Crossgates River Oaks 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: 48927 Based on staff interview, medical record review, policy and procedure review, the medical record for Patient #6 documents the patient informed staff they were leaving the Emergency Department (ED), however staff failed to document attempts to explain the risks verses the benefits of remaining for the competition of the Medical Screening Exam (MSE). The facility did not follow its policy and procedure for correctly documenting the events of patient leaving prior to an MSE for one (1) of 20 medical records reviewed, Patient #6. Findings include: Review of Policy and Procedure titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy” with publish date of 03/26/2026, revealed on page two (2) of 12, “ ...2. Central Log ...B. Documentation when patient refuses treatment ...leaves AMA ...if a patient informs ED staff that they are leaving prior to receiving an MSE, staff should: encourage the patient to stay for evaluation; explain risks of leaving and the benefits of remaining in the ED ...attempt to obtain patient signature, date, time on AMA/Refusal of Care form. If the patient refuses to sign, staff must document the refusal and circumstances ...”. During exit conference on 07/30/2026 at 2:30 p.m. with the Chief Executive Officer, Chief Nursing Officer, Director of Nursing/Emergency Department Director and Quality Manager, survey findings were discussed, and no further documentation was submitted for review. Cross Refer to A2406.”

“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: 48927 Based on staff interview, medical record review, policy and procedure review, the medical record for Patient #6 documents the patient informed staff they were leaving the Emergency Department (ED), however staff failed to document attempts to explain the risks verses the benefits of remaining for the competition of the Medical Screening Exam (MSE). The facility did not follow its policy and procedure for correctly documenting the events of patient leaving prior to an MSE for one (1) of 20 medical records reviewed, Patient #6. Findings include: Review of the facility’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy” with publish date of 03/26/2026, revealed on page two (2) of 12, “ ...If a patient leaves at any time without notifying staff, staff shall document in the ED record/log: that the patient presented, services provided (if any) and the time staff discovered the patient had left ...no presentation record may be deleted, and the individual must still be captured in the central log with the best known identifiers and the most accurate disposition (LWBS/left prior to MSE) ...”. Review of the medical record for Patient #6’s ED visit on 03/16/2026 at 8:45 p.m. revealed Patient presented to the ED with chief complaint of abscess to buttocks with drainage for three (3) days. Patient was triaged at 8:49 p.m. at acuity level four (4). A MSE was initiated at 9:00 p.m. with laboratory testing ordered. Physician #3’s documentation reveals while awaiting return of patient’s renal function to indicate if an IV-contrast CT scan of the area was necessary, the patient decided to leave the emergency department without provider’s knowledge but notified nursing staff she was leaving and going to another facility. Nursing documentation reveals patient left cussing and yelling at staff due to possibly having to be transferred. AMA form in medical record with two RN signatures, however no documentation of attempts to educate the patient on the risks verses the benefits of leaving prior to the completion of the medical screening exam. An interview with the Chief Nursing Officer (CNO) on 07/29/2026 at 9:00 a.m. confirms the documentation of the Against Medical Advice (AMA) event for Patient #6 01/21/2026 at 12:15 p.m. does not include documentation of the education or attempts to educate the patient of the risks verses the benefits of leaving AMA. Review of Policy and Procedure titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy” with publish date of 03/26/2026, revealed on page two (2) of 12, “ ...2. Central Log ...B. Documentation when patient refuses treatment ...leaves AMA ...if a patient informs ED staff that they are leaving prior to receiving an MSE, staff should: encourage the patient to stay for evaluation; explain risks of leaving and the benefits of remaining in the ED ...attempt to obtain patient signature, date, time on AMA/Refusal of Care form. If the patient refuses to sign, staff must document the refusal and circumstances ...”. During exit conference on 07/30/2026 at 2:30 p.m. with the Chief Executive Officer, Chief Nursing Officer, Director of Nursing/Emergency Department Director and Quality Manager, survey findings were discussed, and no further documentation was submitted for review.”