Central Carolina Hospital

“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: 47421 Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings included: The hospital’s Dedicated Emergency Department (DED) failed to log a patient on the DED central log to maintain an accurate log and failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s DED, to prevent delay in determination of an Emergency Medical Condition (EMC) for one (1) of 20 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #5). ~ Cross refer to 489.24(a) and 489.24(c) Medical Screening Examination - Tag A 2406 ~ Cross refer to 489.24(a) and 489.24(c) ED Log - Tag A 2405”

“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: 47421 Based on policy review, emergency department logs, video footage, medical record review, and staff and physician interviews, the hospital’s Dedicated Emergency Department (DED) failed to log a patient on the DED central log to maintain an accurate log for one (1) of 20 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #5). The findings included: Visit #1. Hospital A. Review of Hospital A Emergency Department (ED) log on 09/25/2025 failed to reveal Patient (Pt) #5 was on the log. Review of a medical record number search did not reveal that Pt #5 was registered or had a medical record for 09/25/2025. Review of video footage of Pt #5 revealed a pregnant female presented to the ED lobby on 09/25/2025 at 1747. At 1748 the patient was observed at the ED lobby front desk speaking with a staff member. At 1752 the patient sat down in the ED lobby waiting area. At 1816 a staff member (identified as Registration #1) walked out to speak with Pt #5 in the waiting room, then at 1817 went back behind the registration desk. At 1857 Pt #5 walked to the lobby registration desk. At 1902 Pt #5 was observed walking out of the ED lobby. Interview on 10/21/2025 at 0945 with ED Director #5 revealed that all patients present to the ED first. When an OB patient was below 20 weeks the ED would do the MSE, and when the patient was 20 weeks and above the patient would be sent to OB. Once OB was called and the patient was registered the OB staff would come down with a wheel chair to get the patient. Interview revealed that when the ED or OB goes on the diversion that EMS would be informed. If any patient presents, including walk-in patients, they still have to be evaluated to determine stabilization or the need to transfer. Interview revealed that when OB was on diversion a patient would still be examined by the ED Provider. Interview revealed that the process was to encourage patients to stay for an evaluation and not leave, even when there was a delay. The staff were not to tell patients that the ED or OB were on diversion, and they need to seek treatment elsewhere. Interview revealed that on 09/25/2025 the ED staff were not aware of Pt #5 being in the lobby due to the patient not being registered or on the ED track board. Interview on 10/21/2025 at 1037 with Director #4 revealed Pt #5 presented for decreased fetal movement but was not registered or on the ED log and there was no record that the patient presented. Interview revealed that the patient later presented to Hospital B and to her OB appointment where the story was told. Hospital B encouraged the patient to inform us, and the OB clinic entered an occurrence report. Interview revealed that the reason the patient was not entered on the log was due to the patient not having a room assignment from OB. Interview on 10/21/2025 at 1538 with OB Director #6 revealed that OB was on diversion on 09/25/2025. The last patient admitted was at 1600 on 09/25/2025. Interview revealed that the OB department could not take another patient at that time and remained on OB diversion from 09/25/2025 at 1700 until 09/26/2025 at 0700. Interview on 10/22/2025 at 1250 with Registration #1 revealed the registration staff member had worked in the ED for 3 years and recalled the patient on 09/25/2025. Interview revealed that Registration #1 was aware to call OB when a pregnant patient presented to the ED greater than 20 weeks. Registration #1 revealed that when the OB department was called on 09/25/2025 they were unable to give a room assignment to register the patient and informed Registration #1 they would call back. The patient was made aware that OB was trying to make arrangements and sat down to wait. The registration was not completed at that time. Interview revealed that after some time Registration #1 spoke to OB staff and they informed Registration #1 they were on diversion. Interview revealed that at that point the registration staff did not understand the process and allowed the patient to continue to wait without being on the log. Interview revealed that Pt #5 eventually presented to the registration desk to get an update and Registration #1 called back to OB and spoke to a different RN (RN #3) due to shift change. Registration #1 was informed by RN #3 that OB was busy, but they would try to accommodate the patient in the hallway. Shortly after that RN #3 called back and told Registration #1 that she was just informed they were on diversion, and the patient would need to go somewhere else. Interview revealed that Registration #1 without thinking just repeated what she was told by RN #3. Interview revealed that this was Registration #1’s first and only OB diversion but was now aware that when the OB was on diversion the patient cannot be turned away and should be accommodated even if they need to be treated in the ED. Interview revealed that Registration #1 was reeducated on the diversion process and the new system to add OB patients to the OB waiting room when on diversion in order to get the patient on the log. Cross Refer to A 2406.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 47421 Based on policy review, emergency department log, video footage, medical record review, and staff and physician interviews, the hospital’s Dedicated Emergency Department (DED) failed failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital’s DED, to prevent delay in determination of an Emergency Medical Condition (EMC) for one (1) of 20 sampled DED patients who presented to the hospital for evaluation and treatment, (Patient #5). The findings included: Visit #1. Hospital A. Review of Hospital A Emergency Department (ED) log on 09/25/2025 failed to reveal Patient (Pt) #5 was on the log. Review of a medical record number search did not reveal that Pt #5 was registered or had a medical record for 09/25/2025. Review of video footage of Pt #5 revealed a pregnant female presented to the ED lobby on 09/25/2025 at 1747. At 1748 the patient was observed at the ED lobby front desk speaking with a staff member. At 1752 the patient sat down in the ED lobby waiting area. At 1816 a staff member (identified as Registration #1) walked out to speak with Pt #5 in the waiting room, then at 1817 went back behind the registration desk. At 1857 Pt #5 walked to the lobby registration desk. At 1902 Pt #5 was observed walking out of the ED lobby. Review of the event timeline and corrective actions with Director #4 revealed on 09/25/2025 at 1700 Hospital A’s OB Department went on diversion. On 09/26/2025 Pt #5 called and left a voicemail for the OB Director to share that she was turned away by the hospital greeter (Registration #1). On 09/30/2025 the CNO (Chief Nursing Officer)called Risk Management with a potential EMTALA violation. On 10/02/2025 it was confirmed that the patient had arrived for evaluation at Hospital A and that the patient was sent away. On 10/02/2025 education was provided to the involved Registration staff member on diversion and EMTALA. On 10/03/2025 a leadership meeting took place to debrief the EMTALA violation. On 10/04/2025 the EMTALA violation was self-reported. On 10/06/2025 at 0930 and 10/08/2025 at 1400 leadership meetings took place to develop actions plans based on the root cause and a review of policies. On 10/08/2025 at 1600 a Cerner ticket was placed to create an L&D (Labor and Delivery) waiting room to log OB patients in the EMR (Electronic Medical Record). On 10/09/2025 the Diversion Policy updates were reviewed and approved. On 10/10/2025 all Registration staff education was developed and approved. On 10/13/2025 at 1100 a Quality leadership meeting took place to develop a score card for MOS (measures of success). On 10/13/2025 at 1200 remedial EMTALA education was assigned to providers and staff with a target completion date of 11/04/2025. On 10/13/2025 at 1400 the ED Intake form was modified and went live, with a cognitive aid for registration staff. On 10/16/2025 at 1330 a meeting took place with Cerner for the building of the L&D waiting room. On 10/21/2025 the L&D waiting room and track board was completed and went live. On 10/21/2025 100% of Registration staff completed the diversion education. On 10/20/2025 a Diversion checklist was approved for integration. On 10/22/2025 a flowchart was created to show Registration staff what to do when OB was on diversion. The flowchart would explain when an OB patient should be registered to the OB waiting room versus the ED waiting room, then which the patient would be seen in the ED. Interview on 10/21/2025 at 0945 with ED Director #5 revealed that all patients present to the ED first. When an OB patient was below 20 weeks the ED would do the MSE, and when the patient was 20 weeks and above the patient would be sent to OB. Once OB was called and the patient was registered the OB staff would come down with a wheel chair to get the patient. When a pregnant patient was seen in the ED for non-OB issues the ED staff would still do fetal heart tones prior to discharge. Interview revealed that when the ED or OB goes on the diversion that EMS would be informed. If any patient presents, including walk-in patients, they still have to be evaluated to determine stabilization or the need to transfer. Interview revealed that when OB was on diversion a patient would still be examined by the ED Provider. Interview revealed that the process was to encourage patients to stay for an evaluation and not leave, even when there was a delay. The staff were not to tell patients that the ED or OB were on diversion, and they need to seek treatment elsewhere. Interview revealed that on 09/25/2025 the ED staff were not aware of Pt #5 being in the lobby due to the patient not being registered or on the ED track board. Interview on 10/21/2025 at 1037 with Director #4 revealed Pt #5 presented for decreased fetal movement but was not registered or on the ED log and there was no record that the patient presented. Interview revealed that the patient later presented to Hospital B and to her OB appointment where the story was told. Hospital B encouraged the patient to inform us, and the OB clinic entered an occurrence report. Interview revealed that the reason the patient was not entered on the log was due to the patient not having a room assignment from OB. When OB patients present to the ED for treatment the registration staff would call the OB department and obtain a room number in order to be registered to the OB log. In this case the patient was not assigned a room number or put on the log due to OB being on diversion. Interview revealed that in this case the patient should have been put on the ED log, assigned to the ED waiting room, and the patient should have been evaluated in the ED. Interview revealed that when patients present to the ED they normally start in the ED waiting room and transition through the ED. However in the case of OB there was no waiting room to assign OB patients to so OB patients would need room assignments first. With OB being on diversion no room assignment was available to assign so the patient was not registered. Interview revealed this event led to the building of an OB waiting room in the EMR. Interview revealed that the Director was not aware of any other patients being turned away for treatment and per interview with the Director #4 and Registration staff this had never happened before. Interview revealed that Registration #1 was told that OB was on diversion and could not see the patient, Registration #1 took that as the patient could not been seen at the facility. Further interview on 10/22/2025 at 1016 with Director #4 revealed that the Director was informed by Registration #1 that this was her first time working during a diversion and she had not experienced OB staff not assign a room number in order to register a patient. Interview on 10/21/2025 at 1538 with OB Director #6 revealed that OB was on diversion on 09/25/2025. Staff included three RNs from 7a-7p and 3 RNs from 7p-7a with six admitted patients and two scheduled c-sections. Interview revealed that two additional RNs came in to assist on 09/25/2025, one from 1052-1348 and the other from 1430-1900. Interview revealed the OB MD would make the decision to go on diversion. The last patient admitted was at 1600 on 09/25/2025. Interview revealed that the OB department could not take another patient at that time and remained on OB diversion from 09/25/2025 at 1700 until 09/26/2025 at 0700. Interview on 10/22/2025 at 1250 with Registration #1 revealed the registration staff member had worked in the ED for 3 years and recalled the patient on 09/25/2025. Interview revealed that Registration #1 was aware to call OB when a pregnant patient presented to the ED greater than 20 weeks. Registration #1 revealed that when the OB department was called on 09/25/2025 they were unable to give a room assignment to register the patient and informed Registration #1 they would call back. The patient was made aware that OB was trying to make arrangements and sat down to wait. The registration was not completed at that time. Interview revealed that after some time Registration #1 spoke to OB staff and they informed Registration #1 they were on diversion. Interview revealed that at that point the registration staff did not understand the process and allowed the patient to continue to wait without being on the log. Interview revealed that Pt #5 eventually presented to the registration desk to get an update and Registration #1 called back to OB and spoke to a different RN (RN #3) due to shift change. Registration #1 was informed by RN #3 that OB was busy, but they would try to accommodate the patient in the hallway. Shortly after that RN #3 called back and told Registration #1 that she was just informed they were on diversion, and the patient would need to go somewhere else. Interview revealed that Registration #1 without thinking just repeated what she was told by RN #3. Interview revealed that this was Registration #1’s first and only OB diversion but was now aware that when the OB was on diversion the patient cannot be turned away and should be accommodated even if they need to be treated in the ED. Interview revealed that Registration #1 was reeducated on the diversion process and the new system to add OB patients to the OB waiting room when on diversion in order to get the patient on the log. Interview on 10/22/2025 at 1320 with OB MD #2 revealed MD #2 was the OB provider working on 09/25/2025. MD #2 recalled he was aware they were on diversion at that time and that an OB patient had presented in the ED lobby. Interview revealed that the provider had heard that the OB department was attempting to try to see Pt #5, but that was the last MD #2 had heard of the patient and assumed the patient was ok. Interview revealed that MD #2 was unaware the patient had left the ED without any evaluation until he received a page from Pt #5 on the on-call pager inquiring about other OB locations to present due to Hospital A’s OB being on diversion. Interview revealed that since the patient had already left the facility, MD #2 advised Pt #5 on which OB hospital was nearby. Interview revealed that the patient should have had some sort of evaluation, even if in the ED to determine stabilization or the need for transfer. Interview revealed that MD #2 was up to date on EMTALA education. Interview on 10/22/2025 at 1330 with OB RN #3 revealed that the RN had worked in the OB department for two years and recalled the event on the evening of 09/25/2025. Interview revealed that when OB was on diversion walk in patients were to still be accommodated and not turned away. Interview revealed the RN was the charge nurse that night and recalled a chaotic shift as they were preparing for a c-section at the time. When RN #3 got the call from the registration staff the RN recalled that the patient complaint was not that severe and she informed registration to hold the patient in the ED lobby. Interview revealed that when RN #3 hung up from registration staff she was informed that the OB was on diversion. RN #3 recalled that she called back to registration and without thinking stated that OB was on diversion and the patient would have to be seen somewhere else. Interview revealed that RN #3 did not think to tell Registration #1 to have the patient seen in the ED. Interview revealed that RN #3 had the recent EMTALA and diversion training and was aware that patients could not be turned away and in the future when OB was on diversion and could not assess a walk-in patient, the RN would direct the registration staff to have the patient evaluated in the ED. Visit #2. Hospital B. Closed medical record review of Pt #5 revealed a 28-year-old pregnant female presented to Hospital B’s OB department on 09/25/2025 at 2017 for decreased fetal movement. At 2045 a fetal nonstress test resulted. Review of an OB Provider Note (H&P) on 09/25/2025 at 2051 revealed that labs and a BPP (prenatal ultrasound) were ordered. Further review revealed “ ...at 31w6d per patient presents with decreased fetal movement. Patient attempted to be seen in Sanford, but was told she could not be seen there because they had to deal with an emergency ... Patient to call primary ObGyn in AM for follow up, has appointment Tuesday 9/30 ... “”