Carolina East 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: 28613 Based on hospital policy review, medical record review, physician and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: Based on review of medical records, facility guidelines, and interviews with staff, the facility failed to ensure vital signs were reassessed and reported to the provider responsible for completing the medical screening exam for one of 20 patients (Patients (P) 20). This lack of clinical information could potentially delay the determination of an Emergency Medical Condition. Cross Refer to A2406.”

“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: 28613 Based on a review of medical records, waiting room and triage guidelines, and interviews with staff, the hospital failed to ensure vital signs were reassessed and reported to the provider responsible for completing the medical screening exam for one of 20 patients seen in the Emergency Department (Patients (P) 20). The patient had been triaged as higher acuity patient. This lack of clinical information could potentially delay the determination of an Emergency Medical Condition. Findings include: Review of weekly Emergency Department (ED) Huddle Meetings showed a daily dashboard review of admissions to the ED for the week of 07/19-07/25/2024. Included in the minutes was an ED Update Reminder that stated, “Please review vital sign expectations.” An undated document titled, “Why are vital signs important in the Emergency Department,” was included in the Huddle record. This document stated, “Subtle changes in vital signs are often a prelude to patient deterioration and when identified, help prevent further deterioration. This is why it’s important to: obtain a baseline set of vital signs on arrival . . . Monitor vital signs at frequent intervals and make sure to document them. . .All abnormal vital signs should be reported to the provider, and this should be documented. You should always be aware of your patient’s vital signs and be able to identify any changes.” Under the section, “How often should vital signs be done and documented,” it was stated, “While in the waiting areas. . .they need to be done hourly. While in a patient care area, the frequency of vital signs is dependent on the patient’s ESI [Emergency Severity Index is a tool for ranking acuity on a scale from 1-5 with 1 being most acute], any drips, and nursing judgement.” The document included times for ESI levels as, “ESI 1-every 5-15 minutes until stable and then no more than every 30 minutes; ESI 2 at least every 30 minutes to 1 hour (but could be every 5, 10, or 15 minutes); ESI 3 no less than every 2 hours; ESI 4 and 5 can be less frequent but MUST be done at least every 4 hours and at discharge.” Patient 20 arrived in ED on 09/11/24 at 2:01 PM with complaints of chest pain. The ESI at triage was level 2 (vital signs at least every 30 minutes to one hour). The patient had initial vital signs at 2:17 PM, 4:13 PM, and not again until 10:00 PM. Vital signs were then repeated every half hour. The B/P at 2:17 PM was 192/67. The B/P at 4:13 PM was 201/82. The B/P at 22010:00 PM was 172/59. All B/P results were elevated, and the medical record showed no documentation of reporting to RN or ED provider staff or documentation of interventions for elevated B/P. The patient was subsequently entered into observation services with a diagnosis of hypertensive urgency. During interview with the ED Nurse Manager on 10/30/24 in the conference room at 10:33 AM, the surveyor asked about the document, “Why are vital signs important in the Emergency Department?” The ED Nurse Manager acknowledged that she had gone over it in a Huddle meeting and given it to all nursing staff as guidelines for them to follow. When asked if it were her expectation that the staff would follow the guidelines, she stated that it was her expectation, but it really depended on the acuity of the patient. The ED Nurse Manager further stated that it was not always possible to achieve the timelines, and she audited some charts for timeliness of vital signs but was unable to audit all. Further stated that the expected practice was for the technicians to take hourly vital signs on patients in the waiting room. When asked about reporting abnormal vital signs, she said those should be reported to the triage or charge nurse by the technician.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 34065 Based on observations, review of policy, telemetry logs, medical records, and interviews with the staff, the facility staff failed to adhere to policies and procedures for patients with telemetry leads for 1 of 1 observations (Patient #13). The findings include: Observation on 06/18/2024 at 1335 of the telemetry monitoring room revealed 3 monitor technicians sitting in front of 2 telemetry monitors each. Each technician had handwritten entries of the events of the day on the monitor log. Review of Monitor Technician #1’s monitor log dated 06/18/2024 revealed an entry at 0800 for patient in room 3620 of “leads off” with “Person Notified” and “Time Tele (Telemetry) Restored” as “not fix.” Observation of the next entry revealed at 0818, the same patient in 3620 with leads off with restoration time at 0826, 26 minutes since original documentation of leads off. Observation on 06/18/2024 at 1340 of the telemetry monitoring room revealed a document posted on the wall above the telemetry monitors. The document read: “Calling Process: If a leads off alarm sounds, the Monitor Technician should: 1. Call the unit and speak with the unit and notify them of the monitor is off. a. Fill out the telemetry log (Date, time, Room#, Patient Name, etc.) 2. If still no rhythm after 5 minutes, call the unit second time and notify the House Supervisor. If no one answers the phone, the Monitor Technician will hang up and call back on the ‘red phone.’ If the red phone is not answered, notify the House Supervisor.” Review of open medical record of Patient #13 revealed a 47 year old male admitted on 06/13/2024 with kidney problems with continuous telemetry orders on 06/13/2024 at 2255. Telemetry was resumed at 0826 on 06/18/2024 with no change in condition. Interview on 06/18/2024 at 1340 with Monitor Technician #1 revealed monitor leads were documented as being off at 0800 with documentation of leads being off for over 20 minutes. Interview revealed no reason why the supervisor was not notified of the leads being off over 5 minutes. Interview revealed the Monitor Technician #1 called the primary nurse at 0800 and spoke to the nurse. Interview revealed another phone call to the patient care floor was made at 0818 when the leads were still off, adding another floor nurse placed the leads back on at 0826. Interview on 06/20/2024 at 1300 with CNO revealed “unsure why policy and procedures were not followed” to escalate the off leads. Interview revealed the policy and procedure was not followed. NC00214436, NC00210156, and NC00217003”