Pike County 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 policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#6) of 20 Emergency Department (ED) records reviewed from 07/12/25 through 01/12/26. The hospital’s average monthly census was 484. Findings included: Review of the hospital’s 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) Guidelines for Emergency Department Services,” reviewed 03/2025, showed: - A MSE is a process required to reach, with reasonable clinical confidence. The point at which it can be determined whether the individual has an EMC or not. - All patients shall receive a MSE that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. - The hospital may not discharge a patient who may be reasonably at risk to deteriorate from, during or after said discharge. - MSEs should include at a minimum physical examination of affected systems and potentially affected systems, examination of known chronic conditions and necessary testing to rule out EMCs. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” revised 12/2025, showed the hospital shall provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to any individual coming by him or herself or with another person to the ED and requesting an examination or treatment of a medical condition by qualified medical personnel, to determine whether or not an EMC exists. Primary care of all types of conditions may be administered on an emergency basis. Secondary and tertiary (a higher level of specialized care) care should warrant consultation and transfer where specialized care may be administered if agreed to by the patient. 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: 48359 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for one patient (#6) of 20 Emergency Department (ED) records reviewed from 07/12/25 through 01/12/26. 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, “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) Guidelines for ED Services,” reviewed 03/2025, showed: - A MSE is a process required to reach, with reasonable clinical confidence. The point at which it can be determined whether the individual has an EMC or not. - All patients shall receive a MSE that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis. - The hospital may not discharge a patient who may be reasonably at risk to deteriorate from, during or after said discharge. - MSEs should include at a minimum physical examination of affected systems and potentially affected systems, examination of known chronic conditions and necessary testing to rule out EMCs. Review of the hospital’s document titled, “Medical Staff Rules and Regulations,” revised 12/2025, showed the hospital shall provide an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to any individual coming by him or herself or with another person to the ED and requesting an examination or treatment of a medical condition by qualified medical personnel, to determine whether or not an EMC exists. Primary care of all types of conditions may be administered on an emergency basis. Secondary and tertiary (a higher level of specialized care) care should warrant consultation and transfer where specialized care may be administered if agreed to by the patient. Review of Patient #6’s medical record dated 12/09/26, showed: - At 6:32 PM, she was a 57-year-old who presented to the ED with a nosebleed. - Her past medical history included metastasized (the spread of cancer cells from the place where they first formed to another part of the body) breast cancer and diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing). - The patient stated she had abnormal laboratory findings and “needed her fluid levels checked.” - Her 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; respiration rate [RR] normal 12 to 20 breaths per minute; and body temperature [T] normal 97.8° to 99° Fahrenheit [F]) were BP 154/97 and HR 128. Her oxygen saturation (SAO2, measure of how much oxygen is in blood. A normal is between 95% and 100%. Lung disease normal oxygen saturation level may be lower) was 94%. - At 6:46 PM, her VS were BP 161/83 to 161/93, HR 112 to 120, RR 20, T 97.8° F and SAO2 94% to 95%. - The history of present illness (HPI) showed she had a nosebleed which resolved and had not bled for the past 6.5 hours. She took Eliquis (blood thinning medication) for a history of pulmonary embolism (PE, blood clot in the lung). - The medical decision making (MDM) showed the patient presented with a nosebleed, which was resolved. There were no risk factors for bleeding disorders and the patient was hemodynamically stable (your body has stable blood flow, and your heart is effectively pumping enough blood to all your organs). There was no evidence of anemia (low amounts of oxygen rich blood, causes paleness and weakness). - At 7:00 PM, she was discharged home. - She had no blood work or blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person’s health, normal is 65-115) evaluation. Review of Patient #6’s medical record dated 12/10/25, showed: - At 3:48 AM, she presented to the ED with altered mental status (mental functioning ranging from slight confusion to coma). - The HPI showed she was up all night with coughing episodes and nosebleed that filled up a bucket with tissue paper and became “altered at 3:00 AM.” - At 4:35 AM, her blood work showed her white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4-10) was 32.1, hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal is 11.5-16) was 7.7 and blood glucose was 627. - At 5:45 AM, she was transferred via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) to Hospital B. Review of Patient #6’s Hospital B medical record dated 12/10/25 through 12/15/25, showed she was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) with a profuse nosebleed, acute (sudden onset) anemia, diabetic ketoacidosis (life-threatening condition affecting people with diabetes; occurs when the body breaks down fat too fast causing the blood to become acidic), acute 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), acute 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) due to aspiration (inhalation of foreign material into the lungs) from her severe nosebleed and encephalopathy and severe sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs). During a telephone interview on 01/14/26 at 11:30 AM, Staff F, Physician, stated that she did not order blood work because Patient #6 did not display any symptoms of hemorrhagic shock (a condition of reduced tissue perfusion due to inadequate delivery of oxygenated blood). She was not pale, her BP was stable, and she was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation). She believed her initial HR was due to excitement upon entering the ED. She was not aware of the repeat elevated HR values; the nurse may have documented them after the patient was discharged. She provided good discharge education with instructions to return to the ED with worsening symptoms. During a telephone interview on 01/14/26 at 5:30 PM, Staff K, Registered Nurse (RN), stated that Patient #6’s complaint of abnormal labs was in response to her concern for her Hgb level because of the nosebleed. She had experienced anemia in her past. The patient stated that she had a significant amount of blood loss prior to her arrival but the bleeding had stopped. Staff K and Staff F, Physician, remained in the room with the patient for 15 to 20 minutes and discussed her concerns. The patient remained on the monitor during that time and the physician was aware of her HR. The patient had a follow up with her physician in one to two days and agreed she would follow up for outpatient blood work. Staff K stated that after she reviewed Patient #6’s second ED visit she would request blood work for patient’s that presented to the ED with similar complaints. During a telephone interview on 01/14/26 at 11:00 AM, Staff A, Chief Nursing Officer, (CNO), stated that she expected all staff to follow the hospital’s policies and procedures. She expected every patient who presented to the ED for treatment to receive a complete MSE to include an assessment of known chronic conditions. The MSE was based on the patient’s chief complaint and willingness to accept assessment and treatment. If a patient had a history of diabetes she expected a blood sugar assessment. Patient #6 was well known to the hospital and as a nurse she would have “preferred” she had a blood work evaluation as part of her MSE.”