St Peters Health

“STAFF TRAINING CFR(s): Applicable staff, as identified by the hospital, must be trained annually on the protocols and provisions implemented pursuant to this section. (i) The governing body must identify and document which staff must complete such training. (ii) the hospital must document in the staff personnel records that the training was successfully completed. (iii) the hospital must be able to demonstrate staff knowledge on the topics implemented pursuant to this section This Standard is not met as evidenced by: 47752 Based on interview and policy review, the facility failed to ensure applicable staff received EMTALA education and training annually; the governing body failed to identify and document which applicable staff were required to complete yearly training, and the facility failed to establish a process to ensure that identified staff received the education and training. Findings include: During an interview on 7/27/26 at 2:50 p.m., staff member B stated there had been no EMTALA education provided since 2024. Staff member B stated the providers were contracted and the contracting agency was responsible for educating the providers. Staff member B stated she did not track provider education. During an interview on 7/27/26 at 3:00 p.m., staff members K and L stated education was conducted online via Emergency Medical Review and Perspective. Staff member L stated education was not scheduled yearly. During an interview on 7/29/26 at 2:30 p.m., staff member F stated he had never been formally educated on EMTALA. During an interview on 7/30/26 at 9:00 a.m., staff member A stated the governing body received a packet at each board meeting, and that was how the monitoring of compliance and regulatory requirements were communicated. Staff member A was unaware of any education oversight provided by the governing body. During an interview on 7/30/26 at 9:40 a.m., staff member N stated the type of education that she provided to staff was determined by what had been assigned in the past. Staff member N stated department managers were involved in helping with staff education, especially if there were concerns with a specific topic. Staff member N stated staff received online education and that was how the required education was tracked. Staff member N did not believe there was a formal tracking process. Staff member N stated there was verbal education that was always provided during staff meetings, emails, or huddles. Staff member N was not aware of whether the education was documented during staff meetings or huddles. Review of the Governing Body’s meeting minutes from November 2025-March 2026, showed no documentation identifying staff education or education requirements for staff. Review of a facility policy titled, “Education and Staff Development Plan, not dated, showed: “Purpose: To promote and enhance the professional and technical knowledge of SPH (St. Peter’s Hospital) team members. To provide education and development opportunities based on identified needs, planned, implemented, and evaluated according to the standards established by SPH (St. Peter’s Hospital) and all applicable accrediting agency requirements. ...””

“DISCHARGE PLANNING-FREEDOM OF CHOICE CFR(s): The hospital , as part of the discharge planning process, must inform the patient or the patient’s representative of their freedom to choose among participating Medicare providers and suppliers of the post-discharge services and must, when possible, respect the patient’s or the patient’s representative goals of care and treatment preferences, as well as other preferences they express. The hospital must not specify or otherwise limit the qualified providers or suppliers that are available to the patients. This Standard is not met as evidenced by: 41652 Based on interview and record review, the facility failed to ensure the patient and their representative were aware of their right to freedom of choice for post-hospital services for 3 (#s 3, 6, and 7) of 12 sampled patients. Findings include: During an interview on 12/2/25 at 8:30 a.m., staff member D stated it was the RN care manager’s responsibility to ensure the freedom of choice was signed by the patient or their representative when they received post-hospital health care services. Staff member D stated the form was generated through the EHR system and printed automatically to the unit where the patient was staying. She stated the form listed the post-hospital service providers by type. The form had a place for the patient or representative to sign the form. Once the form was signed, the form was kept with other patient specific papers and was eventually scanned into the EHR. Staff member D stated the only issue was the forms were sometimes lost and did not make it to the scanned documents section within the EHR. During an interview on 12/3/25 at 2:53 p.m., staff member E stated he printed the freedom of choice form twice, once on the unit and once in his office. Staff member E stated he did this so that he was sure to get the form signed. Review of patient #3’s care management notes, dated between 9/24/25 and 10/9/25, showed the patient was to be discharged home with family and home health care services. No signed freedom of choice form was found. Review of patient #6’s care management notes, dated between 11/21/25 and 11/25/25, showed the patient was to be discharged to a skilled nursing facility. No signed freedom of choice form was found. Review of patient #7’s care management notes, dated between 11/14/25 to 11/19/25, showed the patient was to be discharged to a skilled nursing facility. No signed freedom of choice form was found. A request was made on 12/3/25 for the signed freedom of choice forms for resident #s 3, 6, and 7. None were received prior to the end of the survey.”

“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: 44770 Based on interview, record review, and policy review, the facility failed to comply with the conditions of participation outlined in §489.24(a)(1)(i): The facility failed to provide an appropriate MSE (medical screening examination) by a QMP (qualified medical provider) for 2 (#’s 3 and 17) and failed to provide stabilizing treatment for 1 (#17) of 20 sampled patients who presented to the ED for emergency care. Findings Include: Review of a facility policy titled, Triage and Medical Screening Examinations, last reviewed on 11/18/24, showed: “Policy: St. Peter’s Health (SPH) will provide an appropriate medical screening examination and treatment when requested by any person who presents on SPH’s hospital premise requesting examination and treatment. The medical screening will be provided by qualified clinical staff, physician, or mid-level provider and within the capabilities of the Emergency Department (ED) and the ancillary services routinely available to the ED ...” -Patient #3 presented to the ED for evaluation of suicidal ideation and attempted suicide. Patient #3 was a pediatric patient who was brought to the ED by her mother after the patient attempted suicide by cutting her stomach with a knife. Upon arrival at the ED, patient #3 was escorted into the ED and placed in a hallway bed. Patient #3 was not placed on suicide precautions per facility policy. Review of the patient’s medical chart showed the ED provider ordered suicide precautions, which included one to one observation. Patient #3 eloped from the facility prior to receiving an evaluation to determine if she was having an emergency medical condition requiring medical stabilization. (See A-2406 for details.) -Patient #17 presented to the ED for evaluation after a fall. Patient #17 sustained a head injury which required sutures. During patient #17’s initial presentation to the ED, she had an x-ray completed of her left upper extremity. The x-ray was read by the provider in the ED. The provider did not identify the patient sustained a fracture. Patient #17’s x-ray was read by a radiologist the following day, and the report showed the patient had a fracture of the elbow, where the fractured portions of the bone no longer line up with one another. Patient #17 was not informed of the fracture until 11 days later, when she was seen by her primary care provider, despite presenting to the ED on two additional occasions. Patient #17’s fracture was evaluated on the 12th day after her initial injury and a repeat x-ray showed the patient had a fracture of the elbow, and a fracture at the top of the radius (a bone in the lower arm). Patient #17’s fractured left arm was not splinted or stabilized for 12 days. (See A-2407 for details) -Patient #17 presented to the ED for suture removal following a fall that occurred seven days prior. During her visit with the nurse for suture removal, patient #17 explained she was having swelling and pain in her arm. The nurse assessed patient #17’s left arm, applied a compression bandage, and told patient #17 to apply ice to her arm and keep it elevated. Patient #17 did not receive a MSE by a QMP. Two days later, patient #17 returned to the ED and was diagnosed with blood clots which resulted in near complete occlusion of the left internal jugular vein (a major vein in the neck that returns blood from the brain to the heart) and complete occlusion of the left brachial vein (a deep vein that travels from the upper arm to the elbow). Again, the MSE did not identify the patient’s fracture that was identified by the radiologist from x-rays completed on her first presentation. (See A-2406 for details.)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 44770 Based on interview and record review the facility failed to provide an appropriate MSE by a QMP for 2 (#s 3 and 17) of 20 sampled patients presenting to the ED (Emergency Department) for emergency care on two separate occasions. Findings include: 1) Review of patient #3’s EMR showed patient #3 was a 15yo female who presented to the ED with her mother on 2/16/24 at 4:01 p.m. with a presenting complaint of a suicide attempt. Patient #3 had used a knife to cut her abdomen. Patient #3 was escorted to a hall bed in the ED at 4:06 p.m., and staff member M was assigned as the nurse for the patient. Staff member M documented a Columbia Suicide Severity Scale showing patient #3 was High Risk for suicide at 5:06 p.m., an hour after the patient’s arrival at the ED. Orders were placed for suicide precautions to prevent elopement, and provide patient safety at 5:08 p.m., then at 6:26 p.m., documentation showed patient #3 was missing when the MCRT (Mobile Crisis Response Team) arrived to evaluate the patient. The patient’s medical record lacked documentation of 15-minute checks and did not include documentation by a one-to-one sitter. Physician notes showed the patient was evaluated by MCRT and showed the patient was given outpatient resources and the patient was discharged to the care of her mother; however, MCRT did not evaluate the patient, as the patient had eloped prior to their arrival at 6:36 p.m. The medical record lacked documentation from MCRT. Review of hospital video surveillance footage showed patient #3 walked out of the ED doors with her mother at 5:57 p.m. on 2/16/24. During an interview on 8/1/24 at 7:48 a.m., staff member M said he should have done a Columbia Suicide Scale right away for patient #3. He said if a patient is scored as high risk using the Columbia Suicide Scale, the patient should be placed on a one-to-one observation immediately. Staff member M said, “We try to place them in high visibility places. If we can, we put them in room nine (a room designed for suicide precautions). Staff member M said a patient who is on suicide precautions should have charting completed every 15 minutes which indicates the patient’s activity and mood. Staff member M was not able to locate any documentation in patient #3’s EMR which included 15-minute assessments of the patient’s actions or mood. Staff member M stated a patient who is on suicide precautions should not be left without an assigned person to watch them. He stated a person who had attempted suicide should not be unaccounted for over an hour and 18 minutes. Staff member M stated it would not be safe to leave a suicidal patient without one-to-one supervision. Staff member M said he did not know if anyone was specifically assigned to watch patient #3. During an interview on 8/1/24 at 7:59 a.m., staff member A stated the facility policy for one-to-one observation does not allow for parents to act as a one-to-one sitter. Staff member A said there is always someone available to provide one-to-one observation for patients, even if that meant an administrator needed to come in to provide the one-to-one observation. Staff member A said she did not know why staff member M did not follow the facility policy. Review of a facility policy titled, Suicide Precautions/No Self Harm Precautions, last reviewed 8/13/23, showed: “ ...Policy: Suicide Screening Risk Assessment will be done on every patient presenting to the Emergency Department ... The Registered Nurse (RN) will utilize the Suicide Screening Risk Assessment Tool to determine the appropriate level of safety precautions. This is intended to be completed on each admission by either: Emergency Department RN staff or Hospital RN staff ... Risk Level: High Intervention Recommendations ... Refer to Mental Health Professional for further assessment/interventions. Notify Provider, Implement room sweep (remove items that could be a used to harm self or others), every 15-minute checks documented (a staff member trained for one to one observation documents what the patient is doing, mood, etc.), and suicide precautions (removal of items that could be used to harm self), Initiate 1:1 sitter continuous observation ...” 2) Review of patient #17’s electronic medical record (EMR) showed, patient #17 presented to the ED on 5/11/24 to have sutures removed after sustaining a fall on 5/4/24. Staff member V removed the sutures and documented patient #17 left without being seen by a provider (LWBS.) Patient #17’s EMR lacked a provider note for her 5/11/24 ED visit. Patient #17’s EMR showed she presented to the ED on 5/13/24 after being sent to the ED by the Urgent Care for a blood clot in her neck and arm. Patient #17’s record showed the ED physician evaluated patient #17 for the blood clots but failed to recognize the patient had a fractured arm that was not diagnosed on her first visit on 5/4/24. The x-ray was taken during the 5/4/24 visit in the ED and was read by the ED provider as no fracture, however the x-ray was read by the radiologist on 5/5/24 and reported a fracture of the elbow, where the fractured portions of the bone no longer line up with one another. The report from the radiologist was available in the EMR on 5/5/24. During an interview on 8/6/24 at 12:22 p.m., NF2 stated she was with patient #17 on 5/11/24 when she went to the emergency room to have her sutures removed. NF2 said patient #17 told staff member V that her left arm was still very painful and was quite swollen. NF2 said staff member V looked at patient #17’s left arm and stated patient #17 had a hematoma (a large collection of blood that has leaked from a damaged blood vessel). NF2 said staff member V placed an ace bandage on patient #17’s left arm and explained that the hematoma required a “compression” bandage and instructed the patient on how to apply the compression bandage on her arm. NF2 said staff member V also instructed the patient to apply ice to the swollen arm, and to keep the arm elevated. NF2 said patient #17 did not see a physician during her ED visit. NF2 said patient #17 was hoping a physician would look at her arm because it had been causing her a lot of pain. During an interview on 7/31/24 at 2:19 p.m., staff member V said she documented the suture removal for patient #17 on 5/11/24, but she did not remember the patient specifically. Staff member V said suture removals are very short visits, and after the sutures are removed for a patient, the nurses put the disposition of the patient as LWBS (left without being seen) so the patients do not get charged. Staff member V said she does not usually look in the patient chart or ask too many questions about the patient’s health during suture removals. Staff member V said if the patient voiced any concerns, the patient should be seen by a physician. During an interview on 7/31/24 at 1:17 p.m., staff member L said she was the provider who saw patient #17 on 5/13/24. She said she did not review patient #17’s electronic medical record from her previous visits. She said she would have done something about the fracture if she had read the report and realized the patient had an undiagnosed fracture. During an interview on 7/31/24 at 2:34 p.m., staff member A, the Director of Critical Care, said if the patient has any concerns during their suture removal, the patient should be seen by the provider. Staff member A stated nursing staff should not mark LWBS for the disposition of suture removal patients. Review of an Urgent Care note for patient #17, dated 5/13/24, showed: “ ...a 90yr female [came] into urgent care for 2 days of progressive left upper extremity edema. Patient had a fall 9 days ago and was evaluated in the emergency room. Suffered a laceration to the face, multiple facial contusions as well as a left upper extremity contusion and development of a hematoma. At suture removal 2 days ago, ER recommended wrapping left upper extremity with an ace wrap. Since then, she has had worsening edema in the left hand ... Given the marked edema of her left upper extremity I did obtain the left upper extremity ultrasound, and this is concerning for near complete occlusion of the left IJ (internal jugular, a vein that collects blood from the brain and the superficial parts of the face and neck) as well as additional DVT (deep vein thrombosis, a blood clot) of the left upper extremity.” The record indicated patient #17 was sent to the emergency department for treatment. Review of a facility policy titled, Triage and Medical Screening Examinations, last reviewed on 11/18/24, showed: “Policy: St. Peter’s Health (SPH) will provide an appropriate medical screening examination and treatment when requested by any person who presents on SPH’s hospital premise requesting examination and treatment. The medical screening will be provided by qualified clinical staff, physician, or mid-level provider and within the capabilities of the Emergency Department (ED) and the ancillary services routinely available to the ED ...””

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 44770 Based on interview, record review, and review of facility video surveillance footage, the facility failed to provide stabilizing treatment for one (#17) of 20 sampled patients with emergency medical conditions who presented to the ED requesting emergency care. Findings include: Review of patient #17’s EMR showed patient #17 was a 90 yo female who presented to the ED on 5/4/24 for a chief complaint of sustaining a fall in her driveway. Patient #17’s record showed she received two sutures above her eye and an x-ray of her left arm. The x-ray was read by the PA in the emergency department and was reported as no fractures seen. Patient #17 was discharged from the emergency department with instructions to return in seven days to have her sutures removed. Her arm was not splinted during the 5/4/24 visit. On 5/5/24, the radiologist read the x-ray and found a fracture of the elbow, where the fractured portions of the bone no longer line up with one another, and associated joint effusion (when too much fluid builds up in the tissues around a joint). On 5/11/24 patient #17 returned to the emergency department for suture removal. The record indicates the sutures were removed and then she LWBS (left without being seen). She was not informed she had a fracture during the 5/11/24 visit. On 5/13/24 patient #17 returned to the emergency department after she was seen in Urgent Care and a blood clot was found in her internal jugular (a major vein in the neck that returns blood from the brain to the heart) and brachial vein (a deep vein that travels from the upper arm to the elbow) in her left arm. She was not informed she had a fracture during the 5/13/24 visit, the fracture was not splinted or stabilized during the 5/13/24 visit. On 5/15/24 patient #17 was seen in her primary care office. The primary care physician reviewed her x-ray and noted she had a fracture. Her primary care physician made a referral to orthopedics during the visit. (a major vein in the neck that returns blood from the brain to the heart) and complete occlusion of the left brachial vein (a deep vein that travels from the upper arm to the elbow). Review of records for patient #17 from the Orthopedic clinic showed, patient #17 was seen on 5/16/24 and was found to have a Left transcondylar distal humerus fracture and a left radial head fracture (two fractures in her arm). Patient #17’s arm was splinted, and casting was deferred related to the amount of swelling still in the arm. On 5/23/24 patient #17 was seen again in the orthopedics office and a cast was placed as the swelling was sufficiently reduced. During an interview on 7/31/24 at 12:55 p.m., staff member K said she was the provider who took care of patient #17 on 5/4/24. She stated she read the x-ray of patient #17’s arm because it was after hours for the radiologist. She said when she read an x-ray there was a place to document her findings in the x-ray system so the radiologist would know what her findings were, but she doesn’t always document in the system. She said she was never aware the radiologist found a fracture on patient #17’s x-ray so she never called the patient to inform her. She said the radiologist would usually call the emergency department and tell the day shift physician if a discrepancy was found, however she typically would not document in the system when the reading does not have any findings of significance. During an interview on 7/31/24 at 1:17 p.m., staff member L said she was the provider who saw patient #17 on 5/13/24. She said she did not review patient #17’s record from her previous visit. She said she would have done something about the fracture if she had seen the x-ray so she surmised she must not have looked at the record. During an interview on 8/6/24 at 12:22 p.m., NF2 said patient #17 has not been the same since her fall. NF2 said patient #17 is no longer able to live at home and was placed in an assisted living facility. NF2 stated she was with patient #17 on 5/11/24 when she went to the emergency room to have her sutures removed. NF2 said patient #17 told staff member V her left arm was still very painful and was quite swollen. NF2 said staff member V looked at patient #17’s left arm and stated patient #17 had a hematoma (a large collection of blood that has leaked from a damaged blood vessel). NF2 said staff member V placed an “ace bandage” (elastic wrap) on patient #17’s left arm and explained to them the hematoma required a “compression” bandage and instructed her on how to put the compression bandage on the arm. NF2 said staff member V also instructed them to apply ice to patient #17’s swollen arm and to keep the arm elevated. NF2 said staff member V did not tell them patient #17 had a fracture in the arm during the visit on 5/11/24. NF2 said patient #17 continued to complain of pain in her arm after the bandage was applied. NF2 said patient #17 went to bed the night of 5/11/24 with the bandage in place, when she woke in the morning her hand was very swollen, so they removed the bandage and reapplied it the next evening. When patient #17 woke the morning of 5/13/24 her hand and arm was significantly swollen so they decided to go to urgent care. This was when the blood clots were found in her neck and arm, and she was again sent to the emergency department. NF2 said on 5/13/24 when they were sent to the emergency department patient #17 was seen for the blood clots but no one told them patient #17 had a fracture in her arm. Her arm was not splinted or casted. NF2 said movement hurt patient #17 and she was very uncomfortable. NF2 said it wasn’t until they took patient #17 to follow up with her primary physician on 5/15/24 that the fracture was discovered. She said after patient #17 saw the orthopedic doctor on 5/16/24 and the fracture was finally splinted patient #17 was more comfortable and her pain was easier to control. Review of a facility policy titled, Triage and Medical Screening Examinations, last reviewed on 11/18/24, showed: “Policy: St. Peter’s Health (SPH) will provide an appropriate medical screening examination and treatment when requested by any person who presents on SPH’s hospital premise requesting examination and treatment. The medical screening will be provided by qualified clinical staff, physician, or mid-level provider and within the capabilities of the Emergency Department (ED) and the ancillary services routinely available to the ED ...””