Harris Regional Hospital

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39307 Based on policy review, medical record review and staff interviews, the nursing staff failed to conduct pain assessments for patients in the Emergency Department during triage for 10 of 13 medical records reviewed (Patient #3, 4, 5, 7, 8, 13, 14, 15, 17, and 19) and failed to assess/reassess patient’s pain after the administration of medication for 5 of 13 records reviewed. (Patients #5, 7, 12, 13, 23) Findings included: Review of the facility’s Pain Assessment and Management policy effective date 12/2024 revealed, “ ...POLICY This policy provides the guidelines for assessing pain to include the following criteria: 1. Patients will be assessed for the presence, absence, and history of pain using an appropriate rating scale. The pain scale used should be based on the age and condition of the patient and should remain consistent throughout the course of care. the following pain scales are utilized at (Named) Hospital. A. Numeric (0-10): based upon the patient’s self-report b. Wong-Baker Faces-used for assessing non-verbal patients or verbal patients that are unable to articulate pain level ...2. Patients will be reassessed for pain after any intervention, and at regular and periodic intervals using the same scale used for assessment ...ASSESSMENT AND REASSESSMENT ...2. All Emergency Department patients ... patients will be assessed for pain with each visit during triage ...” 1.Closed medical record review on 01/08/2025 for Patient #4 revealed a 46-year-old male presented to the Emergency Department (ED) on 08/25/2024 with a chief complaint of ingestions of two cases of alcohol. Review revealed during triage at 1315 vital signs were obtained without documented assessment of pain. Record review revealed Patient #4 left Against Medical Advice with a documented time of 1630 for discharge. Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 2.Closed medical record review on 01/08/2025 for Patient #5 revealed a 6-year-old male presented to the Emergency Department on 08/31/2024 with a chief complaint of abdominal pain. Review revealed during triage at 2201 vital signs were obtained without documented assessment of pain. Review revealed 360 milligrams of Tylenol was administered without documentation of pain scale. Patient #5 was documented as discharged on 09/01/2024 at 0141 accompanied by a parent without documentation of response to the administration of the Tylenol. Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 3.Closed medical record review on 01/08/2025 for Patient #12 revealed a 59-year-old female presented to the Emergency Department on 10/01/2024 with a chief complaint of fall from bed. Review revealed during triage at 1218 vital signs were obtained with a pain score of 10 out of 10 (with 10 being the most pain). Patient #12 was administered 1 Percocet orally at 1257 for 10 out of 10 pain without reassessment of pain as expected within one hour of the clinical provided intervention. Patient #12 was administered 1 milligram of Hydromorphone intravenously (IV) for a reported pain of 7 out of 10 without documented reassessment . Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 4.Closed medical record review on 01/08/2025 for Patient #14 revealed an 83-year-old male presented to the Emergency Department on 11/14/2024 with a chief complaint of abnormal laboratory values. Review revealed during triage at 1330 vital signs were obtained without documented assessment of pain. Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 5.Closed medical record review on 01/08/2024 for Patient #17 revealed a 75-year-old male presented to the Emergency Department on 12/18/2024 with a chief complaint of hypotension (low blood pressure). Review revealed during triage at 2035 vital signs were obtained without documented assessment of pain. Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 6.Closed medical record review on 01/08/2025 for Patient #19 revealed an 83-year-old female presented to the Emergency Department on 01/01/2025 with a chief complaint of abnormal laboratory values. Review revealed during triage at 1103 vital signs were obtained without documented assessment of pain. Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 7.Closed medical record review on 01/09/2025 for Patient #23 revealed a 22-year-old female presented to the Emergency Department on 01/07/2025 with a chief complaint of abdominal pain. Review revealed during triage at 1334 vital signs were obtained with 8 out of 10 documented pain score. Review failed to reveal interventions or follow up provided for the report of pain 8 out of 10. Interview on 01/08/2025 at 1700 with Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 41946 Findings included: 8. Closed medical record review on 01/07/2025 for Patient #3 revealed a 74-year-old male who presented to the Emergency Department (ED) on 08/05/2024 at 1050 with a presenting complaint of abdominal and chest pain. Review revealed during the nursing triage at 1107, vital signs were obtained without a documented assessment of pain. Patient #3 was transferred to Hospital B on 08/05/2024 at 1511 for sepsis-urinary tract infection, elevated troponin level (indicates heart muscle damage), abdominal abscess, concerning for necrotizing fasciitis (flesh-eating disease). Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 9. Closed medical record review on 01/08/2025 for Patient #7 revealed a 52-year-old female who presented to the ED on 09/23/2024 at 0912 with a chief complaint of stroke-like symptoms. Review revealed during nursing triage at 0944, vital signs were obtained without a documented assessment of pain. Record review revealed Patient #7 received pain medication of Toradol (non-opioid pain management option to alleviate moderate to severe pain) 30 milligrams (mg) intravenous (IV) at 1522 without evidence of a pain assessment or reassessment. Patient #7 was transferred to Hospital B on 09/23/2024 at 1600 for altered mental status. Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 10. Closed medical record review on 01/08/2025 for Patient #8 revealed a 58-year-old male who presented on 09/23/2024 at 1246 to the ED for shortness of breath. Review revealed during nursing triage at 1328 vital signs were obtained without a documented assessment of pain. Record review revealed Patient #8 was transferred to Hospital C on 09/24/2024 at 0120 for NSTEMI (non-ST elevation myocardial infarction-a type of heart attack). Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 11. Closed medical record review on 01/09/2025 for Patient #13 revealed a 76-year-old male who presented to the ED on 10/02/2024 at 1950 for neck swelling, and pain into chest. Review revealed during nursing triage at 2001 vital signs were obtained without a documented assessment of pain. Record review revealed Patient #13 was medicated for chest pain at 2025 and 2030 with sublingual (medication given under the tongue) nitroglycerin (medication given to treat/prevent chest pain) without documentation of pain assessment/reassessment. Patient #13 was transferred to Hospital C on 10/03/2024 at 0350 for STEMI (ST-elevation myocardial infarction-a type of heart attack). Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. 12. Closed medical record review on 01/09/2025 for Patient #15 revealed a 12-year-old female who presented to the ED on 11/15/2024 at 0740 with abdominal pain. Review revealed during nursing triage at 0755 vital signs were obtained without a documented assessment of pain. Patient #15 was transferred to Hospital B on 11/15/2024 at 1320 for abdominal pain, dehydration and hemorrhagic diarrhea. Interview on 01/08/2025 at 1700 with the Chief Nursing Officer revealed it was the expectation to have pain assessment and reassessments conducted per policy for all patients. Interview on 01/09/2025 at 1410 with the ED Nurse Manager revealed it was the expectation that all ED patients would have a documented pain assessment conducted during Triage, at the time of pain intervention provided, and within an hour after the intervention as follow up. NC00222402 NC00222027”

“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: 41946 Based on policy review, medical record review, and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24 (2) (iii). The findings included: Based on policy review, closed medical record review, staff and physician interviews, the hospital dedicated emergency department (DED) failed to ensure appropriate transfer for 6 of 9 sampled records of patients transferred by failing to send medical records (radiology imaging) available at the time of transfer to the receiving hospital. (Patient #6, #7, #8, #9, #3, #15) and failed to complete the EMTALA form for “Accompanying Documentation” in 3 of 9 medical records reviewed. (Patient #3, #13, #15). ~ Cross refer to Appropriate Transfer - Tag A2409.”

“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: 41946 Based on policy review, closed medical record review, staff and physician interviews, the hospital dedicated emergency department (DED) failed to ensure appropriate transfer for 6 of 9 sampled records of patients transferred by failing to send medical records (radiology imaging) available at the time of transfer to the receiving hospital. (Patient #6, #7, #8, #9, #3, #15) and failed to complete the EMTALA form for “Accompanying Documentation” in 3 of 9 medical records reviewed. (Patient #3, #13, #15). The findings included: Review on 01/07/2025 of the policy titled EMTALA - Transfer Policy, [Hospital A], last revised 08/2023 revealed “PURPOSE: To ensure that a patient requesting or requiring a transfer for further medical care and follow-up in connection with treatment for an Emergency Medical Condition (EMC) is transferred appropriately. ... PROCEDURE: ... 3. The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility: ... c. The transferring hospital must send copies of all available medical records pertaining to the individual’s emergency condition to the hospital where the patient is being transferred. (i.) The documents include copies ... records related to the individual’s Emergency Medical Condition, ... results of diagnostic studies or telephone reports of the studies, ... (iii.) Copies of other records not available at the time of transfer should be sent as soon as practical after the transfer. (iv.) Copies of records must accompany the patient whether or not the patient’s Emergency Medical Condition is stabilized; ... 10. These transfer policies refer to any transfer or discharge of a patient who is being stabilized or treated for an Emergency Medical Condition ...” 1. Medical Record review on 01/08/2025 revealed Patient #6 arrived to the Hospital A Emergency Department on 09/22/2024 at 2017. Review of the ED Provider Note, at 2103 revealed “... 44-year-old male who is 10 days status post right orchiectomy (surgical procedure that involves the removal of one or both testicles) at [Hospital B] presents with not feeling well for a couple of days and having a dry cough and shortness of breath. ...Patient has swelling in the area of the surgical scar since yesterday. He has a low-grade fever yesterday. Patient’s diagnosis apparently was chronic orchitis postoperatively. ... Physical Exam ... Gastrointestinal Abdomen is morbidly obese but soft and non-distended. Suprapubic area is erythematous and there is a firm tender area underneath the surgical scar that is about 5 x 5 cm. There is concern for possible abscess versus hematoma. ... Emergency Room Course/Plan/MDM Progress: Cellulitis of suprapubic area. Rule out postoperative abscess. Rule out respiratory infection. ... Clinical Impression: Cellulitis scrotum and suprapubic area. Postoperative complication. Rule out scrotal abscess versus seroma. ...” Review of the Emergency Medical Treatment and Labor Act (EMTALA) Form was completed. Patient #6 was transferred to Hospital B via ambulance on 09/23/2024 at 0130. Review on 01/09/2025 of the Radiology Software; Picture Archiving Communication System (PACS) electronic spreadsheet failed to reveal the CT of the Abdomen and Pelvis imaging was sent electronically to Hospital B for Patient #6 on transfer. The Radiology Manager revealed they did not find evidence that the CT had been sent in the EMTALA transfer packet by disc. Request to interview the EMTALA transfer DED RN #3 revealed they were unavailable for interview. Telephone interview on 01/08/2025 at 1550 with the Radiology Manager revealed “ ...I am unaware of issues with pushing films, scans to other facilities ...” Further interview on 01/09/2025 at 1113 with the Radiology Manager revealed “all films ‘pushed’ [sent electronically] have a confirmation number in PACS to track. There was no evidence the CT films were requested from the ED on 09/23/2024. There was no evidence that the CT images were transferred to [Hospital B] on 09/23/2024 ...” The interview revealed the CT of the Abdomen and Pelvis imaging/scans were not found to be sent on behalf of Patient #6 to Hospital B on 09/23/2024 via disc. Interview on 01/09/2025 at 1210 with the Medical Director of Radiology, MD #4 revealed they had not noticed any issues with sending radiology scans via PACS. “ ... If it’s at night with the virtual Radiologist, the scans are read and scanned into PACS. ... No monitoring of the PACS system that I am involved in at this time. ... The PACS system tracks scans that were sent out ...” The interview with MD #4 revealed the PACS system would be the best way to track radiology scans/images sent to other hospitals. Telephone interview on 01/09/2025 at 1740 with DED MD #5 revealed “we ask the radiology techs to send scans electronically. We can send to those hospitals within the same system. When there is no electronic connection with the receiving facility, a CD is sent. With [Hospital B] we have a good connection. I recall receiving a call, an MD called and couldn’t find a patient’s scans ...” The interview revealed the intention was to send the radiology images available at the time of transfer. Interview on 01/09/2025 at 1345 with the DED Medical Director, MD #6 revealed “ ...we were informed of this within the last 2 weeks. We call radiology ‘please push this.’ The biggest issue was with radiology ...” MD #6 revealed that he had been notified by DED MD’s this was an issue. MD #6 revealed they had not had time to meet and discuss how to resolve getting scans/images sent to receiving facilities. The interview revealed “ ...there is room for improvement.” In summary, the medical record review revealed no evidence that the CT of the Abdomen and Pelvis scans/images were sent to Hospital B for Patient #6. 2. Medical Record review, on 01/08/2024, revealed Patient #7 arrived to Hospital A Emergency Department on 09/23/2024 at 0912. Review of the Emergency Department Medical Note filed 09/23/2024 at 0922, revealed “ ...Mode of Arrival: EMS; Chief Complaint: Altered Mental Status ...History of present illness HPI details: 52-year-old female presents via EMS after being found lethargic and confused after an MVC (motor vehicle accident). Per report patient Patient [sic] lost consciousness while driving calling her to veer off the road striking a road sign. When seen at bedside by police she was found to be confused and lethargic and as a result, EMS was called, and she was transported to the ED for further evaluation. No known precipitating factors. Patient does state this has happened to her 3 separate times last week as well. ... Emergency Department Course/Plan/MDM Progress: 1431 Patient is stable at this time. Patient with altered mental status. Following a traumatic event. After discussion with hospitalist, plan is to transfer to [Hospital B] for further trauma evaluation. Clinical Impression: altered mental status, motor vehicle collision. Plan: plan to transfer to [Hospital B] for further care. Disposition Patient condition stable; ED Disposition: Transfer; ...” Review of the Emergency Medical Treatment and Labor Act (EMTALA) Form was completed. Patient #7 was transferred to Hospital B via ambulance on 09/23/2024 at 1600. Review on 01/09/2025 of the Radiology Software: Picture Archiving Communication System (PACS) electronic spreadsheet failed to reveal the non-contrast CT of the Brain, CT angiogram of the Head, CT Angiography of the Neck, and Chest X-ray were sent electronically to Hospital B for Patient #7 on transfer. Review with the Radiology Manager revealed they did not find evidence the CT’s had been sent in the EMTALA transfer packet by disc. Request to interview the EMTALA transfer DED RN #7 revealed they were unavailable for interview. Telephone interview on 01/08/2025 at 1550 with the Radiology Manager revealed “ ...I am unaware of issues with pushing films, scans to other facilities ...” Further interview on 01/09/2025 at 1113 with the Radiology Manager revealed “all films ‘pushed’ [sent electronically] have a confirmation number in PACS to track. There was no evidence the CT films were requested from the ED on 09/23/2024. There was no evidence that the CT images were transferred to [Hospital B] on 09/23/2024 ...” The interview revealed the non-contrast CT of the Brain, CT angiogram of the Head, CT Angiography of the Neck, and Chest X-ray imaging/scans were not found to be sent on behalf of Patient #7 to Hospital B on 09/23/2024 via disc. Interview on 01/09/2025 at 1210 with the Medical Director of Radiology, MD #4 revealed they had not noticed any issues with sending radiology scans via PACS. “ ... If it’s at night with the virtual Radiologist, the scans are read and scanned into PACS. ... No monitoring of the PACS system that I am involved in at this time. ... The PACS system tracks the scans that were sent out ...” The interview with MD #4 revealed the PACS system would be the best way to track radiology scans/images sent to other hospitals. Interview on 01/09/2025 at 1345 with the DED Medical Director, MD #6 revealed “ ...we were informed of this within the last 2 weeks. We call radiology ‘please push this.’ The biggest issue was radiology ...” MD #6 revealed that he had been notified by two other DED MDs this was an issue. MD #6 revealed they had not had time to meet and discuss how to resolve getting scans/images sent to receiving facilities. The interview revealed “ ...there is room for improvement.” In summary, the medical record review revealed no evidence of the non-contrast CT of the Brain, CT angiogram of the Head, CT Angiography of the Neck, and Chest X-ray scans/images were sent to Hospital B for Patient #7. 3. Medical Record review, on 01/08/2025 revealed Patient #8 arrived to Hospital A Emergency Department on 09/23/2024 at 1246. Review of the Emergency Department Medical Note filed 09/23/2024 at 1646, revealed “ ...Mode of Arrival: Private Vehicle; Chief Complaint: Chest Pain. History of present illness HPI details: 58-year-old male presents with complaints of substernal chest pain present for the past several days. Also notes associated cough and shortness of breath. No fever or chills. Does note radiation to his neck bilaterally. Due to his ongoing symptoms, he presents to the ED for further evaluation. ... Emergency Department Course/Plan/MDM Progress: (DED MD #5): I took over patient care at 7:00pm at shift change. I have reviewed patient’s chart and had multiple discussion with patient about his workup. Patient clearly has had a cardiac event with rapidly increasing high sensitivity troponins. His pain is resolved with nitroglycerin. He was diuresed with 2 doses of Lasix 20 mg IV. Patient was given IV bolus and drip of heparin. He remains hemodynamically stable. He will be transferred to [Hospital C] ...” Consults were named from Hospital C for cardiology and hospitalist services accepting Patient #8. “Clinical Impression: NSTEMI. Disposition: Patient condition: Critical; ED Disposition: Transfer ...” Review of the Emergency Medical Treatment and Labor Act (EMTALA) Form revealed Patient #8 was stable. Diagnosis: NSTEMI; Mode of Transfer ALS, with Cardiac Monitor, Pulse Oximeter, IV pump and Heparin IV drip at 20ml/hour, Receiving Facility: [Hospital C]. Patient #8 was transferred to Hospital C via ambulance on 09/24/2024 at 0120. Review on 01/09/2025 of the Radiology Software: Picture Archiving Communication System (PACS) electronic spreadsheet failed to reveal the Chest X-ray, and CT Chest PE Study scans/images were sent electronically to Hospital C for Patient #8 on transfer. Review with the Radiology Manager revealed they did not find evidence that the CT/X-ray had been sent in the EMTALA transfer packet by disc. Telephone interview on 01/08/2025 at 1350 with DED RN #8 who completed the EMTALA Transfer form for Patient #8 revealed “when I check those boxes means I sent the transfer form report information. Nurses report. All RN documentation - copies of EKG’s go. We only send disc if Radiology was unable to push scans electronically. Then we copy discs to send with the packet ....” The interview revealed a hardcopy of imaging and CT reports are included in the EMTALA transfer packet sent with the patient when transferred. The interview revealed there was not a process in place at this time for the DED RN to confirm radiology images/scans had been sent electronically to the receiving hospital. Telephone interview on 01/08/2025 at 1550 with the Radiology Manager revealed “ ...I am unaware of issues with pushing films scans to other facilities ...” Further interview on 01/09/2025 at 1113 with the Radiology Manager revealed “all films ‘pushed’ [sent electronically] have a confirmation number in PACS to track. There was no evidence the CT films/X-rays were requested from the ED on 09/23-24/2024. There was no evidence that the CT/X-ray images were transferred to [Hospital C] on 09/23-24/2024 ...” The interview revealed the CT Chest Study/Chest X-ray imaging/scans were not found to be sent on Patient 8 to Hospital C on 09/24/2024. Interview on 01/09/2025 at 1210 with the Medical Director of Radiology, MD #4 revealed they had not noticed any issues with sending radiology scans via PACS. “ ... If it’s at night with the virtual Radiologist, the scans are read and scanned into PACS. ... No monitoring of the PACS system that I am involved in at this time. ... The PACS system tracks the scans that were sent out ...” The interview with MD #4 revealed the PACS system would be the best way to track radiology scans/images sent to other hospitals. Interview on 01/09/2025 at 1345 with the DED Medical Director, MD #6 revealed “ ...we were informed of this within the last 2 weeks. We call radiology ‘please push this.’ The biggest issue was radiology ...” MD #6 revealed they had not had time to meet and discuss how to resolve getting scans/images sent to receiving facilities. The interview revealed “ ...there is room for improvement.” In summary, the medical record review revealed no evidence of the CT Chest and Chest x-ray scans/images were sent to Hospital C for Patient #8. 4. Medical Record review, on 01/08/2025, revealed Patient #9 arrived to the Hospital A, Emergency Department on 09/23/2024 at 1849. Review of the Emergency Department Medical Note filed 09/23/2024 at 2005, revealed “ ...Mode of Arrival: Private Vehicle; Chief Complaint: Shortness of Breath. History of present illness HPI details: 52-year-old female presents with complaints of shortness of breath since Thursday. Patients also report bilateral rib pain ...Patient has a history of rheumatoid arthritis for which she is receiving Anakinra (medication used for rheumatoid arthritis) ... Patient tells me that she has been diagnosed multiple times with costochondritis for which the steroids would help her with breathing. Patient also tells me that she has been traveling for about 8 hours on Wednesday and that was the day before the shortness of breath started ... Review of Systems: ... Resp: SOB (shortness of breath), Physical Examination: Constitutional: [Alert and oriented and responds appropriately to questions. Chronically ill-appearing obese, patient is lying flat upon me entering the room and states that in this position she can breathe the best. ... CARD [RRR] No S3 no S4, no murmur (patient also tells me that she has a chronic tachycardia and was already evaluated by cardiologist), RESP: [no respiratory distress] clear in all fields, posterior bases diminished. ... Emergency Department Course/Plan/MDM Progress: (DED MD #5): I took over patient care at 11:00 pm at the end of the Nurse Practitioner’s shift. I have examined the patient and have been instrumental in medical decision making for this patient. In summary she has multiple Pes (pulmonary embolism) with large clot burden and saddle embolism. She has right heart strain with RV (right ventricle) to LV (left ventricle) ratio of 2. She has elevated troponins reflecting right heart strain. Patient received Aspirin. She is on Heparin drip. She will be transferred to [Hospital C] ... for urgent thrombectomy by IR (interventional radiology). ... Differential Diagnosis: PE, Pneumonia, costochondritis, CHF ... Clinical Impression: pulmonary embolus with right heart strain. Disposition: Patient condition critical; ED Disposition: Transfer ...” Review of the Emergency Medical Treatment and Labor Act (EMTALA) Form was completed. Patient #9 was transferred to Hospital C via ambulance on 09/24/2024 at 0900. Review on 01/09/2025 of the Picture Archiving Communication System (PACS) electronic spreadsheet failed to reveal the CTA Chest PE Study with contrast scans/images, were sent electronically to Hospital C for Patient #9 on transfer. Review with the Radiology Manager revealed they did not find evidence that the CT had been sent in the EMTALA transfer packet by disc. Telephone interview on 01/08/2025 at 1350 with DED RN #8 who completed the EMTALA Transfer form for Patient #9 revealed “when I check those boxes means I sent the transfer form report information. Nurses report. All RN documentation - copies of EKG’s go. We only send disc if Radiology was unable to push scans electronically. Then we copy discs to send with the packet ....” The interview revealed a hardcopy of imaging and CT reports are included in the EMTALA transfer packet sent with the patient when transferred. The interview revealed there was not a process in place at this time for the DED RN to confirm radiology images/scans had been sent electronically to the receiving hospital. Telephone interview on 01/08/2025 at 1550 with the Radiology Manager revealed “ ...I am unaware of issues with pushing films scans to other facilities ...” Further interview on 01/09/2025 at 1113 with the Radiology Manager revealed “all films ‘pushed’ [sent electronically] have a confirmation number in PACS to track. There was no evidence the CT films were requested from the ED on 09/23-24/2024. There was no evidence that the CT images were transferred to [ Hospital C] on 09/23-24/2024 ...” The interview revealed the CT Chest PE Study with contrast imaging/scans was not found to be sent on Patient #9 to Hospital C on 09/24/2024. Interview on 01/09/2025 at 1210 with the Medical Director of Radiology, MD #4 revealed they had not noticed any issues with sending radiology scans via PACS. “ ... If it’s at night with the virtual Radiologist, the scans are read and scanned into PACS. ... No monitoring of the PACS system that I am involved in at this time. ... The PACS system tracks the scans that were sent out ...” The interview with MD #4 revealed the PACS system would be the best way to track radiology scans/images sent to other hospitals. Interview on 01/09/2025 at 1345 with the DED Medical Director, MD #6 revealed “ ...we were informed of this within the last 2 weeks. We call radiology ‘please push this.’ The biggest issue was radiology ...” MD #6 revealed that he had been notified by two other DED MDs this was an issue. MD #6 revealed they had not had time to meet and discuss how to resolve getting scans/images sent to receiving facilities. The interview revealed “ ...there is room for improvement.” In summary, the medical record review failed to reveal evidence that the CTA Chest PE study scans/images were sent to Hospital C on 09/24/2024 for Patient #9. 5. Medical Record review on 01/07/2025 revealed sample Patient #3 arrived to the Hospital A, Emergency Department on 08/05/2024. Review of the Emergency Provider Note documented by DED Nurse Practitioner #1 on 08/05/2024 at 1100 hours revealed a 74-year-old male “... Chief Complaint: Abdominal Pain. History of Present Illness: HPI details: ... Patient states he has had abdominal pain for the past 1 week with decreased appetite and multiple episodes nausea vomiting. He reports that he is [sic]soft tissue swelling to the mons pubis region that extends to his testicles. Patient has indwelling Foley catheter that he states needs to be changed. He also reports that he has swelling to the bilateral lower extremities. Review of the Emergency Department Course/Plan/MDM revealed at 1200 results of labs, ekg, chest x-ray were reviewed, triggering possible sepsis. At 1206 DED MD #1 called the transfer center for possible need for higher level of care. At 1430, CT of abdomen pelvis resulted “... Received call from [Radiologist MD #3] in regards to the patient’s CT scan of the abdomen pelvis. CT scan reveals multiple gas pockets inferior to the urinary bladder, small gas bubbles anterior to the pubis symphysis. There is a 3 cm x 1.5 cm fluid collection in the left iliacus muscle anterior to the left pubic bone. there is a 2 cm fluid collection in the inferior aspect of the rectus sheath. This is concerning for necrotizing fasciitis as per radiologist...” The EKG and Troponin was recollected “no STEMI.” Patient and family were updated, and transfer center was updated for request for higher level of care. “Clinical Impression: sepsis UTI, elevated troponin, abdominal abscess, concern for necrotizing fasciitis abdomen (flesh eating disease) ...” Review of the EMTALA Transfer Form revealed Patient #3 was stable, with Diagnosis: Sepsis UTI, elevated troponin, necrotizing fasciitis, abdominal abscesses. “Accompanying Documentation:” Copy of Pertinent medical record was unchecked. Transport vital signs were documented at 1450 as HR 88, RR 20, BP 108/56, and SPO2 93 %, no Temperature was recorded on the transfer form. Patient #3 was transferred to Hospital B by EMS and departed the ED on 08/05/2024 at 1511. Review of EMS report for Patient #3 dated, 08/05/2024 at 1603 revealed transport left Hospital A at 1513, Paperwork from referring was not completed. Patient #3 arrived at Hospital B ED at 1609, “Paperwork to Receiving was not completed. The EMS Run Report revealed Hand-Off paperwork was not noted on the EMS Run Report for Patient #3 on 08/05/2024. Review on 01/09/2025 of the Picture Archiving Communication System (PACS) electronic spreadsheet failed to reveal the CT Abdomen and Pelvis/Chest X-ray scans/images, were sent electronically to Hospital B for Patient #3 on transfer. Review with the Radiology Manager revealed they did not find evidence that the CT of Abdomen/Pelvis/ Chest x-ray had been sent in the EMTALA transfer packet by disc. Telephone interview on 01/08/2025 at 1951 with the DED RN #9 revealed “I remember it was chaotic that day. We were holding inpatients in the ED. Very stressful. What I normally do, complete a Transfer Report that includes MD notes, Meds given, any treatments/interventions, demographics, face sheet, labs, ekg, x-ray reports, medical necessity forms, and 3 EMTALA forms. We call radiology for films to be pushed to the receiving hospital ...” The interview revealed RN #9 did not recall why the Accompanying Documentation on the EMTALA form was not completed for Patient #3. Telephone interview on 01/08/2025 at 1330 with EMS Personnel #10 revealed “I normally put a blurb in at the bottom of the report stating I delivered the packet. It’s written and documented that care was handed off. I do see a Hand Off Communication Box; I’ve never noticed it before. I do remember this patient because of the necrotizing fasciitis, but I don’t recall the paperwork...” The interview revealed medical records were placed in an envelope and sent with EMS personnel with transfer patients to the receiving hospital and handed off with the patient. The interview revealed the Hand Off Communication box, and or written text in the EMS report failed to reveal if a medical packet was received/delivered for Patient #3. Interview on 01/08/2025 at 1250 with Hospital A- EMS Manager revealed “Hand-Off Communication, when we transport a patient to another facility, the transport packet, we check that box on our charting system that we received and that we delivered the transport packet. ...the transport documents are sealed in a manilla folder. I have reviewed at times, but not always opened by EMS staff. I am unaware of any concerns of missing hand-off communication paperwork. We get the packet, and we deliver it ...” The interview revealed there was no policy available for review at this time. Telephone interview on 01/08/2025 at 1550 with the Radiology Manager revealed “ ...I am unaware of issues with pushing films scans to other facilities ...” Further interview on 01/09/2025 at 1113 with the Radiology Manager revealed “all films ‘pushed’ [sent electronically] have a confirmation number in PACS to track. There was no evidence that the CT/X-rays scans/images were requested from the ED on 08/05/2024 for Patient #3. There was no evidence that the CT of Abdomen and Pelvis/X-ray scans/images were transferred to [Hospital B] on 08/05/2024 ...” The interview revealed the CT of Abd and Pelvis and Chest X-ray was not found to be sent on Patient #3 to Hospital B on 08/05/2024. Interview on 01/09/2025 at 1210 with the Medical Director of Radiology, MD #4 revealed they had not noticed any issues with sending radiology scans via PACS. “ ... If it’s at night with the virtual Radiologist, the scans are read and scanned into PACS. ... No monitoring of the PACS system that I am involved in at this time. ... The PACS system tracks the scans that were sent out ...” The interview with MD #4 revealed the PACS system would be the best way to track radiology scans/images sent to other hospitals. Interview on 01/09/2025 at 1345 with the DED Medical Director, MD #6 revealed “ ...we were informed of this within the last 2 weeks. We call radiology ‘please push this.’ The biggest issue was radiology ...” MD #6 revealed that he had been notified by two other DED MDs this was an issue. MD #6 revealed they had not had time to meet and discuss how to resolve getting scans/images sent to receiving facilities. The interview revealed “ ...there is room for improvement.” In summary, the medical record review revealed an incomplete EMTALA Transfer Form. A EMS Run Sheet without evidence the EMTALA transfer packet was delivered with Patient #3 to Hospital B, and no evidence the CT Abdomen and Pelvis scans/images were sent to Hospital B on 08/05/2024 at transfer. 6. Medical Record review on 01/09/2025, revealed Patient #13 who arrived to Hospital A, Emergency Department on 10/02/2024 at 1950. Review of the Emergency Provider Note documented by DED MD on 10/02/2024 at 2015 revealed “ ...76-year-old male presents with intermittent neck pain anteriorly that radiates down to substernal area in upper chest. This pain has been ongoing for about a month but is worse tonight. It started after patient had parathyroidectomy ...Emergency Department Course/Plan/MDM Progress: Patient’s initial evaluation revealed ischemic changes on EKG with ST depression in inferior lateral leads. His initial troponin was negative. Patient was given Aspirin. Later 2nd troponin was done, and it was quite elevated, and the new EKG showed ST elevation in inferior leads 3 and AVF. Code STEMI was started. Patient was started on Heparin drip. Consults: Cardiology ... reviewed EKGs and recommended thrombolytic therapy be given. “A full dose of 50mg IV (intravenous) of TN (Tenecteplase used to dissolve blood clots) was administered ...” Patient will be transferred to [Hospital C]. Clinical Impression: STEMI, Left lower lobe pulmonary nodule. Disposition: Patient condition is critical; ED Disposition Transfer. Review of the EMTALA Transfer Form revealed Patient #13 was stable, with Diagnosis: STEMI ... Accompanying Documentation: Copy of Pertinent medical record was unchecked. Patient #13 was transferred by EMS and departed the ED on 10/03/2024 at 0350. Review on 01/09/2025 of the Picture Archiving Communication System (PACS) electronic spreadsheet failed to reveal the CT Soft Tissue Neck, and CT Chest PE Study scans/images was sent electronically to Hospital C for Patient #13 on transfer. Review with the Radiology Manager revealed they did not find evidence that the CT scans had been sent in the EMTALA transfer packet by disc. Request to interview DED RN #11 revealed they were unavailable for interview. Telephone interview on 01/08/2025 at 1550 with the Radiology Manager revealed “ ...I am unaware of issues with pushing films scans to other facilities ...” Further interview on 01/09/2025 at 1113 with the Radiology Manager revealed “all films ‘pushed’ [sent electronically] have a confirmation number in PACS to track. There was no evidence that the CT scans/images were requested from the ED on 10/02/2024 for Patient #13. There was no evidence that the CT scans/images were transferred to [Hospital C] on 10/02/2024 ...” The interview revealed the CT Chest PE Study, and CT Soft Tissue Neck was not found to be sent for Patient #13 to Hospital C on 10/02/2024. Interview on 01/09/2025 at 1210 with the Medical Director of Radiology, MD #4 revealed they had not noticed any issues with sending radiology scans via PACS. “ ... If it’s at night with the virtual Radiologist, the scans are read and scanned into PACS. ... No monitoring of the PACS system that I am involved in at this time. ... The PACS system tracks the scans that were sent out ...” The interview with MD #4 revealed the PACS system would be the best way to track radiology scans/images sent to other hospitals. Interview on 01/09/2025 at 1345 with the DED Medical Director, MD #6 revealed “ ...we were informed of this within the last 2 weeks. We call radiology ‘please push this.’ The biggest issue was radiology ...” MD #6 revealed that he had been notified by two other DED MDs this was an issue. MD #6 revealed they had not had time to meet and discuss how to resolve getting scans/images sent to receiving facilities. The interview revealed “ ...there is room for improvement.” In summary, the medical record review revealed an incomplete EMTALA Transfer Form with “Accompanying Documentation” and with no evidence that the CT Chest PE Study/CT Soft Tissue Neck scans/images were sent to Hospital C for Patient #13 at transfer. [The EMS Run Report was unavailable for review]. 7. Medical Record review on 01/09/2025 revealed Patient #15 arrived to Hospital A, Emergency Department on 11/15/2024 at 0740. Review of the Emergency Provider Note documented by DED MD on 11/15/2024 at 1007 revealed “ ...Chief Complaint: Abdominal Pain and diarrhea. History of Present Illness: Patient brought in by her grandparents they state that she has been having abdominal pain for the past 2 years usually starts in the morning after she eats. She has been to see a pediatric gastroenterologist. She is on multiple meds; she has a past medical history of ADHD but today her abdominal pain was worse. ... Emergency Department Course/Plan/MDM “ ...Patient was able to give a stool sample she is positive for E coli 157 ST EC (a type of E. coli bacteria causing severe illness, bloody diarrhea, and kidney failure) which raises concern for more serious illness. ...There is no Pediatrics available at this facility she will be transferred to [Hospital B]. I spoke to the pediatric hospitalist there, was accepted the patient [sic] ...Clinical Impression: Dehydration, Active Problem, STEC , Active problem, Hemorrhagic diarrhea, Active problem, Chronic abdominal pain, Active problem; Disposition: Patient condition Stable; ED Disposition: Transfer; Comments: [Hospital B] Pediatric hospital accepting;” Review of the EMTALA Transfer Form revealed “Accompanying Documentation:” Copy of Pertinent medical record was unchecked. Patient #15’s guardian signed the Transfer Form at 1300. Patient #15 was transferred by EMS and departed the ED on 11/15/2024 at 1320. No images were ordered for Patient #15 on 11/15/2024. Request to interview the DED RN #12 who completed the EMTALA Transfer Record was unavailable for interview. Telephone interview on 01/08/2025 at 1350 with DED RN #8 revealed “when I check those boxes means I sent the transfer form report information. Nurses report. All RN documentation - copies of EKG’s go. We only send disc if Radiology was unable to push scans electronically. Then we copy discs to send with the packet ....” The interview revealed a hardcopy of imaging and CT reports are included in the EMTALA transfer packet sent with the patient when transferred. The interview revealed there was not a process in place at this time for the DED RN to confirm radiology images/scans had been sent electronically to the receiving hospital. Interview on 01/09/2025 at 1400 with the ED Nurse Manager, RN #2 revealed the transferring RN was responsible for ensuring the EMTALA transfer packet was completed and ready. The Certified Nurse Assistant/Unit Secretary will assist to get things printed. The interview revealed the EMTALA transfer form Accompanying Documentation should be completed by the RN to document who they gave the packet to, and to document what was included in the EMTALA Transfer packet to accompany the patient to the receiving hospital. The interview revealed this did not occur for Patient #15. In summary, Patient #15 who was transferred to Hospital B on 11/15/2024, had an incomplete EMTALA Transfer Form with “Accompanying Documentation” not completed by the RN at transfer.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 39307 Based on nursing leadership interview, medical record review and staff interviews the hospital staff failed to have evidence of a daily bath offered for 4 of 5 patients records reviewed. (Patient #6, 7, 2 and #10). Request on 3/14/2024 for the hospital policy for bathing or hygiene revealed there was not one available for review. Interview with the Nursing Leadership team (RN #5, QD #10) revealed it was the expectation for nursing staff to offer a patient a daily bath. 1. Open medical record review on 03/15/2024 revealed Patient #6, a 75-year-old male who presented on 03/10/2024 at 2223 to the hospital Emergency Department after a fall at home. Review revealed Patient #6 was transported by ambulance to the hospital for evaluation which revealed a left humerus fracture resulting in a non-surgical treatment plan. Review revealed an Occupational Therapy (OT) Evaluation and Treatment Note on 03/12/2024 at 1243 by OT #6 which had evidence of Patient #6 needing moderate supervision with hygiene/bathing assistance. Record review failed to reveal documentation of a bath offered or declined (03/11/2024 through 03/15/2024) for 5-days reviewed. Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital’s expectation for a daily bath was not met for Patient #6. 2. Open medical record review on 03/15/2024 revealed Patient #7, a 63-year-old male who presented on 03/08/2024 at 0707 for a scheduled colon surgery. Review of Physical Therapy (PT) Progress Notes revealed on 03/09/2024 at 1408 Patient #7 declined evaluation secondary to increased pain. Record review failed to reveal documentation of a bath offer or decline (03/12/2024 through 03/14/2024) for 3 of 7 days reviewed. Record review revealed on 03/14/2024 at 1516 Physical Therapy (PT) Progress Notes by PT #7 revealed “...Impairments are limiting Pt. from completing ADL’s (Activity of Daily Living, i.e., bathing, toileting etc.)...” Record review failed to reveal Patient #7 was offered a bath for 3 of 7 days. Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital’s expectation for a daily bath was not met for Patient #7. 3. Closed medical record review on 03/13/2024 revealed Patient #2, a 90-year-old female who presented on 05/16/2022 at 2047 to the hospital Emergency Department (ED) after a fall at home. Review revealed Patient #2 was transported by ambulance to the hospital for evaluation which revealed the need on 05/17/2022 for surgical repair of a fractured right hip. Review of the History and Physical completed by the Medical Provider (NP) #1 on 05/17/2022 at 1159 revealed a plan to admit for hip fracture and possible pubic fracture “...Patient is at moderate risk for surgery given her chronic hypoxic respiratory failure/COPD, Age/Fragility and CAD (Coronary Artery Disease) ...” Record review revealed Patient #2 had a 20-day admission length of stay, whereby a sampled 7-day period (05/25/2022 through 05/31/2022, while in Intensive Care Unit and Medical Surgical Telemetry Unit) failed to reveal evidence of a bath on 5/27/2022 through 5/30/2022, 4 of 7 days for Patient #2. Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital’s expectation for a daily bath was not met for Patient #2. 41946 4. Closed medical record review on 03/14/2024 revealed Patient #10, a 70-year-old female patient who presented to the emergency department on 03/09/2024 at 1449 with complaints of left leg heaviness, and left arm tingling. Patient #10 was diagnosed with an acute CVA (cerebrovascular accident) and was admitted to the floor on 03/09/2024 at 1906. Review of the Occupational Therapy (OT) Note dated 03/11/2024 by OT #9 revealed “...moderate assist with bathing...” Review of the Nursing Flowsheet failed to reveal evidence of an offer or declined offer for a daily bath on 03/09/2024 through 03/12/2024 (3 days) for Patient #10. Patient #10 was discharged home with home health and physical therapy on 03/12/2024 at 1110 with family. Interview on 03/15/2024 at 0857 with the Senior Nursing Officer, RN #5 revealed the expectation of the facility was that all patients would be offered a daily bath, and the offer or refusal would be documented in the medical record. Interview revealed the hospital’s expectation for a daily bath was not met for Patient #10. NC00192738”