Greenwood Leflore 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: 31935 Based on staff interview, medical record review, and policy and procedure review, the medical record for Patient #6, Patient #11, and Patient #14 documented the patients informed staff they were leaving the Emergency Department (ED), however staff failed to document attempts to explain the risks verses benefits of remaining for the completion of the Medical Screening Exam (MSE) per facility policy. An interview with Registered Nurse #2 revealed she spoke to Patient #8 about leaving Against Medical Advice (ADA), however there is no documentation in the medical record the nurse spoke to the patient or explained the risks verses benefits of remaining for the completion of the Medical Screening Exam (MSE). The facility failed to ensure Patients were informed of risks verses benefits of leaving the ED before a medical screening was completed and documented for four (4) of 20 medical records reviewed. Patient #6, #8, #11, and #14. Finding Include: An interview with the facility’s Accreditation Nurse on 07/08/2026 at 4:15 p.m. revealed patients present to the registration desk and triage and once triaged they wait in the waiting room. If the triage nurse can visualize the patient trying to leave they will talk with the patient. If the triage nurse is with another patient, Security will communicate with those patients who are leaving the facility about the need to stay for treatment. No procedure presented to designate the action Security, or the registration clerk take when a patient informs them they are leaving the emergency department. Review of medical record for Patient #6 revealed Patient arrived at the Emergency Department (ED) on 02/16/2026 at 8:25 a.m. with a complaint of “just don’t feel good.” Patient was triaged at 8:27 a.m. reporting “out of his blood pressure medications” and “ I’m just sick of waking up in the world with a lot of different things. God has a way of taking care of it.” Patient also has a history of a gunshot wound in January. Blood pressure (B/P) 186/89. Triage acuity Level two (2). Order for Sitter at Bedside STAT at 8:36 a.m. At 8:42 a.m. “Nurse Disposition Note” documents Eloped, Charge Nurse notified, Patient walked out of room and stated “y’all have a nice day” then walked out of ED. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider or notification Patient #6 was at risk for suicide. Review of medical record for Patient #8 revealed Patient arrived at the ED on 05/24/2026 at 1:32 p.m. with a complaint of shortness of breath, chest tightness and 14 weeks pregnant. Triaged at 1:44 p.m. Patient reported came to the ED last night and “they sent me home with meds for a kidney infection and a Holter monitor for my premature ventricular contractions PVCS.” Vital signs B/P 132/69, Heart rate 104, Respiration 22. Triage acuity level four (4). Reassessed vital signs at 3:21 p.m. B/P 104/66, Heart rate 77, Respirations 18. At 5:16 p.m. “Nurse Disposition Note” reveals Patient left without treatment, Clinical staff notified Nurse. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider. Interview with Registered Nurse (RN) #2 on 07/08/2026 at 2:35 p.m. revealed she did speak with Patient #8 regarding leaving Against Medical Advice, but the Patient continued to leave, however, the medical record does not document the attempt to educate the patient of the risks verse the benefits of leaving before a medical screening exam. Review of medical record for Patient #11 revealed Patient arrived at the ED on 01/04//2026 at 7:22 p.m. with a complaint of abdominal pain. Triage at 7:40 p.m. Patient reported abdominal pain, back pain and right upper arm pain since around 2:00 p.m. today. Also reports diarrhea for three (3) days with mild nausea. Patient has been taking antibiotics since yesterday from the dentist. Vital signs are B/P 137/90, heart rate 97, respirations 18. Triage acuity level three (3). At 8:16 p.m. “Nurse Disposition Note” documents left without treatment/departed prior to treatment, Clinical Staff notified Nurse, Disposition Detail, Patient walked out at 8:15 p.m. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider. Review of medical record for Patient #14 revealed Patient arrived at the ED on 03/24/2026 at 11:27 a.m. with a complaint of lower back pain. Triaged at 11:43 a.m. Patient reported lower back pain that started three (3) months ago, sharp and stabbing pain off and on. Presently pain rated at eight (8) out of 10 (with one (1) being little pain and 10 the worse pain). Reports in a motor vehicle accident three (3) months ago and has been taking Tylenol, last dose yesterday. Vital signs are B/P 99/67 (sitting), heart rate 77, respirations 18. Triaged at acuity level four (4). At 2:04 p.m. “Nurse Disposition Note” documents left without treatment, departed prior to medical screening examination, Disposition told security that she had to leave. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider. Review of the facility’s policy and procedure “Emergency Services Policy and Position Statement for Evaluating, Treating, and Transferring Emergency Department Patients (EMTALA),” dated 05/01/2024 reveals “ ...Emergency Department personnel must document in the medical record the examination and treatment which were offered to the patient, the risks and benefits of same and the fact that the examination and treatment were refused ...” Review of the facility’s policy and procedure presented for elopement of a patient, titled “Nursing Service Elopement of Patient,” dated last review 04/08/2024, reveals the facility policy for Elopement given to the surveyors fails to address elopement in the Emergency Department. No further information on elopement presented. During exit conference on 07/09/2026 with the Chief Financial Officer, Chief Nursing Officer and Accreditation Coordinator, 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: 31935 Based on staff interview, medical record review, and policy and procedure review, the facility failed to ensure notification of the risks verses benefits of leaving the Emergency Department (ED) before the medical screening exam (MSE) was documented in the medical records per facility policy for four (4) of 20 medical records reviewed; Patient #6, Patient #11, Patient #8, and Patient #14. Findings Include: Review of medical record for Patient #6 revealed Patient arrived at the Emergency Department (ED) on 02/16/2026 at 8:25 a.m. with a complaint of “just don’t feel good.” Patient was triaged at 8:27 a.m. reporting “out of his blood pressure medications” and “I’m just sick of waking up in the world with a lot of different things. God has a way of taking care of it.” Patient also has a history of a gunshot wound in January. Triage acuity Level two (2). Order for Sitter at Bedside STAT at 8:36 a.m. At 8:42 a.m. “Nurse Disposition Note” documents Eloped, Charge Nurse notified, Patient walked out of room and stated “y’all have a nice day” then walked out of ED. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider or notification Patient #6 was at risk for suicide. Review of medical record for Patient #8 revealed Patient arrived at the ED on 05/24/2026 at 1:32 p.m. with a complaint of shortness of breath, chest tightness and 14 weeks pregnant. Triaged at 1:44 p.m. Patient reported came to the ED last night and “they sent me home with meds for a kidney infection and a Holter monitor for my premature ventricular contractions PVCS.” At 5:16 p.m. “Nurse Disposition Note” reveals Patient left without treatment, Clinical staff notified Nurse. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider. Interview with Registered Nurse (RN) #2 on 07/08/2026 at 2:35 p.m. revealed she did speak with Patient #8 regarding leaving Against Medical Advice, but the Patient continued to leave, however, the medical record does not document the attempt to educate the patient of the risks verse the benefits of leaving before a medical screening exam. Review of medical record for Patient #11 revealed Patient arrived at the ED on 01/04//2026 at 7:22 p.m. with a complaint of abdominal pain. Triage at 7:40 p.m. Patient reported abdominal pain, back pain and right upper arm pain since around 2:00 p.m. today. Also reports diarrhea for three (3) days with mild nausea. Patient has been taking antibiotics since yesterday from the dentist. Triage acuity level three (3). At 8:16 p.m. “Nurse Disposition Note” documents left without treatment/departed prior to treatment, Clinical Staff notified Nurse, Disposition Detail, Patient walked out at 8:15 p.m. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider. Review of medical record for Patient #14 revealed Patient arrived at the ED on 03/24/2026 at 11:27 a.m. with a complaint of lower back pain. Triaged at 11:43 a.m. Patient reported lower back pain that started three (3) months ago, sharp and stabbing pain off and on. Presently pain rated at eight (8) out of 10 (with one [1] being little pain and 10 the worse pain). Reports in a motor vehicle accident three (3) months ago and has been taking Tylenol, last dose yesterday. Triaged at acuity level four (4). At 2:04 p.m. “Nurse Disposition Note” documents left without treatment, departed prior to medical screening examination, Disposition told security that she had to leave. No documentation in the medical record the facility attempted to explain the risks of leaving without being seen by a provider. An interview with the facility’s Accreditation Nurse on 07/08/2026 at 4:15 p.m. revealed patients present to the registration desk and triage and once triaged they wait in the waiting room. If the triage nurse can visualize the patient trying to leave they will talk with the patient. If the triage nurse is with another patient, Security will communicate with those patients who are leaving the facility about the need to stay for treatment. No procedure presented to designate the action Security, or the registration clerk take when a patient informs them they are leaving the emergency department. Review of the facility’s policy and procedure “Emergency Services Policy and Position Statement for Evaluating, Treating, and Transferring Emergency Department Patients (EMTALA), dated 05/01/2024 reveals “ ...Procedure: ...4 ... c ...However, in both a patient requested transfer an a Patient refusal of treatment situation, department personnel must go over with the patient and document in the chart the hospital’s duty under federal Law to examine, treat, and appropriately transfer patients ...and also the risk and benefits of recommended medical interventions ...”. “ ...11. Informed Refusal of Examination, Treatment and Transfer a. If a patient or a patient’s responsible party refuses a recommended examination, treatment or transfer, hospital personnel cannot force the recommended intervention. b. However, hospital personnel must take steps to document attempts to inform the patient of why the intervention is recommended and the risks and benefits of same ...”. Review of the facility’s policy and procedure presented for elopement of a patient, titled “Nursing Service Elopement of Patient,” dated last review 04/08/2024, reveals the facility policy for Elopement given to the surveyors is for in-patient residents not Emergency Department patients. No further information on elopement presented. During exit conference on 07/09/2026 with the Chief Financial Officer, Chief Nursing Officer and Accreditation Coordinator, survey findings were discussed, and no further documentation was submitted for review.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 44086 Based on staff interviews, medical record review, and facility medication administration policy and procedure, the facility failed to provide medical record documentation to include content describing treatment and medication administration and progress and response to medication and services on one (1) of thirteen (13) medical records reviewed; patient medical record #9. Findings Include: Interview with Accreditation Director (AD) on 10/02/2024 at 9:00 a.m. to 9:45 a.m. confirms no documentation of subsequent vital signs after triage or medication administration documented for patient record #9 on 08/26/2024. She further confirms a late entry for medication by registered nurse (RN) #6 on 09/10/2024 at 9:54 p.m. Interview with registered RN #6 confirmed she administered medication on 08/26/2024 and did not document it at point of administration. She confirms she made a late nurse entry to record administration on 09/10/2024 after 9:54 p.m. She further confirmed patient #9 was on a continuous vital sign monitor and no vital sign documentation after 3:57 p.m. on 08/26/2024. Interview on 10/03/2024 at 2:10 p.m. with the Quality Director (QD) confirmed no medication administration record for patient #9. She further confirmed no vital sign documentation after initial triage vital sign documentation on 08/26/2024 at 3:57 p.m. Medical record review for patient record #9 revealed no vital sign documentation after 08/26/2024 at 3:57 p.m. and no medication administration record. Review further revealed a late entry for medication administration on 09/10/2024 at 9:54 p.m. with no dosage amount or time of administration. Review of the facility policy titled “Nursing Service, Medication Administration Check (MAK) for medication administration and documentation” dated 02/11/2020 revealed the facility has a policy to chart the medication as given at point of administration using scanning and electronic medical record. Review revealed on page 3 of 7, “ ... At end of shift, return to check Med Summary for any unverified orders. Activate Worklist for any uncharted medications. Utilize MAK for shift to shift report to review ... outstanding physicians orders and any needed medication follow up ...”, and further revealed on pages 3-4 of 7, “ ... b. Charting a medication as not administered in the MAK ...select the medication that is not to be administered, select not admin, the medication is now designated to be charted as non-administered, select chart to complete ...”. During an exit conference on 10/03/2024 at 4:15 p.m. survey findings were discussed with the Chief Executive Officer, Chief Nursing Officer, Vice-President of Operations, QD, AD, and Chief Financial Officer and no additional information was submitted.”

“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: 45467 Based on review of hospital surveillance video, staff interviews, medical record reviews, and facility policy and procedure, Greenwood Leflore Hospital failed to comply with 489.24. Specifically, the facility staff failed to immediately initiate emergency interventions for treatment of Patient #1’s presenting complaints of respiratory distress for one (1) of 20 patient records reviewed (Patient #1). Findings Include: Registered Nurse (RN) #1 failed to initiate immediate interventions to Patient #1 who presented in respiratory distress. Instead, RN #1 directed Patient #1’s mother, who was holding the patient in her arms, to the registration desk prior to triage or placement in the Emergency Department clinical area. During the exit conference on 06/28/2024 at 12:33 p.m. with Chief Nursing Officer, Chief Financial Officer, Director of Quality Management, Vice President of Administrative Services, and Director of Accreditation, survey findings were discussed, and no further documentation was submitted for review. Cross Refer to A-2406”

“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: 45467 Based on review of hospital surveillance video, staff interviews, medical record reviews, and facility policy and procedure, Greenwood Leflore Hospital failed to immediately initiate emergency interventions for treatment of Patient #1’s presenting complaints of respiratory distress for one (1) of 20 patient records reviewed (Patient #1). The hospital’s failure to immediately take Patient #1 to the Emergency Department (ED) clinical area for initiation and treatment of her presenting medical complaints upon arrival to the ED posed an immediate threat to the health and safety of Patient #1. Findings Include: A review of hospital video footage dated May 30, 2024, at 2208 hours showed Patient #1’s mother arriving to the front of the hospital ED and entering the hospital with Patient #1 in her arms in a chest to chest holding position. Patient #1 was limp with no signs of muscle control. Patient #1’s mother encounters a moment with Registered Nurse (RN) # 1, Triage Nurse, while a hospital Security Guard stands behind the mother and Patient #1 with a wheelchair. RN # 1 sends the mother and Patient #1 to the registration area. At 2211 hours the Security Guard escorts Patient #1 and her mother to the treatment area of the ER. A hospital document titled “Nurse Notes” documented by Registered Nurse # 1 stated in entirety, “2211 presented to ER [Emergency Room] via Mothers arms Mother states that she was in the bath had an asthma attack and a seizure and can’t breath (sic) wheezing and gurgling noted patient sat. [oxygen saturation] 50% [percent] on RA [room air] rushed to ER 1 via Mothers arms in w/c [wheelchair] patient naked except for towel breathing and tight/gurgling. Multiple staff to bedside working to apply monitors and start ivs [intravenous lines]. Child collapses at 1018 [2218 hours] and CODE called at 1018 [2218 hours].” Medical record review of “Patient Agreement and Consent Form,” dated May 30, 2024, for Patient #1 reveals a registration time of 2212 hours [10:12 p.m.]. There is a signature of Patient #1’s mother and hospital employee name who administered the agreement documented on the consent form. This was three (3) minutes after arrival and prior to RN #1 or the Security Guard assisting the patient to the ED clinical area for treatment. A hospital document titled “General Medicine (Pediatric) - Nurse Initial Assessment Note” dated May 30, 2024, at 2259 hours, documented by RN #3 states, “Constitutional Pt [patient] presents to the ER accompanied by mother for complaints of seizure/asthma attack - pt obtunded [dulled or reduced level of alertness or consciousness] on arrival, O2 50% at triage desk. Pt brought immediately to RM1 [room 1], ED staff and MD [medical doctor] at beside. Pt found to be pulseless. CPR/ACLS protocol initiated at this time.” A hospital document titled “General Medicine (Pediatric) - Provider Note” dated May 30, 2024, at 2306 hours documented by Medical Doctor #3, under the history of present illness, “ ...This is a 7-year-old female who presents to the emergency room with her mother for altered mental status. The patient was apparently at home when she had a seizure and afterwards had some trouble breathing. The patient apparently came to her mother and said she was having a lot of difficulty breathing. The mother put the patient in the bathtub which did not help. Upon arrival to the emergency room the patient was minimally response. Apparently in triage she was moving a little bit. She was immediately brought to the emergency department. When I walked into the room the patient was not breathing. She did not have a pulse. We started CPR immediately and intubated the patient. She was PEA [pulseless electrical activity] on the monitor for the entire resuscitation. After about 30 minutes of CPR the patient was pronounced dead.” Medical Doctor #3’s physical examination findings documented Patient #1 had “Copious vomitus around the mouth and in the airway. Pupils fixed and dilated. Pulseless.” Patient #1’s time of death was recorded as May 30, 2024, at 2249 hours, with a preliminary cause of death documented as respiratory arrest. Interview with Emergency Department (ED) Director on 06/25/2024 at 3:47 p.m. confirms patients presenting to the ED receive a quick triage assessment that consist of vital signs and complaint. They will then go to the registration department to register and return to the Triage Department to receive a full triage assessment and Emergency Severity Index (ESI) Level rating. Patients will then wait for their Medical Screening Examination (MSE). The ED Director also confirmed emergency medical treatment is provided for patients who present to the ED requiring immediate assistance such as cardiac arrest, respiratory arrest, and stroke signs and symptoms. Interview on 06/26/2024 at 10:03 a.m. with Medical Doctor (MD) #2 confirms, when a patient walks through the door there is a triage nurse present to assess and determine if a patient is non-emergent/emergent. If non-emergent, the patient goes to registration. If the patient is emergent, they are brought immediately back to one of the rooms and the provider will take it from there so we can put orders in the system. MD #2 also said, if the ED is full, which frequently it is, the non-emergent patients are triaged per protocol and then they’re brought back in the order of triage level. Interview on 06/26/2024 at 2:28 p.m. with RN #3, confirmed when Patient #1 arrived, the mother was sitting in a wheelchair with Patient #1 in her lap and was taken to Emergency Room (ER) room one (1), our pediatric room. RN #3 said, the nurse that brought her around the corner said you know we need respiratory stat in ER room one (1). RN #3 stated, “I got up and called respiratory. I paged for them and told them that we had a pediatric patient that needed some attention. Several other staff members and I as well as Medical Doctor #3 got up and went into the room and saw the patient and that she was clearly not breathing, she was undressed, damp, and cold to the touch she was draped in a towel from home. We started CPR and put her on the monitor and called Code Blue.” An interview on 06/26/2026 at 2:43 p.m. with the Director of Emergency Services (DES) revealed she was not working on 05/30/2024, the night Patient #1 was brought to the ED. The DES said, if you are triaging, it’s obvious if patient is stable, throwing up, having respiratory issues and breathing. If you are triaging a stable person, and a patient in obvious distress arrives you should end the triage and perform a brief assessment and determine distress, that patient should immediately be transferred to the back. She further said, in this incident the nurse didn’t tend to the child, she leads them to registration and then takes dyna map to patient and measures oxygen saturation and gets a reading of 50% and then goes back to type on the computer. This incident happened on May 30, 2024, but I know the first and only meeting to identify the “root cause” was held yesterday, June 25, 2024, at 9:00 p.m. There has been no corrective action as far as I know except termination. I did reach out to our education provider for an Emergency Medical Treatment and Labor Act (EMTALA) training presentation. I have not yet heard a reply from them. Interview on 06/26/2024 at 3:40 p.m. with the Director of Risk Management (DRM) confirms the facility performs a quick triage assessment prior to the registration process. After registration a full Triage Assessment is performed. The DRM also confirmed an internal investigation was performed after an incident that occurred on 05/30/2024 and there has not been a change in the ED registration process at this time. Interview on 06/26/2024 at 4:11 p.m. with Chief Nursing Officer confirmed RN #1 was terminated from employment and was not available for interview. Hospital policy titled “Admission Admitting Process” effective November 21, 2006, last revised October 17, 2023, stated the purpose was “To ensure patients are treated in an efficient and courteous manner and accurate receipt of patient information.” Under the policy “Procedure” item six (6), letter “b.” documented “Patients in acute distress or for whom any delay getting to the appropriate care unit would be detrimental, are transported immediately to the care unit and the Admissions process will be completed in the Admitting Department by a family member, ambulance transporter or by facsimile from the nursing unit if no family is available.” Review of the facility’s, “Emergency Services Policy and Position Statement for Evaluating, Treating and Transferring Emergency Department Patients (EMTALA),” dated 10/21/2019, “ ...To ensure the Hospital complies with the requirements ...and associated regulations ...Definitions ...Emergency Medical Condition ...A medical condition manifesting itself by acute symptoms of sufficient severity ...such that the absence of immediate medical attention could reasonably be expected to result in ...serious dysfunction of any bodily organ or part ...When an individual presents to the Emergency Department ...evaluation must be conducted in conformity ...established by Medicare guidelines ...” Review of the facility’s “Emergency Department Triage Classifications,” last revised date 12/2019, “ ...Ensure patients are properly classified after an assessment has been carried out by a registered nurse ...A registered nurse will be responsible for triaging all patients presenting to the Emergency department and classifying complaints or condition ...of the following classifications ...Class III-Emergent, include, but not limited to: Cardiopulmonary arrest, Airway obstruction...Security or the triage nurse takes the patient to the appropriate treatment room...” Review of the facility’s “Emergency Department Emergency Severity Index (ESI) Triage,” last revision date 03/25/2022, “Purpose: To establish an appropriate triage system/process for use in establishing standardized criteria for the nursing staff in the triage role in assigning an appropriate triage level ...ESI Level 1: Those patients who require life-saving interventions. These patients are immediately placed in a treatment area ...” Review of the facility’s “Nursing Service Pediatric Code” policy, dated 05/2024, “Purpose...to provide life supporting treatments to pediatric patients experiencing cardiac or respiratory arrest ...Policy: Maintain procedures to ensure a Pediatric Code is initiated immediately upon noting a pediatric patient without discernible pulse and/or respiration ...Procedure: 1. A pediatric patient is defined as a patient 12 years old or less.” During the exit conference on 06/28/2024 at 12:33 p.m. with Chief Nursing Officer, Chief Financial Officer, Director of Quality Management, Vice President of Administrative Services, and Director of Accreditation, survey findings were discussed, and no further documentation was submitted for review.”

“Subdivision of Building Spaces - Smoke Barrie CFR(s): NFPA 101 Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS. This Standard is not met as evidenced by: 20543 Based on the observation, the facility failed to provide half hour rating in the smoke barrier wall in accordance with NFPA 101 sections 19.3.7.3 and 8.5.6.2. This standard deficiency affected all smoke compartments in the facility on the day of Survey. Findings include: On 6/18/24 at 10:30 AM, observation revealed unsealed holes around data cables at the East Hall smoke barrier wall near Radiology of the facility. The Smoke Barrier Wall was incapable of resisting the passage of smoke throughout the facility. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 6/18/24.”