Providence St Joseph 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: 45448 Based on interview, record review, policy review, and review of an EMS report, 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 provide a MSE (Medical Screening Exam) 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 an emergency medical condition existed for 1 patient (#4) of 22 sampled patients. Findings include: Review of a facility policy, “Transfer ED Department,” effective date 2/2025, showed: “Purpose: All individuals who come to the hospital emergency department requesting examination or treatment shall receive an appropriate medical screening examination to determine if an emergency medical condition exists. ...” -Patient #4 presented to the ED via ambulance on 7/12/25 at 9:51 p.m. The ambulance arrived at the ambulance bay and was immediately approached by staff member L, the administrator on-call for the facility. Staff member L instructed the ambulance crew to bypass the facility if patient #4 was not in critical condition. The ambulance proceeded to depart the ambulance bay and transported patient #4 to the nearest available ED for evaluation and medical care. Patient #4 did not receive an MSE at the facility prior to transfer. (See C-2406)”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45448 Based on interview, record review, policy review and review of an EMS report, the facility failed to provide a MSE (Medical Screening Exam) 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 an emergency medical condition existed for 1 patient (#4) of 22 sampled patients. Findings include: Patient #4 presented to the ED via ambulance on 7/12/25 at 9:51 p.m. for suicidal ideation and acute alcohol intoxication. Upon arrival to the facility, the ambulance pulled into the ambulance bay and was approached by staff member L, the administrator on-call for the facility. Staff member L advised the ambulance crew to bypass the facility if patient #4 was not in critical condition. The ambulance proceeded to depart the facility and transported patient #4 to the nearest available ED (hospital B) for evaluation and medical care. During an interview on 8/13/25 at 12:23 p.m., staff member H stated he had been working at the facility in the ED as a locum. Staff member H stated the night of 7/12/25 was the busiest night he had worked at the facility. Staff member H stated he had three pediatric trauma patients he was caring for and five to six other patients in the waiting room and hallway waiting to be seen. He stated the ED staff were alerted that an ambulance was in route to the facility. Staff member H said he asked the registration secretary to call the administrator on call and explain the situation and ask what the facility protocol was for the ED to be placed on divert. Staff member H said his priority was to evaluate his pediatric patients for life threatening injuries. Staff member H said he asked the administrator on call to, “take care of the situation” and he went about caring for the patients that were in the facility at the time. Staff member H said he did not speak to the ambulance crew and did not see patient #4 for an evaluation. Staff member H said he was familiar with EMTALA regulations, and the training was, “a pretty standard part of his emergency residency training”. During an interview on 8/13/25 at 2:00 p.m., staff member L said he was the administrator on call on 7/12/25. Staff member L stated he received a call from the ED registration secretary who stated the ED was full and had an ambulance in route, and she asked if it was possible for the ED to go on divert. Staff member L stated he understood if the ambulance had not yet arrived at the ED and the patient did not have a critical condition, the ambulance could transport the patient to another facility. Staff member L said the ambulance had not arrived at the facility with patient #4 when he arrived on site. He stated he approached another ambulance crew member who was present in the ambulance bay and asked, after speaking to the ED manager and the physician, if it was possible to transport patient #4 to another facility. Staff member L said while the two were speaking, the ambulance transporting patient #4 arrived at the facility, in the ambulance bay. Staff member L stated he spoke with the ambulance crew transporting patient #4 and the crew reported patient #4 was not in critical condition. Staff member L stated he told the ambulance crew the ED was full and patient #4 would receive care sooner if they transported the patient to another facility. Staff member L stated the ambulance departed the facility; patient #4 did not receive a MSE. During an interview on 8/13/25 at 1:32 p.m., staff member K said she was working day shift on 7/13/25. Staff member K stated she was informed that an ambulance arrived in the ambulance bay during the previous shift and was sent to another facility without the patient being seen and evaluated. Staff member K said she shook her head and told staff the patient should have been seen and provided a MSE. Staff member K said the facility had been using locum physicians to cover shifts in the ED, and they were not always aware of the facility policies and procedures. Staff member K said she was not involved in the onboarding process for locum physicians but there was a binder available with information on facility policies and procedures. Staff member K said the staff in the ED were a resource for the locum physicians and she was available to answer questions. Staff member K said she did not speak to staff member H following the incident with patient #4, as it was one of his last shifts at the facility. Staff member K stated she does not know if staff member H received education on EMTALA regulations following the 7/12/25 incident. During an interview on 8/13/25 at 7:38 a.m., staff member A said the facility was not on divert on 7/12/25. Staff member A stated the ED was busy and all patient exam rooms were occupied, and patients were waiting in the waiting room to be seen. Staff member A said the facility identified they were in violation of EMTALA requirements when patient #4 was transferred to another facility without receiving a MSE. Staff member A stated the facility self-reported the incident. Review of an ambulance report dated 7/12/25, showed: “ ...A female driver pulled over for suspected DUII. Patient advised law enforcement she was en route to the ER for suicidal ideation and also stated concern for a potential diabetic emergency. ...Patient admitted to consuming alcohol since the early afternoon ...Patient reported a personal history of anxiety and recurrent suicidal ideation. She stated that she currently had intent and a specific plan to harm herself. She repeatedly stated she “wanted to die and was ready to meet her maker”. ...Initiated transport to [Hospital A], the nearest appropriate facility. Upon arrival at the ER ambulance bay, EMS was met by hospital administration (identified as [staff member L]) who advised that the patient should be bypassed if not critical. When asked if this directive was in agreement with the attending physician, [staff member L] stated that it was. No diversion documentation was provided. Based on this instruction, the patient was diverted and transport continued to [Hospital B]. ... Arrived at [Hospital A] at 22:16 ...” [sic] Review of patient #4’s “Patient Demographics,” dated 7/12/25, showed patient #4 arrived at [Hospital B] at 10:37 p.m. Review of patient #4’s “Emergency Department Note” (from hospital B), with an admit/service date of 7/13/25, showed: “ ...74-year-old female presenting with concern for suicidal ideation and acute alcohol intoxication. ...Patient is typically seen in [City name]; oddly, however, per EMS report the ambulance was told by an “administrator” at [hospital A] (while in their ambulance bay at the hospital) that they were on divert and patient was then sent to our hospital for evaluation. ...” Review of a facility policy, “Transfer ED Department,” effective date 2/2025, showed: “Purpose: All individuals who come to the hospital emergency department requesting examination or treatment shall receive an appropriate medical screening examination to determine if an emergency medical condition exists. ...””