Pioneer Medical Center

“PROVISION OF SERVICES CFR(s): §485.635 Condition of Participation: Provision of Services This Condition is not met as evidenced by: 35356 Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for the Provision of Services. Based on observation, interview, and record review, the facility failed to: - ensure laboratory personnel followed established policy and procedures for the immediate notification to the ordering provider of critical value laboratory test results (See C1028). - establish policy and procedures for critical value reference ranges which were consistent and reflected the utilized computerized critical value reference ranges utilized to determine critical value laboratory results (See C1028). - establish and implement procedures to ensure laboratory personnel reported in-house laboratory results to out of network providers in a manner which ensured the timely notification of those results (See C1028). - ensure ancillary nursing staff performed quality control testing effectively per the facility’s established policy and procedures and the glucometer testing devices manufacturer’s guidelines for the point of care testing (POCT) of bedside glucose monitoring, overseen by the laboratory manager or designee (See C1028).”

“LABORATORY SERVICES CFR(s): The CAH provides basic laboratory services essential to the immediate diagnosis and treatment of the patient that meet the standards imposed under section 353 of the Public Health Service Act (42 U.S.C. 236a). (See the laboratory requirements specified in part 493 of this chapter.) The services provided include the following: (i) Chemical examination of urine by stick or tablet method or both (including urine ketones). (ii) Hemoglobin or hematocrit. (iii) Blood glucose. (iv) Examination of stool specimens for occult blood. (v) Pregnancy tests. (vi) Primary culturing for transmittal to a certified laboratory. This Standard is not met as evidenced by: 35356 Based on observation, interview, and record review, the facility failed to: - ensure laboratory personnel followed established policy and procedures for the immediate notification to the ordering provider of critical value laboratory test results for 8 (#s 1, 3, 4, 5, 6, 7, 8, and 9) of 17 sampled patients; - establish policy and procedures for critical value reference ranges which were consistent and reflected the utilized computerized critical value reference ranges utilized to determine critical value laboratory results. This deficient practice had the potential to affect the accuracy of reported critical laboratory results; - establish and implement procedures to ensure laboratory personnel reported in-house laboratory results to out of network providers in a manner which ensured the timely notification of those results for 3 (#s 1, 3, and 15) of 17 sampled patients; and - ensure ancillary nursing staff performed quality control testing effectively per the facility’s established policy and procedures and the glucometer testing devices manufacturer’s guidelines for the point of care testing (POCT) of bedside glucose monitoring, overseen by the laboratory manager or designee. This deficient practice had the potential to affect the accuracy of patients’ blood glucose management. The cumulative effect of these deficient practices had the potential to affect safe patient outcomes related to the essential diagnosis and treatment of patients. Findings include: 1. Critical Laboratory Value Notification A review of the facility’s policy and procedure titled Standard Operating Procedure, with an effective date of 9/1/23, showed: “Reporting Results D. All results will be accurately recorded by personnel who are determined to be qualified and competent to perform testing. E. All critical values will be immediately re-tested. If the result is verified, a comment will be placed on the critical result and the provider or designee will be notified within 30 minutes of the final report. F. Test results will be reported to the ordering provider. H. If the ordering provider is not available to receive a critical value, the on-call provider will be notified. I. Notification of critical values will be documented in the Critical Queue in Cerner...” A review of the facility’s policy and procedure titled, Critical Value Immediate Notification, with an effective date of 12/12/23, showed: “Procedure: 2. Once the specimen has been checked for accuracy, the result will be immediately reported. 3. The responsible provider, inpatient location, or private office, is to be called with the results. If the provider is not available, a nurse or other designee can be given the result but should be instructed on the necessity to give this result to the provider in a timely manner. a. Give the result(s) and request a read-back of “what was written down” and document as comment in the LIS [sic]. b. If the results are not given to the provider directly (nurse or designee ), confirm that the recipient acknowledges the severity of the result and that it should be communicated to the provider within 15 minutes. c. When critical results need to be called after hours or when the office is not open, an on-call provider or answering service must be available on a 24-hour basis to take responsibility for receiving the result. If an answering service is called, the urgency of the result and necessity to give this result to the responsible provider is explained, but the result is not reported, and an appropriate call-back number is left. The time and person receiving the call is recorded as a comment in the LIS [sic]. The responsibility for contacting the responsible provider rests with the office/answering service but follow-up must be ensured by the laboratory staff. e. Patient history will be checked and if a similarly abnormal value was reported within the past few days, the repeat critical value will not be treated as an emergency, and will be reported according to our standard protocol (i.e., will not be immediately called)” During an interview on 8/6/25 at 12:52 p.m., NF1 stated patient #1 was receiving frequent blood transfusions and would have a CBC (Complete Blood Count- a blood test that measures the levels of red blood cells, white blood cells, and platelets. These measurements help assess various conditions like anemia, infections, or bleeding disorders) completed at the facility prior to driving to another town for blood transfusions. NF1 stated on 4/28/25, patient #1 had a critically low hemoglobin level of 5.5 gm/dL (a critically low hemoglobin (HGB) level, also known as severe anemia, can lead to serious health complications and even death. It’s a condition where the blood doesn’t carry enough oxygen to the body’s tissues, causing various symptoms and potentially damaging vital organs. A hemoglobin test is often part of a complete blood count). NF1 stated on 4/28/25, the patient had labs drawn at the facility at 7:43 a.m. NF1 stated at 9:42 a.m., the transfusion clinic called and needed orders and the test results for patient #1. NF1 stated she called the facility at 9:57 a.m., and was told by staff member D that staff member I had forgotten to send the results. NF1 stated they received the test results from the facility at 9:59 a.m. NF1 stated the critical value should not only have been faxed but the facility should have immediately called the ordering provider because it was a critical lab value. Review of patient #1’s EHR for the CBC result dated 4/28/25, showed the blood sample was collected at 7:35 a.m., and was processed, resulted, and verified, by the facility at 7:43 a.m. The patient’s HGB was 5.5 gm/dL. The facility’s EHR showed an established critical value reference range for HGB of 6.0 gm/dL to 18.2 gm/dL. A result comment on the report showed, “HGB, sent to [NF1] Clinic. The following result was called back by [staff member I] on 7/28/25 at [2:20 p.m.]: HGB”. The comment utilized to indicate the immediate notification of the critical value did not show the critical value on 4/28/25, was immediately communicated to the ordering provider until 7/28/25 (three months later). During an interview on 8/12/25 at 9:25 a.m., staff member D stated it was the expectation when a critical value was identified, that value was to be immediately reported to the ordering provider and a notation made in the computer system with the date and time the critical value was reported and to whom it was reported. Staff member D stated she had returned to work after being on leave for a couple weeks at the beginning of July 2025, to find that the “Critical Queue” in the EHR had not been monitored while she was away. She stated she provided re-education with staff member I on the process for the “Critical Queue”. Staff member D stated that was why the comment on patient #1’s CBC, dated 4/28/25, showed the critical value was reported to the provider on 7/28/25. She stated however, this would not account for why the “Critical Queue” was not monitored the day of patient #1’s critical value for the HGB. Staff member D stated she monitored the “Critical Queue” a couple times a week. Staff member D stated she had not checked her “Critical Queue” system since 7/28/25. During an interview on 8/12/25 at 11:04 a.m., staff member G stated the expectation for reporting critical lab values was to notify the ordering provider within one hour of the results being verified. She stated the EHR had a “Critical Queue” which notified the lab technicians of any critical lab values. She stated she kept her “Critical Queue” open all day long and checked it frequently for any critical lab values that populate. However, the expectation was to check it at least hourly. A review of staff member D’s “Critical Queue” on 8/12/25 at 9:00 a.m., showed the following patients were identified to have critical lab values which had not been completed in the “Critical Queue” from 5/1/25 to 8/2/25: - 5/1/25 at 2:24 p.m., patient #3, - 5/24/25 at 1:52 p.m., patient #4, - 6/10/25 at 2:49 p.m., patient #5, - 6/23/25 at 12:08 p.m., patient #6, - 7/1/25 at 11:32 a.m., patient #7, - 7/21/25 at 11:56 a.m., patient #8, and - 8/2/25 at 8:39 a.m., and 11:43 a.m., patient #9. During an interview on 8/12/25 at 9:00 a.m., staff member D stated she was not sure why the following patients were still listed in the “Critical Queue”. She stated she thought it was because they had not been completed or finalized. Staff member D stated the ordering providers should have already been notified of all the critical lab values that were currently in the “Critical Queue”. A review of patient #4’s CBC dated 5/24/25, which had been verified/resulted at 2:49 p.m., showed a critically high HGB value of 18.3 gm/dL (A critically high HGB level, which indicates an excess of red blood cells in the blood, can lead to various health complications, including blood clots, stroke, and heart attack). Further review of patient #4’s EHR and laboratory results for 5/24/25 did not show a comment which indicated the critical lab value was immediately reported to the ordering provider. During an interview on 8/12/25 at 1:45 p.m., staff member D stated there was no comment in patient #4’s EHR or for the critical lab value on 5/24/25, which would indicate the critical lab value was not immediately reported to the ordering provider. 2. Critical Value Reference Ranges Consistent with Computer Module A review of the facility’s policy and procedure titled, Critical Value Immediate Notification, with an effective date of 12/12/23, showed their established critical value reference ranges for: - HGB set for a low value at less than 8.0 gm/dL and a high value greater than 18.3 gm/dL. - White Blood Cells (WBC) set for a low value at less than 2,000 mm and a high value greater than 50,000 mm. Review of the facility’s computerized established critical value reference ranges for HGB and WBC showed: - WBC critical low at less than 2,500 mm, and a critical high value at 30,000 mm. - HGB critical low at less than 6.0 gm/dL, and a critical high value greater than 18.2 gm/dL. 3. Timely Notification of In-House Laboratory Results to Out of Network Providers A review of the facility’s policy and procedure titled Standard Operating Procedure, with an effective date of 9/1/23, showed: “... Reporting Results A. All results of in-house testing will be reported within 4 hours unless referred to another facility. C. Testing received after 4:30 p.m. may be reported the following day, if appropriate. F. Test results will be reported to the ordering provider. J. Reference laboratory results will not be modified in any way and will be reported as soon as possible after receipt...” During an interview on 8/6/25 at 12:52 p.m., NF1 stated they were not faxed the results of ordered labs timely by the facility. NF1 stated they would often have to call the facility and ask for the results to be sent to them. During an interview on 8/12/25 at 1:45 p.m., staff member D stated to send out of network providers the laboratory results, the facility would print a hard copy of the lab and fax it to them using the fax machine and then keep a paper copy of the faxed report. She stated the facility recently changed their faxing system to Right Fax. Staff member D stated she wasn’t sure how to obtain a fax verification for any older faxes. A review of the following patient medical charts for April 2025, showed the facility did not have a faxed validation report that showed the out of network provider was faxed a report for their lab results for: Patient #s 1, 3, and 15. During an interview on 8/12/25 at 1:45 staff member D stated she checked, and the facility did not have any fax validation reports for April of 2025 to show that out of network providers were timely faxed the results of ordered labs. 4. Glucose Point of Care Testing Quality Controls A review of the facility’s policy and procedure titled Standard Operating Procedures, with an effective date of 9/1/23, showed: “Laboratory Personnel: C. Day to day operations of the laboratory will be overseen by an individual(s) who meet the CLIA standards for General Supervisor in a high complexity laboratory... Reagents, Controls, Test Kits, and Media: A. All reagents, controls, test kits and media will be marked with the date received, date opened and the expiration date. A review of the facility’s policy and procedure titled, POC Glucose Testing, with an effective date of 5/30/25, showed: “Quality Control Procedure: 6. ...Record the result in the quality logbook. 7. Remove the test strip and dispose. 8. Repeat steps 1-6 with a second control solution. Meter Preparation: 1. Check the QC log to see that the QC was performed on the testing day. If not, run two levels of control as described in the Quality Control procedure section...” A review of the Quality Assurance/Quality Control Reference Manual Manufacturer Guidelines for the Assure Platinum Glucometer, showed: “Assure Platinum Test Strips Storage and Handling ... Do not re-use an Assure Platinum Test Strip. Only use Assure Platinum Test Strips with an Assure Platinum Blood Glucose Meter... Assure Dose Control Solutions ...Use the Assure Dose Control solution within 90 days (3 months) of first opening. It is recommended that you write the date of opening on the control solution bottle label (“Date Opened”) as a reminder to dispose of the opened solution after 90 days...” a. During an observation and interview on 8/11/25 at 2:30 p.m., there were two Assure Platinum Glucose Meters being utilized outside the lab in the facility’s emergency department and the swing-bed long-term care department. The first meter was in the emergency department in a blue basket. The meter had a container of glucose test strips with a lot number of: 634635U. There were no control solutions in the blue basket. There was not a glucose quality control log for the meter in the emergency department. Staff member D stated the log was kept at the nurses’ station. She stated the test strips kept with the glucometer in the emergency department would be utilized for testing a patient’s bedside glucose. During an observation and Record Review on 8/11/25 at 2:30 p.m., the Glucometer Quality Control Logbook at the nurses’ station showed quality controls were ran on both glucometers using the test strips with a lot number of: 634325U. The test strips with lot number 634635U, kept in the blue basket with the glucometer, that was used in the emergency department, did not have quality control documented in the logbook. During an interview on 8/12/25 at 10:30 a.m., staff member B stated the quality controls for the glucometers were ran by the night shift nurses after midnight every night. Staff member B stated both meters and both test strips used with each meter should be quality controlled every night. She stated the test strips in the blue basket were used with the glucometer that was used in the emergency department. Staff member B stated she could not tell from the Glucometer Quality Control Log if the test strips used with the glucometer in the emergency department with lot number 634635 had been quality controlled. b. During an observation on 8/11/25 at 2:30 p.m., a second Assure Platinum Glucose Meter was kept in a pink basket at the nurses’ medication cart. The pink basket contained the glucometer, test strips with a lot number of 634325U, a normal control solution with a lot number of 22224A, and a high control solution with a lot number of 022824A. Both control solutions were opened but there was no date when opened. During an interview on 8/11/25 at 2:30 p.m., staff member D stated it was the expectation that the quality control solutions used to test the normal and high glucose controls should be dated when opened. c. During an observation on 8/11/25 at 2:30 p.m., a second Assure Platinum Glucose Meter was kept in a pink basket at the nurses’ medication cart. The pink basket contained the glucometer, test strips with a lot number of 634325U, a normal control solution with a lot number of 22224A, and a high control solution with a lot number of 022824A. Review of the facility’s Glucometer Quality Control Logs from 7/1/24 to 8/2/25, did not have the lot control numbers for the low or high controls solutions documented. During an interview on 8/11/25 at 2:30 p.m., staff member D stated she thought the nurses were completing the quality controls for the bedside glucometers and it was not something she had been providing oversight on.”

“Based on the regulatory requirements and standards of 42 Code of Federal Regulations (CFR) 485.623(d) for Critical Access Hospitals (CAHs), a life safety code survey was performed on 08/20/2024. Under this regulatory requirement, the facility must meet the applicable provisions of the National Fire Protection Associations (NFPA) 101 Life Safety Code, 2012 Edition, and those mandatory Codes referenced by that edition. The facility was surveyed specifically using Chapter 19 Existing Health Care Occupancies of NFPA 101. The building construction type was found to be Type V (111). The building is separated with a 2 hour barrier from the medical clinic and an assisted living facility. The medical clinic was not identified as being a satellite facility. The CAH is certified for 25 patients. At the time of the survey, the census was 18 residents. These requirements were not met as evidenced by the following deficiencies:”

“Discharge from Exits CFR(s): NFPA 101 Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7 This Standard is not met as evidenced by: 40068 Based on observation, the facility failed to maintain the exit discharge to the public way with respect to keeping a level walking surface free of obstruction in accordance with NFPA 101, 2012 Edition, Section 7.1.6.2. Findings Include: During an observation on 8/20/24 at 12:27 p.m., the exit discharge to the back parking lot was inspected. The walkway was found to have multiple sections of the concrete chipped and broken. The hard-surface path to the public way cannot have more than a 1/4” variation in tread height.”

“Protection - Other CFR(s): NFPA 101 Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. This Standard is not met as evidenced by: 40068 Based on observations and interview, the facility failed to: a) maintain the fire resistive properties of a two-hour barrier in accordance with NFPA 101, 2012 Edition, Section 19.1.3.3., and b) maintain fire doors in accordance with NFPA 80, 2010 Edition, Section 4.6.4, 5.2.4.2 (3) (6) (8). Findings include: 1. During an observation on 8/20/24 at 1:20 p.m., the two-hour wall between the hospital and the assisted living facility was inspected. There were IT wires punched through the two-hour barrier above the double doors. The penetration was not sealed with fire-resistive caulk. 2. During an observation on 8/20/24 at 1:10 p.m., the fire rated door was inspected. The door lacked fire rated hardware, and did not close and latch under the power of the self-closure. Staff member A stated the door was a fire rated door and part of the facility’s fire barrier.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 40068 Based on record review, interview, and observation the facility failed to: a) complete an annual backflow preventer test in accordance with NFPA 25, 2011 Edition, Section 13.6.2.1., b) maintain sufficent area area around a sprinkler head in accordance with NFPA 13, 2010 Edition, Section 8.6.5.2.1.1., and c) ensure sprinkler systems maintained satisfactory performance with respect to activation time in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems, 2010 Edition, Section 8.1.1 (3). Findings include: 1. Record review on 8/20/24 showed the facility had not completed an annual back flow preventer test completed since 6/29/23. During an interview on 8/20/24 at 11:30 a.m., staff member A stated he was unsure why the backflow preventer was not tested. 2. During an observation on 8/20/24 at 1:08 p.m., the walk-in cooler was inspected. There was food stored within 18 inches of a sprinkler head. 3. During an observation on 8/20/24 at 1:36 p.m., room 10A was inspected. A ceiling tile was sagging creating a gap around the sprinkler head.”

“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: 40068 Based on record review and interview the facility failed to conduct fire drills for every shift in every quarter, as well as evidence the fire drills were simulated under varied conditions in accordance with NFPA 101, 2012 Edition, sections 19.7.1.6 and 19.7.2.2. Findings include: 1. During a review of facility fire drills on 8/20/24 it was determined the facility was missing the following fire drills: The day and night shift in the third quarter of 2023 (July - September). The day and night shift in the fourth quarter of 2023 (October - December). The night shift in the first quarter of 2024 (January - March). The night shift in the second quarter of 2024 (April - June). During an interview on 8/20/24 at 11:10 a.m., staff member A stated the facility does not have an after action report to show the fire drills were preformed under varied conditions.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 40068 Based on record review and interview the facility failed to test the fire doors in fire assemblies annually in accordance with NFPA 101-2012, Sections 7.2.1.15.1, 4.6.12 and in accordance with NFPA 80-2010, Section 5.2 (written report). Findings include: Review of the fire safety maintenance records on 8/20/24 showed the facility lacked annual fire door assembly testing documentation. During an interview on 8/20/24 at 11:48 a.m., staff member B stated he was not sure when the last annual fire door inspection had been completed, but he planned to do one in September of this year.”

“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: 40068 Based on record review and interview the facility failed to: a) ensure an annual diesel fuel supply quality test was conducted at least annually per NFPA 101 2012 Edition, Section 9.1.3.1 and NFPA 110, Section 8.3.8., and b) the facility failed to have evidence that the generator was being exercised under load 12 times a year for 30 minutes in accordance of NFPA 110 Standard for Emergency and Standby Power Systems, 2010 Edition, Sections 8.4.1 and 8.4.2.4. Findings include: 1. Review of the emergency generator inspection records on 8/20/24 showed the last diesel fuel quality test was completed on 9/13/23, and the diesel fuel failed the test. During an interview on 8/20/24 at 11:15 a.m., staff member B stated the next annual diesel fuel quality test is scheduled for 8/28/24. 2. Record review of diesel generator information showed there was no documentation for monthly load and annual load testing completed. During an interview on 8/20/24 at 11:45 a.m., staff member A stated the facility did not have any documentation to show the generator had been tested 12 times a year under a 30 minute load, or that an annual load test had been completed.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 40068 Based on observation the facility failed to ensure extension cords were not used in the facility per NFPA 99-2012, Health Care Facilities Code, Section 10.2.4. Fndings include: During an observation on 8/20/24 at 1:35 p.m., the employee break room was inspected. An extension cord was in use. The extension cord was being used to plug in a surge protector.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 44769 Based on interview and record review, the facility failed to ensure 1 (staff member F) of 15 sampled staff members, was current with their ACLS certification. This deficient practice had the potential to affect all patients who received care in the facility. Findings include: Review of the facility personnel requirements document titled, “Registered Nurse, Job Description”, signed by staff member F on 2/12/2024, showed: “ ... Essential Job Functions ... Minimum Qualifications: ... Healthcare Provider CPR Certification, ACLS, PALS, TNCC or CALS required ...” Review of the facility personnel file for staff member F showed, an ACLS certificate with a renew by date of 12/31/23. During an interview on 8/15/24 at 9:17 a.m., staff member A stated he was unable find a current ACLS certification for staff member F. During an interview on 8/15/24 at 10:12 a.m., staff member P stated it was the expectation that nursing staff working in the ED would have current BLS, ACLS and PALS certifications.”

“FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION CFR(s): Freedom from abuse, neglect and exploitation (§483.12(a)(1), (a)(2), (a)(3)(i), (a)(3)(ii), (a)(4), (b)(1), (b)(2), (c)(1), (c)(2), (c)(3), and (c)(4) of this chapter). “ §483.12(a)(1) Freedom from abuse, neglect, and exploitation. The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s medical symptoms.(a) The facility must-(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; “ §483.12(a)(2) Ensure that the resident is free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. “ §483.12(a)(3) Not employ or otherwise engage individuals who- (i) Have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law; (ii) Have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of their property. “ §483.12(a)(4) Report to the State nurse aide registry or licensing authorities any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff. “ §483.12(b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, “ §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: (1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. (2) Have evidence that all alleged violations are thoroughly investigated. (3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. (4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This Standard is not met as evidenced by: 40800 Based on observation, interview and record review, the facility failed to document the use of restraints according to its policy for 1 (#20) of 20 sampled patients who presented to the emergency department for emergency medical treatment. This deficiency had the potential to affect the patient’s safety while in the emergency department. Findings include: Review of patient #20’s electronic medical record showed, patient #20 presented to the emergency department on 7/15/24 via ambulance after being involved in a motor vehicle crash. Patient #20 was combative on the scene, attempted to assault a sheriff deputy, and attempted to take the deputy’s weapon. The record showed transport of the patient was delayed to the facility because law enforcement was required to detain the patient. Law enforcement placed the patient in handcuffs and the patient was transported to the hospital in handcuffs. The medical record showed the patient remained in handcuffs while he was in the CT scanner, and during his treatment in the emergency department. The patient’s medical record lacked orders for restraints, lacked documentation of circulation distal to the restraints, and did not contain documentation showing the facility tried to place the patient in the least restrictive restraint for medical treatment. During an interview on 8/14/24 at 4:25 p.m., staff member P stated patient #20 was in handcuffs the entire time he was in the emergency department. She stated the patient was cooperative with her, but he was aggressive towards the officers who were detaining him. Staff member P stated she was unaware restraint documentation was required for a patient in handcuffs. During an interview on 8/15/24 at 8:43 a.m., staff member Q stated she did not know if there was a policy for law enforcement detained or arrested patients, and she did not know if she was required to assess a patient for restraints if the patient arrived to the facility in handcuffs. Staff member Q said she had not had a situation where that would have been necessary, but she would look at the policy manual to find out what the policy said if she were to have a situation where a patient was detained by law enforcement. Staff member Q said if a patient needed to be restrained in the emergency department, the provider would need to write orders, they would need to ascertain what the least restrictive restraint was for the individual, and they would be required to document the restraints on the restraint flowsheet in the patient’s EMR every 15 minutes. During an interview on 8/15/24 at 8:50 a.m., staff member A said he did not think there was a policy and/or procedure for a patient who presented to the facility that was detained by law enforcement. Review of a facility policy titled Restraint Policy, dated 4/25/23, showed: “POLICY STATEMENT: It is the philosophy of [Facility Name] that patients/residents have the right to be restraint free. In the event that restraint is necessary and after alternatives have been attempted the least restrictive method of restraint that meets the patient/resident assessed need will be used. An exception exists if safety issues demand an emergent intervention. The restraint is to be discontinued at the earliest possible time. The patient/resident ’ s rights, dignity and well-being will be protected and preserved by the interdisciplinary team providing care. The use of a restraint for coercion, discipline, convenience or retaliation by staff is not permitted ... Documentation: a provider ordered based on the assessment/examination of the patient/resident. This order needs to be reviewed and reordered every 24 hours. The alternatives attempted OR why alternatives were not appropriate. The alternatives attempted OR why alternatives were not appropriate. Patient/resident behavior, condition, or symptom(s) that warranted the use of the restraint and any staff concerns regarding safety risks (patient/resident injury) ... Observations and/or assessments. A restraint assessment will be completed quarterly or with significant changes in resident conditions ...” [sic] The policy did not contain direction for restraints placed by law enforcement. Review of a document published by the International Association for Healthcare Security and Safety Foundation, titled Violence in Healthcare and the Use of Handcuffs, dated 10/2/2018, showed, “The custodial officer who is with the patient is responsible for the use of handcuffs while treatment occurs. That does not, however, absolve the medical care facility of a responsibility to protect the patient while treatment is being rendered. For example, if handcuffs are too tight or are impeding medical treatment, the healthcare worker must assess the safety of continued use of restraint ...””

“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: 41652 Based on interview, record review and policy review, the facility failed to comply with the conditions of participation outlined in §489.24; (refer to Appendix V). The facility failed to document the physician explained the risks and benefits of refusing ambulance transfer to a higher level of care and failed to obtain signatures indicating the patient understood the risks and benefits for 4; failed to send medical records to the receiving facility for 2; failed to provide an appropriate MSE for 2; and failed to provide an appropriate transfer for 3 of 20 sampled patients who required stabilizing treatments. Findings include: 1. Review of the facility’s policy titled, “EMTALA: Screening, Stabilization, Transport,” dated 4/11/22, showed when an individual comes to the hospital and a request is made for examination or treatment of a potential emergency medical condition, the individual will receive an appropriate medical screening examination to determine whether the individual has an emergency medical condition. -Review of patient #s 2 and 5 EHRs failed to show the facility provided appropriate medical screening examinations in order to determine if the patient had an emergency medical condition, and what was the extent of the medical condition. (see C-2406) 2. Review of the facility’s policy titled, “EMTALA: Screening, Stabilization, Transport,” dated 4/11/22, showed following the completion of the medical screening examination, if the patient has an emergency medical condition, the QMP will provide stabilizing treatment or transfer if a higher level of care is needed. The policy showed if the patient refused treatment or transfer, the provider was to, “... a. give the individual an explanation of the risks and benefits ... of the examination or treatment or mode of transportation. b. describe in ... medical record the examination and treatment or that [sic] the individual refused. c. take reasonable steps to obtain the written informed refusal ... The document reflecting the refusal should indicate that the individual has been informed of the risks and benefits ... and should be signed ... and placed in the medical record.” The policy showed when a patient is transferred the facility is responsible for sending copies of all available medical records related to the emergency medical condition to the receiving facility. -Review of patient #s 1, 2, 4, and 11 EHRs failed to show the risks and benefits of the patient’s refusal for transfer were explained to the patient or their representative, and failed to show written consent or refusal of the transfers. Review of patient #1’s EHR failed to show the required medical records were sent to the receiving facility. (see C-2408) 3. Review of the facility’s policy titled, “Trauma Transfer Guidelines,” dated 8/2/23, showed a transfer is considered appropriate if, “a. Injuries are outside the scope of care offered by [Facility Name] ..., b. Level of nursing care needed cannot be met at [Facility Name],” and “c. At attending providers discretion” [sic] The policy also showed all appropriate transfer paperwork must be filled out prior to transfer with copies sent with the patient and the rationale for transfer must be clearly documented in a provider note, “including risks and benefits of mode of transport.” -Review of patient #s 14, 15, and 17 EHRs failed to show properly completed transfer certification explaining the risks and benefits of transfer to the patient or their representative and failed to show written consent or refusal of the transfer. Review of patient #14’s EHR failed to show the consulting physician co-signed the transfer certification for a patient transferred in an unstable condition, patient #15’s EHR failed to show the required medical records were sent to the receiving facility, and patient #17’s EHR failed to show the provider signature was appropriately dated and time. (see C-2409)”

“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: 41652 Based on interview and record review, the facility failed to maintain an accurate central log which included all patients who came to the ED seeking emergency care, whether the patient refused treatment, was refused treatment, or was transferred, admitted and treated, stabilized and transferred, or discharged. Findings include: During the entrance conference on 5/20/24 at 10:45 a.m., a request was made for the ED log and the full ED census from 11/1/23 to 5/19/24. Review of the ED census report showed the following: - ED encounters for November of 2023, 81 total; - ED encounters for December of 2023, 75 total; - ED encounters for January of 2024, 88 total; - ED encounters for February of 2024, 69 total; - ED encounters for March of 2024, 88 total; - ED encounters for April of 2024, 73 total; and - ED encounters from 5/1/24 to 5/19/24, 61 total. Review of the facility’s central log, dated 11/1/23 to 5/19/24, showed the following: - ED encounters for November and December of 2023, no encounters in the log; - ED encounters for January of 2024, 72 written in the log, 16 encounters missing from the log; - ED encounters for February of 2024, 58 written in the log, 11 encounters missing from the log; - ED encounters for March of 2024, 84 written in the log, four encounters missing from the log; - ED encounters for April of 2024, 64 written in the log, nine encounters missing from the log; and - ED encounters from 5/1/24 to 5/19/24, 57 written in the log, four encounters missing from the log. During an interview on 5/21/24 at 8:15 a.m., staff member B stated the previous DON (who was no longer at the facility) identified the ED log was not being maintained prior to 1/1/24. Staff member B stated the ED log was restarted on 1/1/24. During an interview on 5/23/24 at 8:00 a.m., staff member G stated the ED log was not being completed prior to 1/1/24. Staff member G stated she did not know the purpose of the ED log and was directed to enter all ED patients into the log. During an interview on 5/23/24 at 9:00 a.m., staff member H stated she had been at the facility for more than 20 years. Staff member H stated the ED log was not done for several years and she was not sure why “it went away or why it came back.” Staff member H stated she was not aware the ED log was an EMTALA requirement. During an interview on 5/23/24 at 11:00 a.m., staff member K stated she was at the facility from July of 2023 through January of 2024. Staff member K stated the use of an ED log initially was not used and near the end of her assignment, they started using a log. During an interview on 5/23/24 at 11:30 a.m., staff member L stated she had been at the facility since February of 2024. Staff member L stated she believed the ED log was used for documenting the arrival and discharge disposition for ED patients. Staff member L stated she did not remember getting education regarding the use or consequences of not completing the ED log.”

“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: 41652 Based on interview and record review, the facility failed to ensure the patient received an adequate medical screening examination (MSE) and failed to obtain a signed Against Medical Advice (AMA) form which identified the risks and benefits of the patient’s refusal to be admitted or transferred for further care for 2 (#s 2 and 5) of 20 sampled patients. Findings include: 1. Review of patient #2’s EHR, dated 5/15/24, showed the patient, a 26-year-old female, presented to the ED via ambulance after fainting at home. The patient lost consciousness for approximately 10 seconds and fell to the floor. The patient’s vital signs on arrival to the ED were BP 99/67, P 89, R 17, T 37.0 and an O2 saturation of 94% on room air. The patient’s BP remained low throughout the ED encounter, going as low as 84/50. The patient had a history (approximately one year ago) of extensive blood clots in her lungs. The patient had a surgical procedure to remove the blood clots and was placed on a blood thinning medication to prevent the development of new clots. The provider’s physical examination failed to show examination of the patient’s spinal bones for fracture, dislocation, or pain after sustaining a fall. The examination also failed to show the provider assessed the resident’s brain, cranial nerve function, or arm and leg strength for evidence of a brain injury or stroke. Laboratory tests, an EKG, and CTs of the head and chest were performed. The results of the CT of the patient’s chest showed multiple lesions, some with cavities (bubble-like formations). The provider’s assessment and plan at discharge failed to show the lung lesions or any recommended follow-up. The provider documented the patient declined admission or transfer for further care and would be leaving AMA. The patient’s EHR failed to show the patient signed anything showing she was notified of the risks and benefits of her refusal or that she was leaving AMA. During an interview on 5/23/24 at 8:00 a.m., staff member G stated she was instructed by staff member F to document the patient and their representative were thoroughly counseled regarding the risks and benefits of refusing treatment and leaving AMA. Staff member G stated she documented the information in the patients medical record, but she did not complete the AMA form. During an interview on 5/28/24 at 9:00 p.m., staff member F, a mid-level provider in the ED, stated he did not consider patient #2 as an AMA discharge. Staff member F stated the patient was feeling better and already had a follow-up appointment scheduled with a specialist. Staff member F stated, “a comprehensive work-up ruled out a stroke, no blood clots, was probably dehydrated and orthostatic.” Staff member F stated the patient was concerned about cost because she did not have health insurance, and already had a follow-up appointment scheduled within a week. Staff member F stated he only discharges patients AMA in extreme cases. He stated he usually does a regular discharge and gives the patient instructions to return if any problems. Staff member F stated he always discusses the risks and benefits with the patient and representative. However, when time is a factor he sometimes forgets to include it in the ED note. 2. Review of patient #5’s EHR, dated 4/3/24, showed the patient presented to the ED after sustaining a right hand injury while using a table saw. Patient #5 was observed to have a deep laceration to the base of his right index finger. The patient’s vital signs on admission to the ED were BP 161/92, P 111, R18, O2 saturation 96% on room air and T 36.6. Plain x-ray films of the patient’s right hand showed no boney abmormailities, only soft tissue disruption at the base of the patient’s right index finger. Because the patient was not able to straighten his index finger, a tendon injury was suspected. Staff member D, the ED physician, examined patient #5’s injury which showed the laceratiom was to the joint at the base of the patient’s index finger, but failed to identify if there was any visible damage into the joint itself. The ED note did show the provider was aware of the patient’s history of lung cancer and current treatment with chemotherapy. Staff member D consulted an orthopedic specialist regarding the care of this patient’s injury. The note failed to show whether or not staff member D informed the orthopedic specialist regarding the patient’s current treatment with chemotherapy. Staff member D’s note showed he was instructed to clean the wound, loosely close the laceration with stitches, immobilize the index finger and cover the wound with a bandage. The note also showed the patient was instructed to follow-up with an orthopedic hand specialist in the next couple of days. The patient’s EHR failed to show any testing or evaluation of the patient’s immune system, which can be depressed during chemotherapy. A depressed immune system placed the patient at a higher risk for infections in the soft tissue or in the bone itself. During an interview on 5/22/24 at 3:30 p.m., staff member D stated there were no associated risks if the follow-up on the hand injury was delayed up to seven days. Staff member D did not mention patient #5’s potential for a depressed immune system related to chemotherapy as a risk for patient #5. Review of patient #5’s operative note, dated 4/4/24, showed the patient had a surgical repair of his injured right hand on 4/4/24. The note showed the surgeon was able to see damage to the cartilage at the end of the hand bone which formed the base of the patient’s index finger. The cartilage around a joint is called the capsule. The damage to the capsule created an opening into the joint itself. Exposing the joint to air increased the risk of infection into the joint itself. The operative report showed the wound was cleaned out, the capsule was repaired, the tendons were repaired, and the wound was closed.”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 40800 Based on record review, interview, and policy review the facility failed to document the ED physician explained the risks and benefits of the patient’s refusal to be transported by ambulance to a higher level of care and failed to obtain signatures indicating the patient understood the risks and benefits of the refusal for 4 (#s 1, 2, 4, and 11); and failed to send medical records to the receiving facility for 1 (#1) of 20 sampled patients. This deficiency had the potential to affect the patients’ decision to be transferred via ambulance and affect the care they received at the receiving facility. Findings include: 1. Review of patient #1’s EHR, dated 5/16/24, showed the patient, a 17-year-old male, had sustained a significant hand injury due to an accident with a power tool. The record showed the patient arrived at the facility at 9:56 a.m., via ambulance. The provider notes showed the patient had x-rays before and after an attempt to reduce the fractures. The provider documented he attempted to close the wound but was unable. The provider, after consulting an orthopedic surgeon, made the decision to transfer the patient to another facility for possible surgical intervention, as the fingers were unlikely to be saved and the sending facility did not have surgical capabilities. The note showed the provider recommended transferring via ambulance for pain control. The patient’s guardian refused to allow the patient to go by ambulance and took patient #1 by private vehicle after the patient was discharged. The patient’s EHR failed to show a written provider certification of the risks and benefits of transfer and a patient or representative consent or refusal for the ambulance transfer. The EHR failed to show a tranfer form was filled out identifying if records were sent to the receiving facility. During an interview on 5/23/24 at 12:00 p.m., staff member M stated he did not usually do transfer forms when a patient went by private vehicle. Staff member M stated this was because the patient was no longer under the control of the facility, and they were discharged. Review of the facility’s form entitled, “[Facility Name] Transfer Form, not dated, showed a check box for, “Copies of appropriate medical records sent with patient.” 2. Review of patient #2’s EHR, dated 5/15/24, showed the patient presented to the ED via ambulance after having a syncopal episode and a loss of consciousness at home. The patient’s vital signs on admission were BP 99/67, P 89, R 17, T 37.0, and O2 sat 94% on room air. Laboratory tests, an EKG, and CTs of the head and chest were performed. The provider note showed he recommended the patient be transferred for additional testing not available at the facility. The provider documented the patient refused transfer and would leave AMA. The EHR failed to show documentation of the provider’s risk versus benefit discussion with the patient, or a refusal of transfer or AMA form signed by the patient. During an interview on 5/28/24 at 9:00 a.m. staff member F, a mid-level provider, stated patient #2’s refused to be transferred to a higher level of care. Staff member F stated he wanted the patient to go but decided she was stable enough to wait for the already scheduled appointment later in the week. Staff member F stated the patient was feeling much better and the high-risk diagnoses of stroke and pulmonary embolism had been ruled out as the reason for not having the patient sign an AMA form. 3. Review of patient #4’s EHR, dated 5/15/24, showed the patient presented to the ED with swelling and redness to his right index finger and had a history of a cut about one month prior. The patient’s vital signs were within normal limits and laboratory tests were normal. Patient #4’s x-ray was “concerning for a septic joint.” Arrangements were made for patient #4 to be seen immediately by an orthopedic specialist at Hospital B. The patient refused ambulance transfer and was discharged, with plans to travel to Hospital B by private vehicle. The EHR failed to show the risks and benefits of the transfer were discussed with the patient and a signed consent or refusal by the patient. During an interview on 5/23/24 at 11:30 a.m., staff member L, an ED RN, stated she did not complete transfer paperwork for patients transferring to a higher level of care who went by private vehicle. Staff member L stated patient #4 was sent to a higher level of care but transported by private vehicle. 4. Review of patient #11’s EHR, dated 1/22/24, showed the patient presented to the ED with a right ankle injury sustained in a fall. X-rays showed a displaced fracture of the right lower leg and a displaced fracture of the inner ankle bone. Staff member D attempted to reduce the patient’s fractures twice. Staff member D consulted an orthopedic specialist at Hospital B. The orthopedist reviewed the x-rays and recommended the patient come to the ED to see if he could get better alignment of the fractures. The patient was instructed to go directly to Hospital B. The patient was marked as discharged by staff member D, although staff member G documented the patient was transferred to another facility. The record failed to show a signed provider certification of the risks versus benefits of a transfer by private vehicle, or a signed consent by the patient. During an interview on 5/23/24 at 8:00 a.m., staff member G, an ED RN, stated she usually completed the transfer paperwork (signed provider and patient consent for transfer and the transfer form). Staff member G stated if a patient wanted to travel by private vehicle, she still did the transfer paperwork. Staff member G was not able to explain why the transfer paperwork was not completed for patient #11. During an interview on 5/23/24 at 11:00 a.m., staff member K stated the paperwork process for discharge versus transfer was a “bit of a gray area.” Staff member K was a travel nurse and was not aware of the facility’s protocol for transferring versus discharge. Staff member K stated she completed the same discharge paperwork regardless of whether the patient went by private vehicle or by ambulance to another facility. Staff member K stated if the patient refused to go by ambulance, she tried to get an AMA form signed. Review of the facility’s policy titled, “EMTALA: Screening, Stabilization, Transport,” dated 4/11/22, showed following the completion of the medical screening examination, if the patient has an emergency medical condition, the QMP will provide stabilizing treatment or transfer if a higher level of care is needed. The policy showed if the patient refused treatment or transfer, the provider was to, “... a. give the individual an explanation of the risks and benefits ... of the examination or treatment or mode of transportation. b. describe in ... medical record the examination and treatment or that [sic] the individual refused. c. take reasonable steps to obtain the written informed refusal ... The document reflecting the refusal should indicate that the individual has been informed of the risks and benefits ... and should be signed ... and placed in the medical record.” The policy showed when a patient is transferred the facility is responsible for sending copies of all available medical records related to the emergency medical condition to the receiving facility.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 41652 Based on interview, record review and policy review, the facility failed to provide a properly completed certificate of transfer for 3 (#s 14, 15, and 17); and failed to provide patient records to the receiving hospital for a facility transfer for 1 (#15) of 20 sampled patients who required stabilizing treatment. This failure could cause unintended adverse medical consequences for the transferred patient. Findings include: 1. Review of patient #14’s EHR dated 1/1/24, showed the patient presented to the ED via ambulance after having been involved in a motor vehicle accident. The patient sustained a number of life-threatening injuries. Arrangements were made for the patient to be transferred by air to the closest trauma center. The patient’s transfer form indicated the patient’s condition had not been stabilized prior to the transfer and failed to show the co-signature of the consulting physician. During an interview on 5/22/24 at 2:15 p.m., staff member E, a mid-level provider, stated she was not aware a physician needed to sign the transfer consent when a patient was unstable at the time of transfer. Staff member E stated she did the transfer paperwork for patient #14. Staff member E stated when an unstable patient in the ED needed to be transferred, she would complete the transfer paperwork as quickly as possible and discussed the patient’s condition with the receiving facility physician. Staff member E stated she was not aware when the patient in the ED was unstable at the time of transfer, a physician (from the sending facility) must be consulted and co-sign the transfer certificate. Review of patient #14’s Emergency Department Reports, dated 1/1/24, showed staff member E consulted the ED physician at the receiving facility and obtained an acceptance of pateint #14 for transfer to the receiving facility. The report does not show any consultation with a physician at the sending facility. Review of patient #14’s transfer form, dated 1/1/24, showed staff member E documented the patient’s condition had not been stabilized. The form also contained a boilerplate statement, “Based on the reasonable risks and benefits to the patient ... the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility out weight [sic] the increased risks ...” The specific risks and benefits portion of the form was blank. The mid-level provider (staff member E) signed the form. There was no physician co-signature on the form. Review of the facility’s policy titled, “EMTALA: Screening, Stabilization, Transport,” dated 4/11/22, showed when a patient has an EMC that has not been stabilized, the patient may be transferred to another facility if the transfer is appropriate, the QMP has consulted with a physician to determine if the benefits outweigh the risks of transfer, and the QMP has signed a certification containing a summary of the specific risks and benefits of the transfer. The consulting physician must co-sign the certification “reasonabl soon.” An appropriate transfer is defined as a transfer where the facility has provided the medical treatment within its capability, has obtained acceptance of the patient by the receiving facility, and has used qualified personnel and equipment to affect the transfer safely. 2. Review of patient #15’s EHR, dated 1/2/24, showed the patient presented to the ED with complaints of leg pain since falling approximately one week prior. The patient’s swelling and pain were worse in his left leg. Laboratory tests showed an elevated D-dimer level which can indicate blood clots. The ED provider determined the patient needed to have an ultrasound of his legs to rule out blood clots. The closest facility with ultrasound capabilities at night was Hospital C. The EHR showed the patient was instructed to go directly to Hospital C’s ED. The transfer form failed to show what medical records were sent to the receiving facility. 3. Review of patient #17’s EHR, dated 1/24/24, showed the patient presented to the ED with a fever and vomiting. The patient’s vital signs showed an elevated pulse (109) and an elevated temperature (39.2 Celsius = 102.5 Fahrenheit). The ED provider determined the patient should have a viral respiratory panel and CSF fluid analysis, which were not available at the sending hospital. The ED provider made arrangements for the patient to be transferred to Hospital C. The patient was discharged to go directly to Hospital C ED by private vehicle. The EHR failed to show the date and time the form was signed by the provider. Review of the facility’s policy titled, “EMTALA: Screening, Stabilization, Transport,” dated 4/11/22, showed transfer is defined as, “The movement (including discharge) of an individual outside the Hospital’s facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital ...” Review of the facility’s policy titled, “Trauma Transfer Guidelines,” dated 8/2/23, showed transfer is considered appropriate if, “a. Injuries are outside the scope of care offered by [Facility Name] ..., b. Level of nursing care needed cannot be met at [Facility Name],” and “c. At attending providers discretion” [sic] The policy also showed all appropriate transfer paperwork must be filled out prior to transfer with copies sent with the patient and the rationale for transfer must be clearly documented in a provider note.””