Iron County Medical Center

“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: 49489 Based on 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) sufficient to determine the presence of an Emergency Medical Condition (EMC), for one patient (#6) of 20 Emergency Department (ED) records reviewed from 10/29/23 through 04/29/24. 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 the hospital’s policy titled, “Emergency Room (ER) EMTALA Guidelines,” dated 08/08/23, showed the following: - Any individual who presented to the ED would be provided a MSE to determine whether the individual was experiencing an EMC. - A MSE should include at a minimum: an ED log entry including disposition of the patient, the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) record, vital signs (VS, measurements of the body’s most basic functions), history, physical exam, necessary testing and any consults. - Any individual experiencing an EMC would be stabilized prior to transfer or discharge. - Stabilization would be achieved when no medical deterioration was likely to result from transfer or discharge or the individual. Review of the hospital’s document titled, “Medical Bylaws,” dated 01/18/07, showed personnel deemed qualified to perform a MSE included Physicians, Nurse Practitioners (NPs, a nurse who has advanced clinical education and training) and Physician Assistants (PA, a type of mid-level health care that can serve as a principal healthcare provider) (contracted or employed), and Registered Nurses (in consultation with a physician) employed by the hospital if the situation arose where a Physician, NP, or PA was not or could not be physically present. See 2405 and 2406 for further details.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 39840 Based on record review and interview, the hospital failed to maintain an Emergency Department (ED) log when one patient (#6) of 20 ED records reviewed from 10/29/23 through 04/29/24, did not have a visit number or chart created. Findings included: Although requested, the hospital failed to provide a policy for maintaining a central log for all ED patients. Review of the ED log dated 04/04/24, showed Patient #6 was on the ED log with an arrival time of 8:21 PM and a departure time of 8:23 PM with no visit number and no disposition. There was only a note entered by the ED Registration Clerk that showed “Patient never got off the stretcher. Staff B, ED Physician, said he was too big for the computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) and Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) said they would go to Hospital B, and wheeled him back out.” During an interview on 04/30/24 at 12:51 PM, Staff J, Chief Executive Officer and Chief Medical Officer, stated that there should have been a record for Patient #6. During a telephone interview on 04/30/24 at 1:53 PM, Staff C, ED Nurse Practitioner (NP, a nurse who has advanced clinical education and training), stated that there should have been a visit number and a chart for Patient #6. During an interview on 04/30/24, Staff F, ED Registration Clerk, stated that every patient who comes to the ED was entered on the log with their name and a visit number was created. During a telephone interview on 04/30/24 at 2:30 PM, Staff K, ED Registration Clerk, stated that every patient who comes to the ED would be on the ED log and have a visit number created.”

“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: 49489 Based on interview, record review, video review and policy review, the hospital 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) for one patient (#6) of 20 Emergency Department (ED) records reviewed from 10/29/23 through 04/29/24. 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 the hospital’s policy titled, “Emergency Room (ER) EMTALA Guidelines,” dated 08/08/23, showed the following: - Any individual who presented to the ED would be provided a MSE to determine whether the individual was experiencing an EMC. - A MSE should include at a minimum: an ED log entry including disposition of the patient, the triage (process of determining the priority of a patient’s treatment based on the severity of their condition) record, vital signs (VS, measurements of the body’s most basic functions), history, physical exam, necessary testing and any consults. - Any individual experiencing an EMC would be stabilized prior to transfer or discharge. - Stabilization would be achieved when no medical deterioration was likely to result from transfer or discharge or the individual. Review of the hospital’s document titled, “Medical Bylaws”, dated 01/18/07, showed personnel deemed qualified to perform a MSE included Physicians, Nurse Practitioners (NPs, a nurse who has advanced clinical education and training) and Physician Assistants (PA, a type of mid-level health care that can serve as a principal healthcare provider) (contracted or employed), and Registered Nurses (in consultation with a physician) employed by the hospital if the situation arose where a Physician, NP, or PA was not or could not be physically present. Review of the pre-hospital report titled, “Incident 24-707,” dated 04/04/24, showed Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) found Patient #6 in his home with several bloody rags in a trash can he had used to stop a nosebleed. He had also coughed up blood and saw blood in his stool that evening. The bleeding had resolved before EMS arrived. The patient requested to be transported to Iron County Medical Center. He was able to walk outside to the ambulance and had an uneventful transport. Staff D, Emergency Medical Technician (EMT), called report to Staff C, NP, who stated this patient sounded familiar and recently needed transfer to a different facility for computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray). When they explained that they were already pulling into the parking lot she said “okay” and ended the call. Patient #6 was brought into the hospital and EMS were told by the ED staff that Iron County Medical Center was unable to care for the patient due to his size. The patient was wheeled back into the ambulance and taken to Hospital B without further incident. Review of the hospital’s undated document titled, “ED log for April 2024,” showed on 04/04/24 at 8:21 PM, Patient #6 presented to the ED by ambulance. The log identified Staff B as the ED physician and Staff C as the ED nurse. The nature of his injury/illness was listed as “nosebleed that wouldn’t stop.” An additional note showed, “Patient never got off stretcher, Staff B said he was too big for CT and EMS said they would go on to Hospital B and wheeled him back out.” He was not assigned a visit identification number or medical record number, no disposition was listed, and his departure time was 8:23 PM. Review of the video footage from the ED on 04/04/24 showed: - At 8:20 PM, an ambulance arrived driven by Staff E, Paramedic; - At 8:21 PM, EMS brought Patient #6 into the ED on a stretcher. Staff D, EMT, paused in the hallway with the patient and Staff E, Paramedic, approached the nurse’s station off camera; - At 8:22 PM, Staff E returned to the patient moving quickly and they rolled the patient back outside. Staff B, ED Physician, was seen standing in the hallway speaking to them and then waved as they exited; - At 8:23 PM, the patient and EMS exited the ED; - At 8:24 PM, the ambulance left the hospital. During an interview on 04/30/24 at 11:12 AM, Staff E, Paramedic, stated that Patient #6 requested to be transported to Iron County Medical Center. When they arrived at the ED; Staff C, NP, said, “I don’t know why you brought him here. We can’t treat him here. I had to transfer him last time.” Staff E then told the staff he would transport the patient to Hospital B instead and started to wheel the stretcher back out. As he was walking out Staff B, ED Physician, said to the patient “you know we can’t treat you here.” He stated that the ED staff didn’t try to stop him from leaving. Staff E stated he believed that the statements made by Staff B and Staff C indicated that they refused to treat Patient #6. During an interview on 04/30/24 at 1:53 PM, Staff C, NP, stated that when EMS arrived Staff E, Paramedic, approached the nurse’s station and Staff C and Staff B, ED Physician, asked why they came to this hospital and explained they were probably going to have to transfer the patient. Staff E said “Fine, we’ll just go to Hospital B”, then wheeled the patient out and loaded him back in the ambulance. Staff C said, “we should have assessed him since he was on our grounds. We should have made a chart. But he didn’t even give us a chance, he just stormed off with the patient.” During an interview on 04/30/24 at 12:51 PM Staff J, Chief Executive Officer (CEO)/Chief Medical Officer (CMO), stated the staff couldn’t tackle the EMS crew and force them to stay. He acknowledged, “the patient was on property and we didn’t provide an MSE. The staff should have made a record and the doctor should have documented something. We needed to screen him.” During an interview on 04/30/24 at 10:06 AM, Staff B, ED Physician, stated that they questioned EMS as to why they brought the patient to this facility and EMS got upset and left. He stated that they never refused to see the patient. Staff E, Paramedic, decided to leave and didn’t give them a chance to assess the patient to determine whether or not he would need transfer. During an interview on 04/30/24 at 11:04 AM, Staff D, EMT, stated that she heard Staff B, ED Physician, say to Patient #6 “you know we can’t treat you here, bye.” During an interview on 04/30/24 at 2:16 PM, Staff L, ED Charge Nurse, stated that she did not think it sounded like the ED staff were refusing the patient. She thought what they communicated was that they would treat him; but they couldn’t give the treatment he most likely needed and would have to transfer him again. In her opinion Staff E, Paramedic, took the conversation the wrong way.”