid infection. - At 5:39 PM, he was discharged home. He did not receive IV fluids, IV antibiotics, or additional monitoring. Review of Patient #12’s medical record from Hospital B, showed: - On 08/31/25 at 7:03 PM, he arrived at the ED with a chief complaint of right sided flank pain (discomfort felt in the area between the ribs and the hip, can indicate infection in the kidney). He had a nephrostomy tube in place. It had been draining less and was difficult to flush. He reported fevers all day. He had just been seen at Hospital A and was referred to Hospital B. - At 7:10 PM, his VS were obtained and showed a HR of 120 and a temperature of 99.7 F. - Lab work was obtained and showed a WBC of 12.46. A urinalysis was positive for protein and blood, suspicious for a UTI. - An abdomen and pelvis 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 perinephric fat stranding (swelling in the fat surrounding the kidney) that may have been indicative of pyelonephritis (a life-threatening F - Physician documentation showed he had a history of bladder cancer and had body aches that began that day. He completed his chemotherapy and radiation two weeks prior. His pain was all over, but worst on his right side, where the nephrostomy tube was. His wife reported that they presented at Hospital A, where no testing was performed, and had a temperature of 102 F. - He received intravenous (IV, in the vein) fluids and antibiotics in the ED. - At 11:20 PM, he was diagnosed with pyelonephritis (a life-threatening bacterial infection in the kidneys and urinary tract) and admitted to Hospital B as he met sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) criteria. During an interview on 09/30/25 at 1:44 PM, Staff H, ED Physician, stated that Patient #12’s presentation was consistent with an infection, to include the elevated HR and low-grade fever. He called Patient #12’s oncologist and spoke to a Nurse Practitioner (NP, a nurse with advanced clinical education and training) who was the on-call provider. They discussed Patient #12’s VS and lab work. They were aware of his elevated BP as well. They felt comfortable discharging him home and would follow up with him. He was also comfortable with the discharge, and felt Patient #12 received a full and complete MSE. There was no additional testing or imaging he felt was necessary. If the Oncologist had wanted more testing, he would have ordered it. During an interview on 09/29/25 at 11:05 AM, Staff I, Licensed Practical Nurse (LPN), stated that she had been concerned about his HR, and spoke to Staff H, ED Physician, about it. Staff H advised her that it was related to his infection. He also had an elevated BP, but he told her that he had a history of high BP and took medication for it, so she was not concerned. He had a low-grade fever that did not require medication as it was below 100.4 F. VS should be re-checked within 10 minutes of discharge. She remembered that she had re-checked Patient #12’s VS but had written them down on the “charge sheet” in the room, which was shredded after the patient left. The VS machines did not automatically save directly to the medical record, they needed to be manually entered. She was certain his HR had improved when he was discharged but could not remember exactly what it was. During an interview on 09/30/25 at 8:24 AM, Staff J, Registered Nurse (RN), stated that she had not directly cared for Patient #12, but had reviewed and signed off on Staff I’s, LPN, documentation and attempted to draw his lab work. She did not have concerns about the care he received. Staff H, Physician, had called Patient #12’s Oncologist’s office to discuss his care, which was typical for such patients. She agreed it was appropriate to send him home with antibiotics after blood and urine cultures were obtained. If he had needed to be admitted, the hospital could have potentially treated his infection.”

“Exit Signage CFR(s): NFPA 101 Exit Signage 2012 EXISTING Exit and directional signs are displayed in accordance with 7.10 with continuous illumination also served by the emergency lighting system. 19.2.10.1 (Indicate N/A in one-story existing occupancies with less than 30 occupants where the line of exit travel is obvious.) This Standard is not met as evidenced by: 39354 Based on observation and interview, the hospital failed to install exit signage in the kitchen area. This failure had the potential to affect all hospital occupants that used the kitchen area. The hospital census was 10. Observation during the Life Safety Code tour on 05/20/25 between 9:00 A.M. and 4:00 P.M., showed there were no exit signs located in the kitchen area to identify the route of exit in the event of an emergency. During an interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, stated that he did not know why there were no exit signs in the kitchen area. The National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, states: - 7.10.2 Directional Signs. - 7.10.2.1 A sign complying with 7.10.3, with a directional indicator showing the direction of travel, shall be placed in every location where the direction of travel to reach the nearest exit is not apparent. - 7.10.2.2 Directional exit signs shall be provided within horizontal components of the egress path within exit enclosures as required by 7.10.1.2.2.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 39354 Based on interview and record review, the hospital staff failed to inspect and test the fire alarm system in accordance with the 2010 edition of NFPA 72 (National Fire Alarm and Signaling Code), when the staff failed to provide complete and verifiable documentation for 100 percent inspection and testing of the fire alarm system semi-annually. Failure to inspect and test the fire alarm system in accordance with the standard had the potential to prevent the proper function of the fire alarm system and delay response procedures in the event of an emergency. The hospital census was 10. Review of the hospital’s fire alarm system inspection, testing and maintenance records, dated May 2023 through May 2025, showed no documentation of a semi-annual fire alarm system inspection. During an interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, stated that he was responsible for ensuring the fire alarm system was inspected as required and that he was unaware a semi-annual inspection was required. Review of The National Fire Protection Association (NFPA) 72, 2010 edition, stated: 14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction. 14.4.5* Unless otherwise permitted by other sections of this Code, testing shall be performed in accordance with the schedules in Table 14.4.5, or more often if required by the authority having jurisdiction.”

“Elevators CFR(s): NFPA 101 Elevators 2012 EXISTING Elevators comply with the provision of 9.4. Elevators are inspected and tested as specified in ASME A17.1, Safety Code for Elevators and Escalators. Firefighter’s Service is operated monthly with a written record. Existing elevators conform to ASME/ANSI A17.3, Safety Code for Existing Elevators and Escalators. All existing elevators, having a travel distance of 25 feet or more above or below the level that best serves the needs of emergency personnel for firefighting purposes, conform with Firefighter’s Service Requirements of ASME/ANSI A17.3. (Includes firefighter’s service Phase I key recall and smoke detector automatic recall, firefighter’s service Phase II emergency in-car key operation, machine room smoke detectors, and elevator lobby smoke detectors.) 19.5.3, 9.4.2, 9.4.3 This Standard is not met as evidenced by: 39354 Based on observation, interview and record review, the hopsital staff failed to conduct monthly fire fighter operation testing. This failure had the potential to place all building occupants who used the elevators at risk for their safety. The hospital census was 10. Observation during the Life Safety Code tour on 05/20/25 between 9:00 A.M. and 4:00 P.M., showed the hospital featured two passenger elevators that were equipped with fire fighter operation. Review of the hospital’s elevator inspection records showed no documentation of monthly fire fighter operation testing. During an interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, state that he did not know that monthly fire fighter testing for the elevators was required. Review of The National Fire Protection Association (NFPA) 101, 2012 edition, Section 9.4.6.1 showed elevators shall be subject to periodic inspections and tests as specified in ASME A17.1/CSA B44, Safety Code for Elevators and Escalators.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 39354 Based on observation, interview and record review, the hospital failed to ensure two of two operating rooms were equipped with Line Isolation Monitors (LIMs). This failure had the potential to affect all building occupants who used the operating rooms. The hospital census was 10. Observation during the Life Safety Code tour on 05/20/25 between 9:00 A.M. and 4:00 P.M., showed the hospital featured two operating rooms. Record review of the hopital’s maintenance records showed no documentation of LIMs testing. During interview on 05/21/25 at 10:20 A.M., Staff V, Maintenance Director, stated that the hospital had never had LIMs in the operating rooms and that he did not know why they had never been installed. Review of the 2012 edition of The National Fire Protection Association (NFPA) 99, showed the following: 3.3.138* Patient Care Room. Any room of a health care facility wherein patients are intended to be examined or treated. (MED) 3.3.138.1* Basic Care Room. Room in which the failure of equipment or a system is not likely to cause injury to the patients or caregivers but can cause patient discomfort. (Category 3). (MED) 3.3.138.2* Critical Care Room. Room in which failure of equipment or a system is likely to cause major injury or death of patients or caregivers (Category 1). (MED) 3.3.138.3* General Care Room. Room in which failure of equipment or a system is likely to cause minor injury to patients or caregivers (Category 2). (MED) 3.3.138.4* Support Room. Room in which failure of equipment or a system is not likely to have a physical impact on patients or caregivers (Category 4). (MED) 6.4.1.1.4 Essential electrical systems shall have a minimum of the following two independent sources of power: a normal source generally supplying the entire electrical system and one or more alternate sources for use when the normal source is interrupted. 6.4.1.1.5 Where the normal source consists of generating units on the premises, the alternate source shall be either another generating set or an external utility service. 6.4.1.1.6 General. Generator sets installed as an alternate source of power for essential electrical systems shall be designed to meet the requirements of such service. NFPA 70 (NEC): Patient Bed Location. The location of a patient sleeping bed, or the bed or procedure table of a critical care area. [99:3.3.137] 517.19 Critical Care Areas. (A) Patient Bed Location Branch Circuits. Each patient bed location shall be supplied by at least two branch circuits, one or more from the emergency system and one or more circuits from the normal system. At least one branch circuit from the emergency system shall supply an outlet(s) only at that bed location. All branch circuits from the normal system shall be from a single panelboard. Emergency system receptacles shall be identified and shall also indicate the panelboard and circuit number supplying them. The branch circuit serving patient bed locations shall not be part of a multi-wire branch circuit.”