Roosevelt Medical Center

“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: 47752 Based on observation, interview, record review and policy review, the facility failed to comply with the conditions of participation outlined in §489.20 and related requirements at 489.24: (refer to Appendix V). The facility failed to maintain a central log on each individual who comes to the emergency department, 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 for one patient (#3); and the facility failed to provide a MSE (medical screening examination) by a QMP (qualified medical provider) within the capability of the hospital’s ED (emergency department), including ancillary services routinely available to the ED, to determine whether or not an emergency medical condition exists for one patient (#3) of 20 sampled patients who presented to the ED for emergency care. Review of a facility policy titled, “Patient Care Services-ER Services,” dated 1/29/2010, showed: ... “All patients are assessed by the nursing staff and treated as deemed necessary by the Provider.” ... Patient #3 presented to the nurse’s station on 1/2/25 because her PEG tube had become dislodged. The patient was not provided a MSE by a QMP. [See C-2406]”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 47752 Based on observation and interview, the facility failed to post signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions, and the rights of women in labor, in a conspicuous area to be noticed by all individuals entering and receiving care in the ED (emergency department). Findings include: During an observation on 3/25/25 at 8:45 a.m., the ED entrance was observed. One EMTALA sign was found, printed on white paper, laminated, and hung on a white bulletin board. The sign was not easily identifiable, it did not contain required patient rights information, and did not consist of simple terms that could be easily understood by all patients. During an Interview on 3/25/25 at 8:47 a.m., staff member A stated the facility had EMTALA signs posted in each of the treatment rooms. Staff member A stated the ED had three treatment rooms. During an observation on 3/25/25 at 8:50 a.m., the ED treatment rooms were inspected. An EMTALA sign was found in treatment room #1. The signage was in a frame, located on top of some cabinets near computer wires and equipment. The sign was not easily readable or identifiable by patients or patient representatives. Treatment rooms #2 and #3 lacked signage. The facility did not have a policy for posting signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions, and the rights of women in labor.”

“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: 47752 Based on interview, record review, and policy review, the facility failed to maintain a central log which included all patients who presented to the facility, whether the patient refused treatment, was transferred, admitted and treated, stabilized and transferred, or discharged, for 1 (#3) of 20 sampled patients. Findings include: During an interview on 3/25/25 at 10:12 a.m., patient #3 stated she presented to the hospital on 1/2/25 because her PEG tube had become dislodged. Patient #3 stated she spoke to a nurse at the ED and was told the facility did not have the supplies she would require and instructed her to go to [hospital B]. Patient #3 stated she was not offered an examination by a provider. A review of a facility document titled, “Register of January 2025,” showed no entry into the emergency room registration log for patient #3 on 1/2/25. Review of patient #3’s electronic medical record showed no record of patient #3 arriving at the facility, no documentation of any care or refusal of care, and no documentation of a provider being notified of her presentation to the ED. During an interview on 3/25/25 at 10:50 a.m., staff member B stated the facility did not have a visit record for patient #3. Staff member B stated, “I believe the nurse called the on-call provider and I also believe he offered to see patient #3, but she refused. Staff member B stated there was no documentation because patient #3 was not registered as a patient. Review of a facility policy titled, “Emergency Room Record,” dated 9/8/2010, showed: “Purpose: To provide accurate, permanent record of patient information and care provided. ...11. Enter visit in the ER log, ER log consists of: date, time, patients name, ER/ED diagnosis, time seen, ...RN initials, treatment done, dispensed to where and time.”

“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: 47752 Based on interview, record review, and policy review, the facility failed to provide a MSE (Medical Screening Exam) by a QMP (qualified medical provider) 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 for one patient (#3). Findings include: During an interview on 3/25/25 at 10:12 a.m., patient #3 stated she walked over to the ED on 1/2/25 because her PEG (Percutaneous Endoscopic Gastrostomy) tube came out of her stomach. Patient #3 stated she walked up to the nurses that were working in the ED and told them what had happened with her PEG tube. Patient #3 stated she was talking to one of the nurses and was told they could not help her. Patient #3 stated the nurse told her she was going to call the on-call provider and let him know what had happened. Patient #3 stated the nurses never offered to evaluate or assess her. Patient #3 stated, “When the nurse talked with me, she told me the ED did not have the supplies that I would have needed, and she told me it would be better to go to [hospital B], where they could address the problem.” Patient #3 stated she was never asked if she would like to be seen by a provider. Review of patient #3’s electronic medical record showed there was no record of her arriving at the facility on 1/2/25, and no documentation of any care or refusal of care provided at the facility. During an interview on 3/26/25 at 8:50 a.m., staff member G stated she was working the morning patient #3 arrived at the ED. Staff member G stated patient #3 came in the front doors, prior to 8:00 a.m. Staff member G stated patient #3 was holding her feeding tube in a plastic bag. Staff member G stated she communicated with patient #3 on a note pad, and patient #3 wrote that her feeding tube came out and wanted a ride to [hospital B]. Staff member G stated she asked patient #3 if she wanted to be evaluated and patient #3 refused. Staff member G stated patient #3’s feeding tube being dislodged was not an emergency. Staff member G stated, “She was visually stable, she was not bleeding out. I know she was stable because I know her. If her trach had come out than it absolutely would have been an emergency, and she would have had an ER visit and exam done by the provider.” Staff member G stated, “Vital signs were not done on patient #3 because it was not an emergency.” Staff member G stated, “I do not know a lot about feeding tubes, but I do know that we don’t do anything with them here, patients need to be seen somewhere else.” Staff member G stated she had called the on-call provider and made him aware of the situation. During an interview on 3/26/25 at 9:15 a.m., Staff member F stated she was working with staff member G the day patient #3 came into the building. Staff member F stated she had not talked to patient #3, staff member G communicated with her because she knew her. Staff member F stated, “From what I understood her feeding tube dislodged and she wanted a ride to [hospital B]. Staff member F stated staff member G notified the on-call provider about the feeding tube coming out and patient #3 had refused to be seen. Staff member F stated, “I called a nurse that I work with at [hospital B] on my personal cell phone and let her know that patient #3 was on her way and that her feeding tube had dislodged.” Staff member F stated vital signs were not performed on patient #3 because staff member G stated patient #3 was, “fine.” Staff member F stated, “Most of the information I received was second hand from staff member G. I did not see any of the communication that occurred between them. Staff member F stated she did not see the written communication where patient #3 refused to be seen, and was told by staff member G patient #3 had refused to be seen. During an interview on 3/26/25 at 12:36 p.m., staff member D stated he was the provider on-call when patient #3 arrived at the ED on 1/2/25. Staff member D stated, “I am very familiar with patient #3, I am her primary care provider.” Staff member D stated patient #3 was non-verbal and communicated by written means or text. Staff member D stated, “Staff are very familiar with patient #3, she worked here for like 10 years, so she knows most of the staff and the routines. Staff member G called me and informed me that her PEG tube had come out, but she did not want to be seen, she just wanted a ride to [hospital B]. A few minutes later, staff member G called me back and let me know they had found a ride for her.” During an interview on 3/25/25 at 2:20 p.m., staff member C stated his expectation for MSE’s, and transfers was to follow all EMTALA regulations. Staff member C stated the MSE is completed by the provider who is on-call or covering the ED at the time a patient presents to the ED. Staff member C stated, “With this being a rural area we do not turn anyone away, we see everyone who walks through the doors.” Staff member C stated he had been made aware of an incident which involved patient #3. Staff member C stated, “Patient #3 worked in this facility for many years, and she had come into the building requesting a ride. I was not here when the incident occurred, but what I was told by staff was that she refused any type of treatment or care and just wanted a ride to [hospital B].” Review of patient #3’s electronic medical record from [hospital B] showed the patient arrived at their ED on 1/2/25 at 8:17 a.m. with a dislodged PEG tube. Patient #3 was seen by NF2 (the emergency room physician on duty) at 8:19 a.m. Patient #3’s diagnosis was, “PEG tube malfunction”. The assessment showed NF2 attempted to replace patient #3’s PEG tube and was unsuccessful. NF2 called NF5 (general surgeon on call) for a consult. NF5 came to patient #3’s bedside and “spent a considerable amount of time attempting to replace the PEG tube.” Patient #3’s PEG tube was unable to be replaced, and a 12 Fr. Foley catheter was placed on a temporary basis. Patient #3 received a post procedure x-ray to verify the placement of the foley. The final x-ray report dated 1/2/25 at 10:53 a.m., showed the foley was properly positioned within the stomach and no signs of leakage were present. Patient #3 was discharged on 1/2/25 at 11:40 a.m., with a follow-up surgery scheuled for 1/15/25. During an interview on 3/25/24 at 12:10 p.m., NF1 stated patient #3 was sent to [hospital B] because her PEG tube was dislodged. NF1 stated the transferring facility sent her to [hospital B] without having any type of assessment or medical screening exam completed. NF1 stated the transferring facility, “did not even do a set of vital signs on the patient.” NF1 stated patient #3 stated she was told she had to go to [hospital B] because the transferring hospital could not address the PEG tube or site. NF1 stated patient #3 stated she was dropped off at the hospital by a bus. NF1 stated patient #3 was alert and orientated, pleasant and cooperative with care. During an interview on 3/25/25 at 5:05 p.m., NF3 stated patient #3 presented to the ED at [hospital B] on 1/2/25. NF3 stated patient #3 came in because her PEG tube had become dislodged. NF3 stated on 1/2/25, she had received a call on her personal cell phone from staff member F earlier that morning. NF3 stated staff member F told her there would be a patient coming to [hospital B]. NF3 stated she informed NF2 of the phone call and the possibility of patient #3 presenting to the ED. NF3 stated NF2 was asking for a report on patient #3, and when NF3 could not provide one, NF2 wanted to speak with staff at the transferring facility. NF3 stated she called the transferring facility to obtain a verbal report from staff. NF3 stated she spoke to staff member F again and staff member F stated patient #3 came into the facility via the front door with her PEG tube in a small plastic bag. NF3 stated she was told by staff member F that patient #3 was told they could not help her, and she would need to go to [hospital B] for care, Staff member F stated patient #3 had not been seen by a provider. NF3 stated she notified NF2 of the call she had placed to the transferring facility. NF2 had become upset and told NF3 she needed to notify Risk Management of the situation. NF3 stated when patient #3 arrived at [hospital B], NF2 had tried to replace the PEG tube, but was unable to replace it. NF3 stated NF2 had to call the on-call surgeon for a surgical consult. NF3 stated the surgeon could not replace the PEG tube but was able to place a foley catheter on a temporary basis, until patient #3 could be scheduled for surgical replacement of the PEG tube. During an interview on 3/25/25 at 8:00 p.m., NF2 stated he was the ED physician on duty the day patient #3 was sent to [hospital B]. NF2 stated he had become upset because he was not able to get any kind of report or medical history from the transferring facility. NF2 stated he had tried to replace her PEG tube but was unsuccessful. NF2 stated he had to call the on-call general surgeon in to consult. NF2 stated, “I felt so bad for that poor woman. When you have a PEG tube that becomes dislodged, every minute counts, if Roosevelt Medical Center would have assessed her, she may not have had to have the PEG surgically replaced. They could have done something and then transferred her if needed. I get they may not have a ton of resources, but they could have tried to help her. They did not even take a set of vital signs. It was just poor all the way around, the patient was done a huge dis-service.” NF2 stated any provider, including mid-level providers, could replace a PEG tube under local anesthesia. Review of a facility policy titled, “Patient Care Services-ER Services,” dated 1/29/2010, showed: ... “All patients are assessed by the nursing staff and treated as deemed necessary by the Provider.” ... Review of a facility policy titled, “EMTALA Emergency Medical Treatment & Labor Act/Transfer Form,” dated 5/25/10, showed: ... “6. Refusal to Consent to Examination, Treatment, or Transfer. If the hospital offers examination, treatment, or transfer an individual to another hospital for services [Facility Name] does not provide and an individual or person acting on an individual’s behalf refuses, [Facility Name] will document and attempt to obtain the individual’s signature of the “Refusal of Medical Screening Examination and/or Consent to Treatment and/or Transfer form which addresses: 1. Explination of risks and benefits... 2. Documentation that the individual has been informed of the risks and benefits of the examination and/or treatment; 3. All reasonable stepsto obtain from the individual... written informed refusal to consent to an examination, treatment, or transfer... 4. Serves as documentation in the medical record a description of the examiniation or treatment that was refused by or on behalf of the individual.” Review of a facility policy titled, “Refusal of Medical Screening Examination and/or Consent to Treatment and/or transfer,” dated 5/25/2010, showed: “The Physician and/or Qualified Medical Provider has explained the risks of my refusal ... This person has advised me of the availability of and need for further medical examination and treatment ... ... I fully accept responsibility for the refusal of this examination and/or medical treatment ... of my medical condition and hereby release [Facility Name] ...from any responsibility whatsoever for unfavorable or untoward results which I understand may occur as a consequence of my refusal...””