Quitman Community 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: 44086 Based on observation of emergency department video footage at Facility #1 (Quitman Community Hospital) on 04/13/2026, at approximately 8:00 p.m., staff interviews, Emergency Department (ED) central log review, policy and procedure review, review the facility’s diversion log, Quality/Leadership Council Meeting minutes, and medical record review from Facility #2, Quitman Community Hospital failed to provide an appropriate Medical Screening Exam (MSE) to individuals who presented to the emergency department to determine if an Emergency Medical Condition (EMC) existed. This deficient practice affected three (3) of 20 medical records reviewed: Patients #1, #2, and #3. Findings Include: Observation of Facility #1’s Emergency Department (ED) video footage from 04/13/2026 at 8:02:04 p.m. to 8:07:09 p.m. revealed a male adult escorting four (4) adolescents (one (1) male and (3) three females) and a Sheriff’s Deputy into the Facility’s ED entry waiting room at approximately 8:00 p.m. The adult male reported three (3) of the adolescents were in an accident involving an All-Terrain Vehicle (ATV) four-wheeler and have injuries. The adult male also reported the male adolescent has not been able to talk. Video observation showed the injured adolescent male with deficits while walking; the patient kept his head hung down and does not talk. A nurse comes into the waiting room and announces they can see them and they can be treated but that they do not have a computerized tomography (CT) scanner available for testing. The adult male told the nurse he knows two (2) of the three (3) will need that especially the boy; and he wants to call the male adolescent’s mother to see what she wants to do. The nurse left the entry waiting room area when the adult male went outside while talking on his phone. The three (3) adolescents were sitting in waiting room attended by the Sheriff’s Deputy only. One (1) female is observed crying and appears to be in pain, the male is hanging his head down and slumping over. At approximately 8:05 p.m. the adult male returns to the ED waiting room and instructs the adolescents to go back to the car. The Sheriff’s Deputy returns to the waiting area and informs the receptionist the adult male was taking the injured adolescents to Facility #2 for treatment. The Emergency Department video review revealed no attempts to provide a Medical Screening Exam or provide the guardian education on risks of leaving without being seen or to obtain documentation of leaving the facility against medical advice. An interview with complainant on 04/21/2026 at 10:30 a.m. to 11:00 a.m. confirmed Patients #1, #2 and #3 arrived at Facility #2’s Emergency Department (ED) in a private vehicle; and no ambulance transfer was initiated or report from Facility #1 to Facility #2. An interview with the Administrator and the Director of Nursing (DON) on 04/21/2026 at 12:30 p.m. confirmed the observation and findings of Facility #1’s ED video footage dated 04/13/2026 at 8:02:04 p.m. to 8:07:09 p.m. An interview on 04/22/2026 at 10:40 a.m. with the new Chief Executive Officer and Regional Nursing Director for Facility #1 confirmed there is a new service agreement in place, and facility is awaiting delivery of a computerized tomography (CT) scanner. A phone interview with Registered Nurse (RN) #1 at 3:00 p.m. on 04/22/2026 confirmed she was the nurse working on 04/13/2026 at 8:00 p.m. RN #1 further confirmed she walked into the entry waiting area after receiving a call from receptionist and saw the male adult and four (4) others with him. She confirmed telling him they could be seen but facility is not able to do a CT scan. She verified the adult male called someone on the phone, then gathered the adolescents and took them to the car. RN #1 confirmed no entry for the patients was made in the Emergency Department Central Log, no triage or medical screening was initiated, and no attempts to provide the guardian education on risks of leaving without being seen or to obtain documentation of leaving the facility against medical advice were made. Review of Facility #1’s ED Central Log for 04/13/2026 revealed no documentation for Patients #1, #2, or #3 Emergency Department visit. No medical record review from Facility #1, no medical record generated by Facility #1 for review for Patients #1, #2, or #3 for ED visit on 04/13/2026. Review of Facility #2’s medical record for Patient #1 revealed patient was triaged and a medical screening exam (MSE) was completed. History and physical assessment revealed Patient #1 with a history of a previous traumatic brain injury (TBI), and imaging tests revealed the evidence of a sustained skull fracture. Patient #1 was transferred to a higher level of care due to diagnosis and previous history of TBI with medical transport at 3:11 a.m. on 04/14/2026. Review of Facility #2’s medical record for Patient #2 revealed patient presented to the emergency department with a complaint of pain in back and both lower extremities. A medical screening exam and imaging testing revealed a hematoma and abrasion to left anterior head, abrasions to nose and right upper lip, abrasions to right hand, right arm, left flank and left shoulder and multiple abrasion to left hip. Patient #2 was treated and provided medication for pain relief and discharge home in care of parents at 12:26 a.m. on 04/14/2026. Review of Facility #2’s medical record for Patients #3 revealed patient presented to the emergency department with a complaint of headache, back pain and bilateral leg pain after being ejected from an All-Terrian Vehicle (ATV). Triage and a MSE was completed, imaging ordered. Patient #3 was discharged home with parents at 1:19 a.m. on 04/14/2026 with a diagnoses of multiple abrasions in stable condition. Review of the facility policy and procedure titled “EMTALA Policy,” with approval date 01/23/2025 revealed, “ ...Policy: A. The hospital will provide an appropriate medical screening examination within the capability of the hospital’s dedicated emergency department ...B. The hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility ...Procedure: A. Triage and Registration 1. Triage a. as soon as practical after arrival, individuals who come to the emergency department should be triaged to determine the order in which they will receive a medical screening examination ...B. Medical Screening Examination 1. The hospital screening examination to any individual who comes to the emergency department ...C. 1. The hospital must maintain a central log of individuals who come to the emergency department and include in such a log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ...”. Review of the facility policy and procedure titled “Emergency Department Scope of Services, Limitations, and Transfer Policy,” with no date revealed, “ ...Policy Statement ...emergency department provides emergency medical screening, stabilization, and treatment within the scope of available staff, equipment, and specialty services.. When a patient’s condition exceeds the hospital’s capabilities, appropriate stabilization measures will be initiated, and timely transfer to a higher level of care will be arranged. I. Emergency Department Capabilities ... medical screening exams, initial assessment, triage, and stabilization, management of common medical emergencies, basic trauma stabilization, IV therapy, medications, oxygen therapy, wound care, splinting, and fracture stabilization, cardiac monitoring and emergency resuscitation, diagnostic services as available (labs, x-ray, CT if available) ...II. Emergency Department Limitations ...advanced trauma surgery or trauma center-level care ...III. Management of patients beyond hospital capability: Completion of medical screening exam, initiation of stabilization, determination of need for higher level of care prompt initiation of transfer process, continuous monitoring until transfer ...” Review of the Diversion Log revealed Facility #1 was on diversion 02/20/2026 and again on 03/03/2026 until present for no CT scanner capabilities. Review of the facility policy and procedure titled “Diversion Policy,” with approval date 01/23/2025 revealed, “ ...ALL patients arriving on hospital property will be evaluated by a provider regardless of diversion status ...”. Review of Quality/Leadership Council Meeting Minutes dated March 12, 2026, revealed CT scanner currently unavailable and meeting minutes dated April 16, 2026, revealed CT scanner remains unavailable, replacement still in progress. During an exit conference held 12:15 p.m. to 12:40 p.m. on 04/23/2026 with the Administrator, Director of Nursing (DON), Regional DON and the Chief Executive Officer (CEO), the survey findings were discussed, and no additional information was submitted. Cross Refer to C2406 for additional findings.”

“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: 44086 Based on video footage observation, staff interview, review of the Emergency Department Central Log, review of the facility Emergency Medical Treatment and Labor Act (EMTALA) policy and procedures, the facility 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 three (3) out of 20 sampled patients, Patient #1, #2, #3. Findings Include: Observation of video footage of Facility #1’s (Quitman Community Hospital) Emergency Department from 04/13/2026 at 8:02:04 p.m. to 08:07:09 p.m. revealed a male adult escorting three adolescents (one male and two female) and a sheriff’s deputy into entry waiting room around 8:00 p.m. He reports injuries to the three involved in an ATV accident. A nurse comes into the waiting room and announces they can see them and they can be treated but that they do not have a computerized tomography (CT) scanner available for testing . The adult male says he knows two (2) of the three (3) will need that especially the boy and that he wants to call the mother to see what she wants to do. The nurse left the entry waiting room when the adult male went outside talking on the phone while the three (3) sitting in waiting room were attended by the Sheriff’s Deputy. One (1) female is observed crying and appears to be in pain, the male is hanging his head down and slumping over. At approximately 8:05 p.m. the adult male returns to the ED waiting room and instructs the adolescents to go back to the car. The Sheriff’s Deputy comes back into the waiting area and informs the receptionist the adult male was taking the injured adolescents to Facility #2 for treatment. The video review revealed no attempts to obtain information from the injured individuals while in the waiting room. An interview with the Administrator and the Director of Nursing (DON) on 04/21/2026 at 12:30 p.m. confirmed the observation and findings of Facility #1’s ED video footage dated 04/13/2026 at 8:02:04 p.m. to 8:07:09 p.m. Phone interview with Registered Nurse (RN) #1 at 3:00 p.m. on 04/22/2026 confirmed no entry for Patients #1, #2, #3 was made in the Emergency Department’s Central log after presenting to the Emergency Department on 04/16/2026 for injuries obtain in an accident. Review of Emergency Department (ED) Central Log for 04/13/2026 for Facility #1 revealed no names entered for Patients #1, #2, or #3. Review of the facility policy and procedure titled “EMTALA Policy” with approval date 01/23/2025 revealed, “ ...Procedure: C. 1. The hospital must maintain a central log of individuals who come to the emergency department and include in such a log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ...”. During an exit conference held 12:15 p.m. to 12:40 p.m. on 04/23/2026 with the Administrator, Director of Nursing (DON), Regional DON and the Chief Executive Officer (CEO), the survey findings were discussed, and no additional information was submitted.”

“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: 44086 Based on video footage observation, staff interview, absence of medical records to review, and review of policies and procedures, the facility (Quitman Community Hospital) failed to provide a medical screening exam (MSE) within the capability of the hospital’s Emergency Department (ED) by a qualified individual to determine if an emergent medical condition existed (EMC) for patients who presented to the facility requesting assistance with injuries after an All-Terrain Vehicle (ATV) accident for three (3) of 20 sampled patient; Patient #1, #2, #3. Findings Include: Observation of Facility #1’s (Quitman Community Hospital) Emergency Department (ED) video footage from 04/13/2026 at 8:02:04 p.m. to 8:07:09 p.m. revealed a male adult escorting three (3) adolescents (one (1) male and (2) two females) and a Sheriff’s Deputy into the Facility’s ED entry waiting room at approximately 8:00 p.m. The adult male reported three (3) of the adolescents were in an accident involving an All-Terrain Vehicle (ATV) four-wheeler and have injuries. The adult male also reported the male adolescent has not been able to talk. Video observation showed the injured adolescent male with deficits while walking; he keeps his head hung down and does not talk. A nurse comes into the waiting room and announces they can see them and they can be treated but that they do not have a computerized tomography (CT) scanner available for testing. The adult male told the nurse he knows two (2) of the three (3) will need that especially the boy; and he wants to call the male adolescent’s mother to see what she wants to do. The nurse left the entry waiting room area when the adult male went outside while talking on his phone. The three (3) adolescents were sitting in waiting room attended by the Sheriff’s Deputy only. One (1) female is observed crying and appears to be in pain, the male is hanging his head down and slumping over. At approximately 8:05 p.m. the adult male returns to the ED waiting room and instructs the adolescents to go back to the car. The Sheriff’s Deputy comes back into the waiting area and informs the receptionist the adult male was taking the injured adolescents to Facility #2 for treatment. The video review revealed no attempts to provide a Medical Screening Exam or provide the guardian education on risks of leaving without being seen or to obtain documentation of leaving the facility against medical advice. Interview with the Administrator and the Director of Nursing (DON) on 04/21/2026 at 12:30 p.m. confirmed observation and findings of emergency department video footage dated 04/13/2026 at 8:02:04 pm to 8:07:09 p.m. A phone interview with Registered Nurse (RN) #1 at 3:00 p.m. on 04/22/2026 confirmed no triage or medical screening exams were initiated for Patients #1, #2, #3 who presented to the emergency department on 04/13/2026 after an All-Terrain Vehicle (ATV) accident and report of male adolescent not able to talk. No medical records or documentation was initiated for Patients #1, #2, or #3. Review of the facility policy and procedure titled “EMTALA Policy” with approval date 01/23/2025 revealed, “ ...Policy: A. The hospital will provide an appropriate medical screening examination within the capability of the hospital’s dedicated emergency department ...B. The hospital will: (a) provide to an individual who is determined to have an emergency medical condition such further medical examination and treatment as is required to stabilize the emergency medical condition, or (b) arrange for transfer of the individual to another medical facility ...Procedure: A. Triage and Registration 1. Triage a. as soon as practical after arrival, individuals who come to the emergency department should be triaged to determine the order in which they will receive a medical screening examination ...B. Medical Screening Examination 1. The hospital screening examination to any individual who comes to the emergency department ...”. Review of the facility policy and procedure titled “Emergency Department Scope of Services, Limitations, and Transfer Policy,” with no date revealed “ ...Policy Statement ...emergency department provides emergency medical screening, stabilization, and treatment within the scope of available staff, equipment, and specialty services. When a patient’s condition exceeds the hospital’s capabilities, appropriate stabilization measures will be initiated, and time transfer to a higher level of care will be arranged. I. Emergency Department Capabilities ...medical screening exams, initial assessment, triage, and stabilization, management of common medical emergencies, basic trauma stabilization, IV therapy, medications, oxygen therapy, wound care, splinting, and fracture stabilization, cardiac monitoring and emergency resuscitation, diagnostic services as available (labs, x-ray, CT if available) ...II. Emergency Department Limitations ...advanced trauma surgery or trauma center-level care ...III . Management of patients beyond hospital capability: Completion of medical screening exam, initiation of stabilization, determination of need for higher level of care prompt initiation of transfer process, continuous monitoring until transfer ...” Review of the facility policy and procedure titled “Diversion Policy,” with approval date 01/23/2025 revealed “ ...ALL patients arriving on hospital property will be evaluated by a provider regardless of diversion status ...”. During an exit conference held 12:15 p.m. to 12:40 p.m. on 04/23/2026 with the Administrator, Director of Nursing (DON), Regional DON and the Chief Executive Officer (CEO), the survey findings were discussed, and no additional information was submitted. Cross Refer to C-2400 for additional findings.”

“Fire Alarm System - Installation CFR(s): NFPA 101 Fire Alarm System - Installation A fire alarm system is installed with systems and components approved for the purpose in accordance with NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm Code to provide effective warning of fire in any part of the building. In areas not continuously occupied, detection is installed at each fire alarm control unit. In new occupancy, detection is also installed at notification appliance circuit power extenders, and supervising station transmitting equipment. Fire alarm system wiring or other transmission paths are monitored for integrity. 18.3.4.1, 19.3.4.1, 9.6, 9.6.1.8 This Standard is not met as evidenced by: 43981 Based on observations, the facility failed to maintain a complete manual fire alarm system as directed by NFPA 72 Chapter 10, and NFPA 101 section 9.6. The deficient practice affected the entire facility on the day of survey. Findings Include: On 12/22/25 at 11:45 AM, observation revealed a “trouble signal” on the fire alarm system panel in the facility. The System is operable and sends signal to the monitoring company. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 12/22/25.”

“Fire Drills CFR(s): NFPA 101 Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7 This Standard is not met as evidenced by: 43981 Based on record review and interviews, the facility failed to properly perform fire drills as per NFPA 101 section 19.7.1.2. This deficiency affected the entire facility on the day of the survey. Findings include: On December 22, 2025, at 1:35 PM, the facility failed to provide documentation showing fire drills performed for the 2nd shift for the 1st, 2nd and 3rd quarter of the current year of 2025. The finding was acknowledged by the Administrator and Maintenance Supervisor verified this observation during the exit interview on 12/22/25.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 43981 Based on the review of documentation, the facility failed to properly document records of testing the generator annually as directed by NFPA 99 sections 6.4.4.1.1.3 and 6.4.4.2. This deficient practice had potential of affecting the entire facility on the day of facility survey. Findings include: On 12/22/25 at 1:30 PM, the facility could not produce documentation showing the current 2025 annual testing and service of the generator. The facility ’ s last annual test of the generator is unknown. The finding was acknowledged by the Administrator and Maintenance Supervisor during the exit interview on 12/22/25.”

“INFECTION PREVENT & CONTROL & ABT STEWAR PROG CFR(s): The CAH must have active facility-wide programs, for the surveillance, prevention, and control of HAIs and other infectious diseases and for the optimization of antibiotic use through stewardship. The programs must demonstrate adherence to nationally recognized infection prevention and control guidelines, as well as to best practices for improving antibiotic use where applicable, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms. Infection prevention and control problems and antibiotic use issues identified in the programs must be addressed in coordination with the facility-wide quality assessment and performance improvement (QAPI) program. This Condition is not met as evidenced by: 48927 Based on staff interviews, review of quarterly Governing Body Meeting minutes from November 2024 through October 2025, and review of the Medical Staff Rules and Regulations, the facility failed to have an active facility-wide program for the surveillance, prevention, and control of Hospital Acquired Infections (HAIs) and other infectious diseases and for the optimization of antibiotic use through stewardship. The facility also failed to demonstrate a qualified professional was appointed by the Governing Body to be responsible for the program. The facility failed to have documented policies and procedures for an infection control program for preventing and controlling transmission of infections and that reflects the scope and complexity of the services provided. The facility’s Governing Body failed to ensure systems were in place and operational for tracking and reporting infection surveillance and antibiotic use, infection control policy and procedures were in place and that the infection control program collaborated with the facility’s Quality Program. The facility failed to show adherence to nationally recognized infection prevention and control guidelines, as well as best practice for improving antibiotic use, and for reducing the development and transmission of HAIs and antibiotic-resistant organisms for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:22 p.m. confirmed the facility does not have an implemented Infection Control Program and the DON could not identify any program components such as surveillance, prevention strategies, evaluation processes, or identify a designated Infection Control professional appointed by the Governing Body. An Interview on 12/18/2025 via telephone at 1:15 p.m. with the facility Pharmacist confir”

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 48927 Based on staff interviews, review of Governing Board Meeting Minutes from November 2024 through October 2025, and review of Medical Staff Rules and Regulations, the facility failed to develop, implement, and maintain an effective, ongoing, facility wide data-driven quality assessment and performance improvement (QAPI) Program that encompasses the complexity of its services, has objective measures to evaluate and analyze its processes, functions, and services, prevents and reduces medical errors and adverse events and focuses on improving health care outcomes and setting priorities for performance improvement and consider high risk, problem prone areas for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:30 p.m. confirmed the facility does not have a Quality Assessment Performance Improvement Program. An Interview with Administrator on 12/18/2025 at 2:20 p.m. confirmed the facility has not developed, implemented, or maintained comprehensive ongoing, data driven a QAPI Program, and the facility does not have any data collection, policy and procedures for Quality Assurance. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, the facility failed to identify any documented evidence the facility maintains a Quality Improvement program, or at least annually reviews policy and procedures, utilization of services, quality of care prevention/identification, identifications of nosocomial infections, medication therapy and the quality and appropriateness of diagnosis and treatment by mid-level and doctors of medicine/osteopathy. No policies and procedures/data collection for quality assessment, annual reviews, infection control presented for review.”

“EMERGENCY AND SUPPLIES CFR(s): Equipment and supplies commonly used in life-saving procedures, including airways, endotracheal tubes, ambu bag/valve/mask, oxygen, tourniquets, immobilization devices, nasogastric tubes, splints, IV therapy supplies, suction machine, defibrillator, cardiac monitor, chest tubes, and indwelling urinary catheters. This Standard is not met as evidenced by: 48927 Based on observation, interview, and record review, the facility failed to ensure that equipment and supplies commonly used in life-saving procedures were available and maintained in a safe and usable condition, as evidenced by expired emergency supplies and no current preventative maintenance documentation for three (3) of three (3) survey days. Findings include: Observations made on 12/16/2025 at 2:45 p.m. to 4:45 p.m. during tour of the Medical/Surgical Unit, Emergency Department, Central Supply, Senior Unit, Radiology Unit, and the Respiratory Department with the Director of Nursing (DON) revealed multiple expired supplies and equipment with outdated preventative maintenance stickers, including but not limited to: 1. Infant lumbar puncture tray in the trauma room of the emergency department expired 04/30/2024 2. Adult lumbar puncture tray expired 07/31/2024 in the trauma room of the emergency department 3. Two (2) Central venous catheter kits expired 01/31/2025 and 07/31/2025 in the trauma area of the emergency department 4. Cricothyroidotomy catheter tray expired 04/15/2025 in the trauma room of the emergency department 5. Opened Pediatric Ambu bag expired 05/29/2023, in the trauma room on the pediatric emergency cart; one pediatric Ambu bag in the respiratory department expired 05/27/2025 6. Fifteen (15) Laryngoscope blades expired 07/31/2022 in the respiratory department 7. Duoderm dressings expired 08/12/2024 and 08/27/2024 in the central supply room 8. Xeroform packets expired 05/21/2025 in the central supply room 9. One stylite expired 02/2024 in the respiratory department 10. Four (4) introducer Bougie catheters expired 10/2/2023 in the respiratory department 11. Central su”

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 48927 Based on observations, interviews with facility directors, and review of facility policy and procedure the Critical Access Hospital (CAH) failed to ensure that all essential mechanical, electrical, and patient-care equipment was maintained in safe operating condition to protect patient safety with no active preventive maintenance program identified for three (3) of three (3) survey days. Findings include: During the facility tour 12/16/2025 at 2:45 p.m. to 4:45 p.m. the surveyor also observed on the Medical/Surgical Unit, Emergency Department, Central Supply, Senior Unit, Radiology Unit, and the Respiratory Department with the DON, multiple types of patient care equipment with outdated preventative maintenance stickers including but not limited to: 1. Pediatric Automated External Defibrillator (AED) machine in the trauma room on the pediatric emergency cart with preventative maintenance (PM) sticker due 06/2025 2. Suction machine on the pediatric emergency cart in the trauma room of the emergency department with no PM sticker 3. AED on adult emergency cart in trauma area with no current PM sticker 4. Suction on adult emergency cart in trauma room of emergency department with no current PM sticker 5. Cardiac monitor mounted on wall at trauma bed #1 with PM sticker date due 06/2025 6. Intravenous pump (IVP) by trauma bed #1 with PM sticker due 06/2025 7. Trauma bed #2 IVP by bed with PM sticker due date of 06/2025 8. ER Room #3 with digital mobile vital sign monitor with no PM sticker noted 9. Trauma room Electrocardiogram machine with PM sticker due 01/2024 10. IVP in Medical/Surgical patient room #1 with no PM sticker 11. Medical/Surgical Room 104 with an intravenous pump with PM sticker”

“PATIENT CARE POLICIES CFR(s): [The policies include the following:] (iv) Rules for the storage, handling, dispensation, and administration of drugs and biologicals. These rules must provide that there is a drug storage area that is administered in accordance with accepted professional principles, that current and accurate records are kept of the receipt and disposition of all scheduled drugs, and that outdated, mislabeled, or otherwise unusable drugs are not available for patient use. This Standard is not met as evidenced by: 48927 Based on observations during tours, interview with facility administration, and review of facility policy and procedure and daily temperature logs, the facility failed to ensure drugs and biologicals were stored, handled, and monitored in accordance with accepted professional principles by labeling multidose vials with opened date or do not use dates on two (2) of three (3) medication storage locations, Pharmacy and Medical/Surgical/Emergency medication areas; and did not demonstrate consistent monitoring to ensure medications were stored within required temperature ranges on three (3) of three (3) medication storage locations, Senior Care Unit, Medical/Surgical/Emergency, and Pharmacy for three (3) of three (3) days of survey. . Findings include: During a tour of the facility pharmacy department and medication storage rooms with the Director of Pharmacy on 12/17/2025 at 4:20 p.m. to 4:40 p.m., one (1) opened multidose vial of Lispro was identified in the pharmacy department medication storage refrigerator and one (1) opened multidose Lispro vial and one (1) opened Humulin R multidose vial were identified in the medical/surgical/emergency room medication storage refrigerator without opened dates or beyond use dates documented on labels. During a tour of the facility pharmacy department and medication storage rooms with the Director of Pharmacy on 12/17/2025 at 4:20 p.m. to 4:40 p.m. revealed three (3) medication storage refrigerators were identified with incomplete temperature daily monitoring logs in the pharmacy department, senior care unit medication room, and the medical/surgical/emergency medication rooms. The Director of Pharmacy confirmed during interview on 12/17/2025 at 4:50 p.m. that three (3) opened multi-dose vials lacked required opened or discard-by labeling. He further confirm”

“INFECTION PREVENT & CONTROL ORG & POLICIES CFR(s): Infection prevention and control program organization and policies. The CAH must demonstrate that: (1) An individual (or individuals), who is qualified through education, training, experience, or certification in infection prevention and control, is appointed by the governing body, or responsible individual, as the infection preventionist(s)/infection control professional(s) responsible for the infection prevention and control program and that the appointment is based on the recommendations of medical staff leadership and nursing leadership; This Standard is not met as evidenced by: 48927 Based on staff interviews, review of quarterly Governing Body Meeting minutes from November 2024 through October 2025, and review of the Medical Staff By-Laws the facility failed to appoint a designate individual who is qualified and appointed by the governing body to be responsible for an Infection Prevention and Control Program for three (3) of three (3) days of survey. Findings Include: An interview with the Director of Nursing (DON) on 12/17/2025 at 5:22 p.m. confirmed the facility does not have and has not appointed a qualified individual to be responsible for an Infection Prevention and Control Program. Review of Governing Board Meeting Minutes from November 2024 through October 2025, Medical Staff Rules and Regulations, approved 2019, failed to identify any documented evidence a designated Infection Control professional was appointed to oversee a facility-wide Infection Control/Antibiotic Stewardship Program for the surveillance, prevention and control of infections and Antibiotic Stewardship Program. No Infection Control Policy and Procedures or evidence of an Infection Control/Antibiotic Stewardship Program were provided for review as requested. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“INFECTION PREVENT & CONTROL POLICIES CFR(s): The infection prevention and control program, as documented in its policies and procedures, employs methods for preventing and controlling the transmission of infections within the CAH and between the CAH and other healthcare settings; This Standard is not met as evidenced by: 48927 Based on staff interviews, review of quarterly Governing Body Meeting minutes from November 2024 through October 2025, and review of the Medical Staff Rules and Regulations, the facility failed to provide policies and procedures that employ methods for preventing and controlling the transmission of infections within the facility and between other healthcare settings for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:22 p.m. confirmed facility does not have any available documented policies and procedures regarding infection control practices for preventing and controlling the transmission of infections within the facility. Review of Governing Board Meeting Minutes from November 2024 through October 2025, Medical Staff Rules and Regulations, approved 2019, failed to identify any documented evidence of policies and procedures for a facility-wide Infection Control/Antibiotic Stewardship Program. No Infection Control Policy and Procedures or evidence of an Infection Control/Antibiotic Stewardship Program were provided for review as requested. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes 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: 48927 Based on staff interviews, review of Governing Board Meeting Minutes from November 2024 through October 2025, Medical Staff Rules and Regulations the facility failed to identify any documented evidence of a facility-wide Infection Control/Antibiotic Stewardship Program, activities of surveillance, prevention and control of Health Care Associated Infections (HAIs), or address any infection control issues identified by public health authorities for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:22 p.m. confirmed the facility does not have any documented evidence of Infection Control Program activities such as surveillance and reporting of infections and HAIs. Review of Governing Board Meeting Minutes from November 2024 through October 2025, Medical Staff Rules and Regulations, approved 2019, failed to identify documented evidence of collection and reporting of Infection Control Program activities including surveillance, prevention, and control of Health Care Associated Infections (HAIs), or policies and procedures for a facility-wide Infection Control/Antibiotic Stewardship Program. No Infection Control Policy and Procedures or evidence of an Infection Control/Antibiotic Stewardship Program were provided for review as requested. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“INFECTION PREVENT & CONTROL SCOPE & SEVERITY CFR(s): The infection prevention and control program reflects the scope and complexity of the CAH services provided. This Standard is not met as evidenced by: 48927 Based on staff interviews, review of Governing Board Meeting Minutes from November 2024 through October 2025, and review of Medical Staff Rules and Regulations fail to identify documented evidence the facility has any evidence of written documentation of an Infection Control Program which reflects the scope and complexity of the facility’s services provided for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:22 p.m. confirmed the facility does not have documentation of a facility-wide Infection Prevention and Control Program which reflects the scope and complexity of the services provided by the facility. Review of Governing Board Meeting Minutes from November 2024 through October 2025, Medical Staff By-Laws Rules and Regulations, approved 2019, fail to identify any documented evidence of a facility-wide Infection Prevention and Control Program which reflects the scope and complexity of the services provided by the facility. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1204/485.640 for additional findings.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (1) The governing body, or responsible individual, must ensure all of the following: (i) Systems are in place and operational for the tracking of all infection surveillance, prevention and control, and antibiotic use activities, in order to demonstrate the implementation, success, and sustainability of such activities. This Standard is not met as evidenced by: 48927 Based on staff interviews, review of Governing Board Meeting Minutes from November 2024 through October 2025, and review of Medical Staff Rules and Regulations, the facility’s Governing Body failed to ensure the facility has systems in place and operational for the tracking of all infection surveillance, prevention and control and antibiotic use activities for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:22 p.m. confirmed there is no documentation for infection surveillance, prevention and control or antibiotic usage for the facility. An Interview with the Pharmacist on 12/18/2025 at 1:15 p.m. confirmed the facility does not have an antibiotic stewardship program and has no documented evidence of antibiotic use activities performed. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, approved 2019, fail to identify any documented evidence of a facility-wide Infection Prevention and Control Program which includes systems in place and operational for the tracking of infection surveillance, prevention and control and antibiotic use activities. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (ii) All HAIs and other infectious diseases identified by the infection prevention and control program as well as antibiotic use issues identified by the antibiotic stewardship program are addressed in collaboration with the CAH’s QAPI leadership. This Standard is not met as evidenced by: 48927 Based on staff interviews, review of Governing Board Meeting Minutes from November 2024 through October 2025, and review of Medical Staff Rules and Regulations, the facility failed to ensure collaboration with the Quality Assurance Performance Improvement (QAPI) leadership on three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing on 12/17/2025 at 5:30 p.m. confirmed the facility does not have infection control data or a Quality Assessment and Performance Improvement (QAPI) team. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, approved 2019, failed to identify any documented evidence of a facility-wide Infection Prevention and Control Program which includes collaboration with a QAPI team. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (2) The infection prevention and control professional(s) is responsible for: (i) The development and implementation of facility-wide infection surveillance, prevention, and control policies and procedures that adhere to nationally recognized guidelines. This Standard is not met as evidenced by: 48927 Based on staff interviews, review of Governing Board Meeting Minutes from November 2024 through October 2025 and review of the Medical Staff Rules and Regulations, the facility failed to provide any documentation which indicates the facility follows nationally recognized guidelines as it relates to infection control and prevention on three (3) of three (3) days of survey. . Findings Include: An Interview with the DON on 12/17/2025 at 5:22 p.m. confirms there are no policies and procedures for following nationally recognized guidelines for their infection control activities. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, approved 2019, failed to show documented evidence that the facility has policy and procedures for following nationally recognized guidelines for infection control. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“LEADERSHIP RESPONSIBILITIES CFR(s): (3) The leader(s) of the antibiotic stewardship program is responsible for: (i) The development and implementation of a facility-wide antibiotic stewardship program, based on nationally recognized guidelines, to monitor and improve the use of antibiotics. This Standard is not met as evidenced by: 48927 Based on staff interview, review of Governing Board Meeting Minutes from November 2024 through October 2025 and review of the Medical Staff Rules and Regulations, the facility failed to develop an Antibiotic Stewardship Program for three (3) of three (3) days of survey. Findings Include: An interview with the facility Pharmacist on 12/18/2025 at 1:15 p.m. via telephone confirmed the facility does not have an Antibiotic Stewardship Program. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, approved 2019, failed to show documented evidence that the facility has an Antibiotic Stewardship Program. No policy and procedures presented for review as requested. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1203/485.640 for additional findings.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (1) Be appropriate for the complexity of the CAH’s organization and services provided. This Standard is not met as evidenced by: 48927 Based on interviews with hospital leadership, review of the facility’s Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff By-Laws Rules and Regulations, the facility failed to develop and implement a quality assessment and performance improvement (QAPI) Program that encompasses the complexity and scope of services provided for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:30 p.m. confirmed the facility has not performed evaluation of the facility’s scope of services and does not have a Quality Assurance Performance Improvement Program. An Interview with Administrator on 12/18/2025 at 2:20 p.m. confirmed there is no documented evidence of a Quality Assurance Performance Improvement (QAPI) Program for the facility. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff By-Laws Rules and Regulations fail to identify any documented evidence that the facility has a QAPI. No policies and procedures related to a program evaluation was provided for review. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1300/485.641 for additional findings.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (2) Be ongoing and comprehensive. (3) Involve all departments of the CAH and services (including those services furnished under contract or arrangement). This Standard is not met as evidenced by: 48927 Based on interviews with hospital leadership, review of the facility’s Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff By-Laws Rules and Regulations, the facility failed to develop and implement a quality assessment and performance improvement (QAPI) Program that is on going and comprehensive and includes all departments and services including services furnished under contract for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:30 p.m. confirmed the facility does not have an ongoing comprehensive QAPI program that includes all departments and services. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff By-Laws Rules and Regulations fail to identify any documented evidence that the facility has an ongoing comprehensive QAPI program that includes all departments and services. No policies and procedures related to a QAPI program was provided for review. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1300/485.641 for additional findings.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (4) Use objective measures to evaluate its organizational processes, functions and services. This Standard is not met as evidenced by: 48927 Based on interviews with hospital leadership, review of the facility’s Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, the facility failed to develop and implement a quality assessment and performance improvement (QAPI) Program that uses objective measures to evaluate its organizational processes, functions, and services for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:30 p.m. confirmed the facility does not have outcome measures to evaluate processes, functions, and services for the facility. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, approved 2019, fail to identify any documented evidence the facility performed quality reviews with objective measure to evaluate the facility’s processes, services, and functions. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1300/485.641 for additional findings.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (5) Address outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, CAH acquired conditions, and transitions of care, including readmissions. This Standard is not met as evidenced by: 48927 Based on interviews with hospital leadership, review of the facility’s Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, the facility failed to develop and implement a quality assessment and performance improvement (QAPI) Program that addresses outcome indicators related to improved health outcomes and the prevention and reduction of medical errors, adverse events, facility acquired conditions and the transitions of care including readmissions for three (3) of three (3) days of survey. Findings Include: An Interview with Administrator on 12/18/2025 at 2:20 p.m. confirmed there is no periodic evaluation or quality assessment review performed that addresses outcome indicators for the evaluation of health outcomes, the facility does not have a QAPI program. Review of the Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, approved 2019, fail to identify any documented evidence the facility performs QAPI audits that evaluate healthcare outcomes. No policies and procedures provided for Quality Assessment, annual reviews, program review. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1300/485.641 for additional findings.”

“QAPI CFR(s): (c) Standard: Governance and leadership. The CAH’s governing body or responsible individual is ultimately responsible for the CAH’s QAPI program and is responsible and accountable for ensuring that the QAPI program meets the requirements of paragraph (b) of this section. This Standard is not met as evidenced by: 48927 Based on staff interview, review of the facility’s Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff Rules and Regulations, the facility’s governing body or responsible individual failed to ensure development and implementation of an ongoing comprehensive Quality Assessment Performance Improvement (QAPI) Program for three (3) of three (3) days of survey. Findings Include: An Interview with the Director of Nursing (DON) on 12/17/2025 at 5:30 p.m. confirmed the facility does not have a QAPI program. An Interview with Administrator on 12/18/2025 at 2:20 p.m. confirmed the facility has not developed, implemented, or maintained comprehensive ongoing, data driven a QAPI Program, and the facility does not have any data collection, policy and procedures for Quality Assurance. Review of Governing Board Meeting Minutes from November 2024 through October 2025 and Medical Staff By-Laws Rules and Regulations, approved date 2019, fail to identify any documented evidence the facility performed a periodic evaluation of the facility’s total program, or has any documentation of a QAPI program. No policies and procedures related to a program evaluation were provided for review as requested. During the exit conference on 12/18/2025 at 4:00 p.m. with the Administrator, Director of Nursing and via telephone the Chief Administrative Officer survey findings were discussed, and no further documentation was submitted for review. Cross refer to CoP C-1300/485.641 for additional findings.”

“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 interviews, review of the facility’s diversion list document, facility Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedure, the facility’s Emergency Department (ED) Central Log, email documents from the tele-emergency physician provider service, and review of Emergency Medical Service (EMS) Provider #2’s ambulance run report document, the facility failed to comply with the responsibilities of the emergency department to provide an appropriate Medical Screening Exam (MSE) to an individual presenting to the emergency department for one (1) of one (1) confirmed patient arriving by ambulance. Findings include: Review of a document from Emergency Medical Services (EMS) Provider #2 referred to as a “Run Report,” dated 12/04/2024 at 1:05 p.m. (EMS Response # 24-07527) revealed EMS Patient #1 (80-year-old female) arrived via ambulance to the facility’s Emergency Department (ED) at 2:40 p.m. with bilateral lower leg pain and infected wounds on both legs. Report reveals EMS attempted to contact the facility to give a pre-hospital report but was sent to voicemail. On arrival EMS Patient #1 was unloaded and taken to triage and then told they could not see the patient and must transport the patient to another facility. Quitman Community Hospital had no documentation of EMS Patient #1 arriving at the facility ED in the ED Central Log and no documented evidence of triage or a medical screening exam (MSE). Review of the facility’s, “Diversion List,” dated 06/17/2024 to 12/04/2024 reveals 15 dates the facility was on diversion which included: four (4) diversions for internet service interruptions which prevents the facility from using the tele-emergent contract arrangement for physician services; three (3) diversions for no radiology technician available, one (1) diversions for imaging machines not in service; six (6) diversions for cardiac due to not having Troponin supplies (measures protein that is unique to heart muscle) in stock preventing cardiac workup; and one (1) diversion on 12/04/2024 due to tele-emergent contract arrangement for physician services terminated. Interview on 12/09/2024 at 5:00 p.m. with the facility Administrator confirmed three (3) to five (5) patients presented to facility for services and were not logged into the ED’s central log on 12/04/2024 after the facility went on diversion. Interview with facility Administrator on 12/10/2024 at 10:45 a.m. confirms the facility’s documentation of diversion status from 06/17/2024 - 12/04/2024. Review of the facility’s ED Central Log against the facility’s Diversion List reveals no documentation of patients presenting to the ED for service in the ED Central Log from 12/04/2024 at 8:24 a.m. until 12/05/2024 at 1:11 p.m. Review of the facility’s EMTALA policy and procedure dated 06/18/2022, revealed “ ...If an individual comes to the Emergency Department ...The Hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Dedicated Emergency Department ...to determine whether an emergency medical condition exists; and ....The Hospital will maintain a list of physicians from its medical staff who are on-call for duty after the medical screening examination to provide further medical examination and treatment as necessary to stabilize individuals who have been found to have an emergency medical condition ...As soon as practical after arrival, individuals who come to the Emergency Department should be triaged to determine the order in which they will receive a medical screening examination ...The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department ...The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ...”. Cross Refer to 2405 and 2406.”

“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: 31935 Based on staff interviews, review of the facility’s diversion report and Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedures, review of facility staff written statement of 12/04/2024 diversion event, review of Tele-emergency physician services contract termination email document, and review of Emergency Medical Service (EMS) Provider #2’s ambulance run report document, the facility failed to document on the facility’s Emergency Department (ED) Central Log on each individual who “comes to the emergency department,” seeking assistance, for one (1) of one (1) confirmed patient arrival via ambulance. Findings Include: Interview on 12/09/2024 at 5:00 p.m. to 5:15 p.m. with facility Administrator confirmed three (3) to five (5) patients that presented to facility’s ED for services were not logged into the ED’s Central Log during diversion status on 12/04/2024 and that one (1) patient present via ambulance and the Nurse Practitioner (NP) #1 and Registered Nurse (RN) #1 told the EMT they were on diversion and did not accept the patient. Interview on 12/11/2024 at 11:40 a.m. with Nurse Practitioner (NP) #1 confirmed he was the provider on duty 12/04/2024 when facility ED department diversion was initiated. He also confirmed a patient (EMS Patient #1) arrived by Emergency Medical Services (EMS) Provider #2 on a stretcher. The Emergency Medical Technician (EMT) reported he could not get an answer when he called the facility to give report during transport. NP #1 confirmed he could not exam a patient without a collaborating physician and refused to complete a medical screening exam on the patient. NP #1 also confirmed the patient was not signed into Emergency Department (ED) Central Log and did not have a medical screening. Interview on 12/11/2024 at 12:00 p.m. with emergency department staff Registered Nurse (RN) #1 confirmed diversion status on 12/04/2024 related to telehealth contract being terminated and that she was there working as an ED staff nurse that shift. RN #1 reports notifying the EMS service of the diversion status by calling EMS Provider #1 around 2:00 p.m. to 2:30 p.m. RN #1 further confirmed a patient was brought in after that by EMS Provider #2 (an EMS provider from another county and company that the facility does not usually receive patients from) and the EMT driver was told of the facility diversion status. RN #1 reported the patient was not signed in on the facility ED Log and did not receive a medical screening exam, RN #1 further confirmed knowledge of EMTALA regulations. Review of the written statement by the administrator dated 12/09/2024 revealed an ambulance did arrive on 12/04/2024 during diversion status and the nurse practitioner and staff nurse on duty told the EMT they were on diversion and did not accept patient. Review of the Emergency Department Central Log dated 12/04/2024 - 12/05/2024 revealed the facility had no documented evidence of patients presenting to the ED during the diversion date 12/04/2024 with no entries noted from 12/04/2024 at 8:24 a.m. until 12/05/2024 at 1:11 p.m. Surveyors are unable to determine the number and names of the individuals who presented to the ED for treatment and were refused a medical screening due to no documented evidence of the individuals in the facility’s ED Central Log. Review of the facility’s EMTALA policy and procedure dated 06/18/2022, revealed “...The Hospital must maintain a central log of individuals who come to the emergency department and include in such log whether such individuals refused treatment, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged. The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE ...”. During Exit Conference on 12/11/2024 at 4:00 p.m. survey findings were discussed, and no further documentation was submitted for review. Cross Refer to 2400 and 2406.”

“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: 31935 Based on facility staff interviews, review of written statement from the facility Administrator, and document review of Emergency Medical Services (EMS) Provider #2 ambulance service “run report,” review of the facility’s on-call schedule, email documents from the contracted facility providing provider Tele-emergency physician services, Emergency Medical Treatment and Active Labor Act (EMTALA) policy and procedures, and review of facility daily safety meeting minutes, the hospital failed to provide an appropriate medical screening examination (MSE) on a patient presenting to the Emergency Department (ED) by ambulance during diversion status for one (1) of one (1) confirmed patient. Findings Include: Review of a facility document, written statement by the Administrator dated 12/09/2024 revealed an ambulance did arrive on 12/04/2024 during diversion status. Nurse Practitioner (NP) #1 and Registered Nurse (RN) #1 were on duty and told the ambulance Emergency Medical Technician (EMT) the facility was on diversion and did not accept patient. Review of EMS Provider #2 document referred to as a “Run Report,” dated 12/04/2024 1:05 p.m. (EMS Response # 24-07527) revealed EMS Patient #1 (80-year-old female) arrived via ambulance to the facility’s Emergency Department (ED) at 2:40 p.m. with bilateral lower leg pain and infected wounds on both legs. Report reveals EMS attempted to contact the facility to give a pre-hospital report but was sent to voicemail. On arrival EMS Patient #1 was unloaded and taken to triage and was then told they could not see the patient and must transport the patient to another facility. No facility documentation available for review for EMS Patient #1 including documentation of triage or a medical screening exam (MSE). An Interview on 12/09/2024 at 5:00 p.m. with the facility Administrator confirmed the facility’s Emergency Department (ED) went on diversion status on 12/04/2024 at 10:00 p.m. and during diversion status three (3) to five (5) patients presented to facility’s ED for treatment of a potential emergent medical condition and were not provided a medical screening exam, further interview revealed the patients who presented to the ED were not recorded in the ED central log on 12/04/2024 after going on diversion. Interview on 12/11/2024 at 11:40 a.m. with Nurse Practitioner (NP) #1 confirmed NP #1 was the provider on duty 12/04/2024 when facility’s diversion status was initiated. NP #1 also confirmed a patient arrived by Emergency Medical Services (EMS) on a stretcher and the Emergency Medical Technician (EMT) said he could not get an answer when he called the facility to give report during transport. NP #1 confirmed he could not exam a patient without a collaborating physician and refused to complete a medical screening exam on the patient. NP #1 further explained that the Administrator encouraged him to see the patient, but he pulled the EMT aside and told him he couldn’t see the patient without a collaborating physician available. NP #1 also confirmed the patient was not recorded in the Emergency Department (ED) Central Log. When asked if he was knowledgeable about Emergency Medical Treatment and Active Labor Act (EMTALA) regulations, NP #1 confirmed he should have screened the patient but feels he was put in a position where he could not screen them. Interview on 12/11/2024 at 12:00 p.m. with ED Registered Nurse (RN) #1 confirmed diversion status on 12/04/2024 related to the facility’s telehealth contract being terminated and that she was working as an ED staff nurse that day. RN #1 reports notifying the EMS service of the diversion status by calling EMS Provider #1 around 2:00 p.m. to 2:30 p.m. RN #1 further confirmed a patient was brought in after 2:30 p.m. by EMS Provider #2. RN #1 further confirmed the EMT driver was told of the facility diversion status and that the patient was not recorded on the ED Central Log. RN #1 confirmed knowledge of EMTALA regulations and also confirmed the patient did not have a medical screening. Review of the facilities Provider and On-call Schedule for December 2024 revealed the facility was staffed with one nurse practitioner and no physician on duty at facility or on call for 12/04/2024 until 10:00 a.m. on 12/05/2024. Review of the Emergency Department Log dated 12/04/2024 - 12/05/2024 revealed the facility had no documented evidence of any patients presenting to the ED during the diversion and no entries noted from 12/04/2024 at 8:24 a.m. until 12/05/2024 at 1:11 p.m. Surveyors are unable to determine the number and names of the individuals who presented to the ED for treatment due to no documented evidence of the individuals in the facility’s ED Central Log. Review of facility’s daily safety meeting minutes for 12/04/2024 and 12/05/2024 revealed the facility had no Tele-emergency physician provider coverage and that staff were to continue to assess patients arriving to the facility seeking medical assistance. Review of the email document dated 12/04/2024 at 10:57 a.m. from the contracted facility providing provider Tele-emergency physician services revealed the contract was terminated with the facility effective 11/29/2024. Review of the email document titled “Notice of Termination and Educational Affiliation Agreement ...” dated 12/09/2024 from the Administrative Assistant III of the contracted facility revealed, “ ...notice of termination as of midnight December 6, 2024, of the agreement due to ...breach of its terms.” Review of the facility’s EMTALA policy and procedure dated 06/18/2022, revealed “ ...If an individual comes to the Emergency Department ...The Hospital will provide an appropriate medical screening examination within the capability of the Hospital’s Dedicated Emergency Department ...to determine whether an emergency medical condition exists; and ....The Hospital will maintain a list of physicians from its medical staff who are on-call for duty after the medical screening examination to provide further medical examination and treatment as necessary to stabilize individuals who have been found to have an emergency medical condition ...As soon as practical after arrival, individuals who come to the Emergency Department should be triaged to determine the order in which they will receive a medical screening examination ...The Hospital shall provide a medical screening examination to any individual who comes to the Emergency Department ...”. During Exit Conference on 12/11/2024 at 4:00 p.m. survey findings were discussed, and no further documentation was submitted for review. Cross Refer to 2400 and 2405.”