Greene County Hospital

“COMPLIANCE WITH 489.24 CFR(s): [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, record review, Governing Body By-laws and Policy and Procedure Review the facility (Hospital #1) failed to provide an appropriate Medical Screening Exam (MSE) to an individual who presented to the emergency department to determine if an Emergency Medical Condition (EMC) existed. This deficient practice affected one (1) of 20 medical records reviewed (Patient #1) and had the potential to affect all pregnant individuals presenting to the emergency department seeking care. Findings Include: Patient #1 presented on hospital property on 12/10/2025 approximately 6:30 a.m. requesting medical care related to vaginal bleeding. Hospital #1 failed to enter Patient #1 on the ED log, triage or perform an appropriate medical screening exam. Emergency Department staff informed Patient #1 their facility did not provide obstetrical care, but that Hospital #2 did. Patient #1 was not informed of risks or benefits of remaining at Hospital #1’s ED for an evaluation. Hospital #1 provided documentation that following the incident with Patient #1 involved staff were counseled. Additionally, Emergency Department (ED) staff were reeducated on logging each individual that presents for treatment on the ED central log and that EMTALA (Emergency Medical Treatment and Labor Act) requires the hospital to complete an appropriate medical screening exam on all persons seeking care. During exit conference on 12/18/2025 at 5:00 p.m. with the Administrator and the Director of Nursing survey findings were discussed and no further documentation was submitted for review. Cross Refer to O 2406.”

“EMERGENCY ROOM LOG CFR(s): [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: 31935 Based on staff interview, review of the facility policies and procedures, and review of the Emergency Department Log, the facility (Hospital #1) failed to maintain a central log of all individuals who come to the Emergency Department (ED) seeking medical treatment to ensure the required information (refused treatment, was refused treatment, transferred, admitted and treated, stabilized and transferred or discharged) was documented. This deficient practice affected one (1) out of 20 sampled patients, Patient #1. Findings Include: During a telephone interview on 12/16/2025 at 9:35 p.m., Registration Clerk (RC) #1 revealed in the early morning of December 10, 2025, Patient #1 and her mother (Parent #1) presented to the Emergency Room (ER). RC #1 said the mother reported something was coming out of Patient #1’s vagina and that she would fill out the paperwork but wanted her daughter to be taken back. RN #1 approached the registration window from inside and told the mother the facility did not have obstetrical services, but sister Hospital #2 did, however, we would be glad to see the patient. RC #1 reported the mother and Patient #1 walked out saying they would go to Hospital #2. The father then came into the ER and said he wanted his daughter (Patient #1) to be seen, and it was agreed that she would be seen, then father walked out of the ER. RC #1 stated, “I thought he was going to get his wife and daughter, but he never returned”. RC #1 said the paperwork was never completed so I never put the patient’s information in the computer. RC #1 told the Surveyor she did not know where the forms were the mother began filling out. In an interview on 12/16/2025 at 11:10 a.m., the Administrator confirmed he went to the Emergency Room to locate a chart with Patient #1’s last name on it, and could not find it because Patient #1 was not signed in. In a telephone interview on 12/15/2025 at 3:47 p.m., RN #1 confirmed she was on duty the morning of 12/10/2025 and spoke with the mother and Patient #1. RN #1 informed the mother and Patient #1 if this was obstetrical problem, this facility does not have an obstetrician/gynecologist. RN #1 said she told them Hospital #2 did, but they would be glad to see her at this facility. RN #1 said the mother and Patient #1 said they were going to a hospital in another town and walked out. RN #1 confirmed, triage nor a medical screening exam was not provided, and a transfer was not offered. Review of the Emergency Department Registration Log revealed no documentation of Patient #1 presenting to the Emergency Department on 12/10/2025. Review of facility document titled “Policies and Procedures,” article XIV, “ ...44 (a) an appropriate medical record shall be kept for every patient receiving emergency services and incorporated into the hospital record. The record shall include (a) adequate patient Identification; (b) information concerning the time of patient’s arrival, means of arrival and by whom transported ...”. Review of facility policy titled “Admitting,” dated 02/2018 reveals “ ...The admitting department clerk will register the patient per policy and procedures ...”. No other documentation on a central log was presented for surveyor review. During exit conference on 12/18/2025 at 5:00 p.m. with the Administrator and the Director of Nursing survey findings were discussed and no further documentation was submitted for review. Cross Refer to O 2406.”

“MEDICAL SCREENING EXAM CFR(s): (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, review of policies and procedures, and grievance information, the facility (Hospital #1) failed to provide an appropriate medical screening exam within the capability of the hospital’s Emergency Department (ED) by a qualified individual to determine if an emergent medical condition exist for a patient who presented to the facility requesting assistance with a complaint of something coming out of her vagina for one (1) of 20 sampled patients, Patient#1. Findings Include: In an interview on 12/18/2025 at 1:33 p.m. with Patient #1’s parents, it was confirmed they arrived in private vehicle at Hospital #1 on 12/10/2025 at approximately 6:30 a.m. requesting medical care for their daughter. The mother said she told the facility receptionist, “ ...something was coming out of Patient #1’s vagina and she needed to be seen ...”. The mother reported the receptionist began entering the patient data into the electronic system, confirmed address, telephone number, and read it back to the mother and then corrected the telephone number. The mother confirmed her daughter was standing behind her stooped over when she was handed a clipboard to fill out medical information. The mother stated. “I told Receptionist #1 to take my daughter back and I would complete the medical record ...”. The mother reported a Registered Nurse (RN #1) came to the registration window and asked what was going on and if the patient was pregnant. The mother said she told the nurse she did not know and RN #1 told them if she is pregnant, they do not have obstetrical services at this facility. The mother said RN #1 repeated they do not have obstetrical services three (3) times and she pretty much begged RN #1 to take her daughter back. After the third time the mother said she laid the pen down and said we have got to go. The mother stated “ ...at that time I thought my daughter was going to die...and by the time we got to the car my daughter was in excruciating pain ...” The mother said her husband went back in and asked them to see our daughter and when he came back to the car my daughter was getting worse, so I said let’s take her to the other hospital. Patient #1’s father (Parent #2) confirmed they left Hospital #1 and arrived at Hospital #2 around 6:58 a.m. In a telephone interview on 12/15/2025 at 3:47 p.m., RN #1 confirmed she was on duty the morning of 12/10/2025 and spoke with the mother and Patient #1. RN #1 confirmed Patient #1 and mother entered the facility and told the registration clerk she had something coming out of her vagina. RN #1 said she asked the mother and Patient #1 if she was pregnant and the mother responded they do not know. RN #1 informed the mother and Patient #1 if this was obstetrical the facility does not have an obstetrician/gynecologist. RN #1 said she told them Hospital #2 did, but they would be glad to see her at this facility. RN #1 said the mother and Patient #1 said they were going to a hospital in another town and walked out. RN #1 said the patient did not appear to be pregnant or in distress. RN #1 reported that the father (Parent #2), entered the Emergency Department and said he wanted his daughter to be seen and went outside to get her, RN #1 said she walked outside to look for them about two (2) minutes later, but they were no longer at the facility. RN #1 stated to surveyor, “ ... I know now we should of went on and signed her in ...”. RN #1 confirmed, triage nor a medical screening exam was not provided, and a transfer was not offered. During a telephone interview on 12/16/2025 at 9:35 p.m., Registration Clerk (RC) #1 revealed in the early morning of December 10, 2025, Patient #1 and her mother (Parent #1) presented to the Emergency Room (ER). RC #1 said she did not get a good look at Patient #1 because her mother was standing in front of her. RC #1 said the mother reported something was coming out of Patient #1’s vagina and that she would fill out the paperwork but wanted her daughter to be taken back. RN #1 approached the registration window from inside and told the mother the facility did not have obstetrical services, but Hospital #2 did, but we would be glad to see the patient. RC #1 reported the mother and Patient #1 walked out saying they would go to Hospital #2. The father then came into the ER and said he wanted his daughter (Patient #1) to be seen, and it was agreed that she would be seen, then father walked out of the ER. RC #1 stated, “I thought he was going to get his wife and daughter, but he never returned”. RC #1 said the paperwork was never completed so I never put the patient’s information in the computer. RC #1 told the Surveyor she did not know where the forms were the mother began filling out. Hospital #1 did not generate a medical record for Patient #1. Therefore, there was no medical record documentation for surveyor review from Hospital #1. Review of medical record from Hospital #2 documented Patient #1 presented on 12/10/2025 at 7:00 a.m. with triage complaints of vaginal bleeding stated, “I had a miscarage [miscarriage].” The nursing note documented Patient #1 had blood all down pants leg and socks. Reported she (Patient #1) started having abdominal pain yesterday that increased the morning of 12/10/2025 and started having vaginal bleeding. Hospital #2 nursing note documented, “I don’t want to see it. Its in my pants [referring to fetus].” In an interview on 12/16/2025 at 11:10 a.m., the Administrator confirmed he was aware of the incident and received a telephone call from father of Patient #1 on 12/10/2025 at 11:49 a.m. and spoke with him about the incident that happened earlier that morning. The Administrator said when the nurse told them there was no obstetrical services, the mother probably did not even hear the nurse say, they would see the patient anyway. The Administrator stated to the survey team, “ ...we have very few grievances and I have already talked to the father. The patient never signed in and left ...”. Hospital #1 provided documentation that following the incident with Patient #1 involved staff were counseled. Additionally, Emergency Department (ED) staff were reeducated on logging each individual that presents for treatment on the ED central log and that EMTALA (Emergency Medical Treatment and Labor Act) requires the hospital to complete an appropriate medical screening exam on all persons seeking care. Review of Facility Policy titled “Pregnant Patients Presenting to the ER,” date 04/2018, revealed “ ...When a pregnant patient presents to the emergency department with an obstetrical related complaint, the registration personnel will immediately contact emergency department nurse who will screen the patient to determine the appropriate area for evaluation of her complaint, i.e., Abdominal pain or bleeding greater than 20 weeks gestation will be evaluated further in labor and delivery (L&D) ... If the patient is treated in the emergency department, the patient will be registered into the computer system/logbook... Ambulatory pregnant patients who are greater than 20 weeks gestation will be screened by the triage nurse in the emergency department who will decide if the patient will be evaluated in the emergency department or sent straight to the L&D ...Imminent delivery (e.g. crowning) will remain in the Emergency Department under the care of the Emergency Department Physician ...”. No other updated policy and procedure presented for review. Review of facility policy titled “Treatment-Emergency, Triage Policy,” review date 04/2018 revealed, “ ... All patients presenting to the emergency department for care should be triaged upon arrival ... triage evaluations by the triage nurse that occur prior to the patients speaking to the registration personnel... Patients presenting to the emergency department are entitled to receive care in the emergency department ... Patient presenting to the emergency department have a routine triage evaluation performed and entered the patient’s medical record as follows, patient name, day of and time of initial patient contact with the triage nurse, mode of arrival (walk, wheelchair, car, ambulance, etc)... Date of birth, chief complaint ...”. Review of facility policy titled “Admitting,” dated 02/2018 reveals “ ...The admitting department clerk will immediately notify the triage nurse if any individual presents with: ...severe pain ...Pregnant patient with pain or bleeding ...”. During exit conference on 12/18/2025 at 5:00 p.m. with the Administrator and the Director of Nursing survey findings were discussed and no further documentation was submitted for review.”

“Compliance with Federal, state, and local law CFR(s): (a)The REH must be in compliance with applicable Federal laws related to the health and safety of patients. (b) The REH must be located in a state that provides for the licensing of such hospitals under state or applicable local law; and is (1) Licensed in the state as an REH; or (2) Approved as meeting standards for licensing established by the agency of the state or locality responsible for licensing hospitals. (c) The REH must assure that personnel are licensed or meet other applicable standards that are required by state or local laws to provide services within the applicable scope of practice. This Condition is not met as evidenced by: 31935 Based on observation and staff interviews, the facility failed to meet the standards for licensing established by the state to have an operational low voltage nurse call system with an annunciator at the nurses’ work area for four (4) of (4) patient exam rooms in the Emergency Department (ED); Emergency Room #1, #2, #3 and Trauma/Obstetric (OB) Room. Findings Include: During a tour of the Emergency Department (ED) on 12/04/2024 at 11:38 a.m. with Registered Nurse (RN) RN #1, observation and testing revealed four (4) of the four (4) ED patient exam rooms did not have a functional electric nurse call system, ER #1, ER #2, ER #3, Trauma/OB room. During an interview with RN #1 on 12/04/2024 at 11:38 a.m., it was confirmed the electric nurse call system is not functional. RN #1 further confirmed the nonfunctional call light was not working this morning on arrival to the morning shift. During an interview with RN #1 on 12/04/2024 at 11:48 a.m., it was confirmed the staff report maintenance issues to the Maintenance Assistant if repairs are needed. During an interview with the Administrator on 12/04/2024 at 11:55 a.m., it was confirmed the electric nurse call system in the ED is not functional. The Administrator further confirmed a work order has not been received or a replacement unit has not been ordered. The Administrator confirmed the maintenance assistant will be notified. During an interview with RN #1 on 12/04/2024 at 3:35 p.m., the electric nurse call system worked for a few minutes after the maintenance assistant replaced the batteries, but the call system stopped working shortly after the batteries were replaced. During an interview with the DON on 12/05/2024 at 9:40 a.m., it was confirmed when staff identify broken equipment or anything that needs repairs, staff are to fill out a maintenance request and send the request to the maintenance department. During an interview with the Maintenance Assistant on 12/05/2024 at 11:04 a.m., it was confirmed a work order is not available for the nonfunctioning electric call system in the ED. It was further confirmed the maintenance assistant was notified yesterday of the electric nurse call system not working in the ED, and the batteries for the desktop electric nurse call system were replaced. The maintenance assistant confirmed the electric nurse call system worked for a little while after the batteries were replaced and then quit working again. The maintenance assistant further confirmed there is currently no plan at this time to replace the electric nurse call system. During an interview with the DON on 12/05/2024 at 1:42 p.m., it was confirmed the facility does not have a policy for the electric nurse call system, or a policy for submitting a work order to maintenance for repairs. During exit conference on 12/05/2024 at 4:00 p.m. with the Administrator and the Director of Nursing (DON), survey findings were discussed, and no further documentation was submitted for review.”

“Provision of services. CFR(s): (c) The policies must include the following: (1) A description of the services the REH furnishes, including those furnished through agreement or arrangement. (2) Policies and procedures for emergency medical services. (3) Guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the REH. (4) Policies and procedures that address the post-acute care needs of patients receiving services in the REH. This Condition is not met as evidenced by: 48128 Based on staff interview and review of the facility’s attestation for conversion to Rural Emergency Hospital (REH) sent to CMS with their CMS-855 application to convert from a Critical Access Hospital (CAH) to a Rural Emergency Hospital (REH) dated 02/07/2024, ref# 3240240201, Provider # 251329, (conversion request documentation in CMS), the facility failed to ensure the development, approval, or adoption of required policies and procedures: a description of the services it furnishes including those furnished through agreement or arrangement; policies and procedures for emergency medical services; policies for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral; the maintenance of health care records; and procedures for the periodic review and evaluation of the services furnished; and policies and procedures that address the post-acute care needs of patients receiving services in the REH for three (3) of three (3) days of survey. Findings Include: During the Entrance Conference on 12/03/2024 beginning at 1:00 p.m. with the Director of Nursing (DON) conducted by the team leader, a request was made for the facility’s policy and procedures for services it furnishes to include those furnished through agreement or arrangement; polices for the medical management of health problems, consultation or referral, maintenance of health care records, and procedures for the periodic review and evaluation of the services provided and discharge planning, and the facility’s attestation for conversion to Rural Emergency Hospital (REH). No documented evidence of requested policies and procedures presented for review. During an interview with the Director of Nursing (DON) on 12/05/2024 at 1:42 p.m., it was confirmed the last review of the facility’s policies and procedures was 09/14/2022. It was further confirmed the policies and procedures are to be reviewed annually. The DON confirmed there are no policies available for review for the Rural Emergency Hospital (REH) at this time. Review of the facility document, “Greene County Hospital, Summary of Conversion Plan,” sent to CMS with their CMS-855 application to convert from a Critical Access Hospital (CAH) to a Rural Emergency Hospital (REH) dated 02/07/2024, ref# 3240240201, Provider # 251329, (conversion request documentation in CMS), “ ...Attestation: I understand that as an REH, the facility must meet all Conditions of Participation (CoP) in 42 CFR, Part 485 ...including the following: ...485.514 CoP: Provision of Services ...currently meets and will continue to meet all requirements for Rural Emergency Hospitals set forth in Subpart E of 42 CFR, Part 485 and other applicable Federal law and regulation ...”, signed by the Administrator. During exit conference on 12/05/2024 at 4:00 p.m. with the Administrator and the Director of Nursing (DON), survey findings were discussed, and no further documentation was submitted for review.”

“Infect prevent & control program org & policy CFR(s): (a)(3) The infection prevention and control program include surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 45467 Based on staff interview, policy and procedure review, review of documents titled “Patients’ Rights,” “Employee Incident Exposure Protocol,” the facility failed to maintain and a clean and sanitary environment to avoid sources and transmission of infectious diseases by allowing exotic animals (monkeys and McCaw) to be temporarily housed in an inpatient area not currently being used in the facility, and having monkeys in a cage sitting on a gurney in the Emergency Department (ED) during two (2) separate reported incidents. Findings Include: Review of facility Patient’s Right Acknowledgement Form, Revision 3.0, dated 10/02/2023, “ ...Each patient has the right to reasonable access to care ...including matters of applicable laws and regulations ...Each patient has the right to receive care in a safe setting ...”. Review of the facility Employee Incident Exposure Protocol, not dated “...Notify the Supervisor of the incident ...no later than the end of shift ...complete the Employee Occurrence Form ...fill out the Accident Investigation and Miss. Workers Comp Physicians Choice Form ...Employees are to register and be evaluated by ER MD (at no cost to the employee) and receive a Tetanus Booster ...follow up with the employee health nurse ...”. Interview with Director of Nursing (DON) on 09/11/2024 at 11:48 a.m. confirmed Employee #1 sustained a bite from a monkey, no medical evaluation was performed after the bite, Incident Report was not filed, and documentation of the incident was not recorded in the Infection Control Surveillance Log. Interview with Employee #1 on 09/11/2024 at 12:59 p.m. confirmed a bite from a monkey was sustained and a medical evaluation was not performed, and an Incident Report was not filed. Interview with Nurse Practitioner #1 on 09/11/2024 at 1:07 p.m. confirmed a monkey was brought to the facility and an employee was bitten on the finger. Review of facility OSHA policy and procedure, policy number 28A, dated May 2015, “ ...The Federal Occupational Safety and Health Administration (OSHA) published the standard of Occupational Exposer to Blood Borne Pathogens ...all healthcare employers protect workers against occupational exposure to ...blood borne pathogens ...The regulations require the following ...Exposure Control Plan ...Follow-up exposure incidents ...Compliance with all the above is mandatory ...”. Review of facility policy and procedure Employee Health, policy number 24A, dated March 2024, “ ...The Infection Control Program ...in important in protecting both patients and personnel from unnecessary risk of disease ...establish a system for detecting and reporting infection illnesses in hospital personnel ...All personnel ...having on the job injury should report to their supervisor and Employee Health/Infection Control Nurse ...personnel having on the job injury must complete an Employee Occurrence Form ...First aid will be provided in the Emergency Room for any on-duty employee ...Employees ...exposure incident should adhere to the established guidelines ...”. Review of facility Infection Control, Policy Number 1A, dated May 2018, “ ...recognize, prevent, and control ...correction and follow up determine the problem have been corrected ...”. Review of facility Infection Control, Policy Number 3A, dated May 2018, “ ...implement and maintain a clearly defined system of identifying and resolving problems pertaining to infection control ...”. Review of facility Infection Control Performance Improvement Plan, Policy Number 6A, dated May 2018, “ ...hospital wide system for surveillance, prevention, and control of infections ...Identification and resolution of problems ...efficiently monitor ...surveillance activities ...measurable variables related to structure, process, or outcomes ...Prevention indicators ...a specific problem or an opportunity for improvement, a plan will be formulated ...actions taken ...the ...goal ...is to provide services in an environment that is safe for both patient and employees ...resolve problems that are identified ...”. During exit conference with the Administrator and the DON on 09/12/2024 at 1:53 p.m. survey findings were discussed and no further document submitted for review.”