Dlp Swain County Hospital LLC

“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 perform an appropriate medical screening exam for one (1) of 20 sampled records by failing to provide Ultrasound [US] services available to Emergency Department patients when criteria was met. (Patient #8). ~ Cross refer to Appropriate Transfer - Tag A2406.”

“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: 41946 Based on policy review, closed medical record review, staff and physician interviews, the hospital dedicated emergency department (DED) failed to perform an appropriate medical screening exam for one (1) of 20 sampled records by failing to provide Ultrasound [US] services available to Emergency Department patients when criteria was met. (Patient #8). The findings included: Review of the policy, Imaging Services Call Policy, last revised 07/2024 revealed “PURPOSE: To define expectations of staff in various modalities and to establish criteria for appropriateness of callback in each modality. ... DEFINITIONS: ...The purpose of this policy is to define call coverage for [Hospital C] and [Hospital A] Imaging Department. ...Ultrasound is open/available M-F, 0730 - 1900, Saturday 7a - 1630 and on call afterward. ... Venous Doppler Study - Patient not currently on blood thinners and pain, erythema, and swelling in extremity of interest. ... PROCEDURE: ... **Note*** If a patient presents to the Emergency Department and needs a study performed that is considered NON-EMERGENT, the patient will be done the following morning or at the patient’s convenience, unless the ordering physician contacts the Radiologist for approval and has precertification to have procedure. The ER will instruct the patient to call central scheduling to make an appointment. They will be added to our schedule as an outpatient and will be done at their scheduled time. The patient is to contact or follow up with the Emergency Department for their results.” Closed medical record review on 02/05/2025 for Patient #8 revealed a 56-year-old female was admitted to Hospital A DED on 10/14/2024 at 2025 for lower extremity pain. Triage at 2107 revealed Patient #8 arrived by private vehicle. Patient #8 had a Pain score of 5 (scale 0 no pain, - 10 most pain) and was assigned an acuity of 3 [emergency severity index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acutely ill]. Review revealed “Patient reports left lower leg pain behind her left knee over the past 4 days with redness and tenderness increasing.” The MSE began at 2110 by the DED Physician’s Assistant #10. Patient #8 did not have lab work or imaging ordered to be completed on 10/14/2024. Review of the Emergency Department Note filed 10/14/2024 at 2110 by the DED PA #10 revealed “Chief Complaint: Left lower extremity pain redness swelling ...History of present illness HPI details: 56-year-old female here today with left lower extremity pain redness and swelling has been driving 18 hours. She states she has been mildly tachycardic but no respiratory distress nontoxic ill-appearing no recent trauma. Physical Exam: ... Extremities: pulses intact with good cap refills, no LE [lower extremity] pitting edema or calf tenderness, mild-to-moderate tender to palpate posterior left thigh negative Homan cord sign [pain associated with forced dorsiflexion of the ankle] mild erythema [redness of skin] two-point discrimination intact normal gait. ...Emergency Department Course/Plan/MDM Progress: patient was given Lovenox weight dose will have outpatient ultrasound done in the morning if positive she will sign back into the emergency department placed on Eliquis and appropriate workup. If negative patient will go home to follow up with primary care doctor she agrees with plan. ... Clinical Impression: left lower extremity pain/rule out DVT. ... Disposition Patient condition: stable; ED Disposition: home; ...” Discharge instructions given at 2130 “call in the morning to this hospital to make sure ultrasound is here and available, if not go to Hospital C to have ultrasound performed. If symptoms persist or worsens, please go to the nearest hospital for re-evaluation.” Discharge included a paper script with order “Dx [diagnosis] L [left] Ext [extremity] pain/redness. US L Lower Ext for DVT [deep vein thrombosis] 10/15/2024.” Patient #8 was discharged on 10/14/2024 at 2130. Patient #8 did not return the next day for the US of left lower extremity. Telephone interview on 02/06/2024 at 1130 with DED PA #10 revealed he had no recall of Patient #8’s visit. “She was stable for discharge, that is our standard of care. I always call to see if I can get anyone to come in. I refer to the Wells/Criteria [standard of care] for DVT/PE [pulmonary embolus] check list. I review that list. The standard of care of 1 dose of lovenox, which was given. He had no active chest pain, no shortness of breath [SOB]. This was the standard of care. I explained to the patient in depth what to look for. That’s what I did. I talked with radiology department. I ask them if I can get an US. If the patient had chest pain/SOB then you would transfer them. If not, I added blood thinners to cover. This is standard of care. I make sure to tell the patient, to stay after the ultrasound and get the report if positive, then to sign back into the ED. A patient that agrees to return, 99% of patients come back. We don’t discharge patients that are unstable. You discharge stable patients; you cover them and get them back for US. I would transfer a patient to [Hospital C], to the ED/Hospitalist if patient needed care right then. I can reach out to Dr. [ED Medical Director] anytime I need to. The interview revealed DED PA #10 felt standard of care was followed for Patient #8. Telephone interview on 02/07/2025 at 0948 with the DED Medical Director of Hospital A revealed “ ...So I have not reviewed these cases. This whole pattern unsatisfactory, we would all prefer to have US techs .... If a patient was not on blood thinning medications that would meet criteria. If you suspect DVT, and don’t have US, it was appropriate to initiate therapy and get the US the next availability. ...It sounds like the 2nd patient [patient #8] did meet criteria for ultrasound to be called back. It is our pattern to call the radiologist and ask regardless. Clearly [PA #10] felt she could have a DVT. There may have been a lapse in the 2nd case [Patient #8]. ...I’d always had a concern for this policy. This illustrates well this could be an issue. ... If a patient came in with an EMC [emergency medical condition] and needed an US, and US service at Hospital A was not available, then sending the patient to Hospital C by EMS to get that done was there. ... The Providers at Hospital A were not satisfied with US services at Hospital A, due to the US Techs being called back to Hospital C. We have to wait for a US tech or transfer the Patient over to Hospital C by EMS. We are told it is difficult to get adequate staff for US technicians ....” The interview revealed Patient #8 met criteria for US technician to be called in to rule out a DVT. The interview revealed the hospital policy was not followed.”

“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 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 provide, within the capabilities of the staff and facilities, further medical examination and treatment as required to stabilize a patient with an emergency medical condition for one (1) of 25 patients reviewed who arrived to the DED seeking emergency care. (Patient #13) ~ Cross refer to Stabilizing Treatment - 489.24(d)(1-3) - Tag C2407”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. 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 provide within the capabilities of the staff and facilities available further medical examination and treatment as required to stabilize a patient with an emergency medical condition for one (1) of 25 patients reviewed. (Patient #13) The findings included: Review of the EMTALA (Emergency Medical Treatment and Labor Act) policy, effective 08/2023 revealed “...If an emergency medical condition is found to exist, the Hospital will....provide (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services)... .” DED [Dedicated Emergency Department] medical record review, on 06/04/2024, revealed Patient #13, an 8-year-old male who arrived to the DED on 02/23/2024 at 1608 with a complaint of right wrist/hand pain. Review of the Triage Note at 1618 revealed “Tenderness noted to right hand and wrist. No swelling noted. Redness noted to the post. of right hand and wrist. Mother states - pt [patient] fell on stairs at home.” The MSE [medical screening examination] was initiated at 1617 by Physician’s Assistant [PA] #2 and indicated “ ...Chief complaint: Right hand pain. History of Present Illness HPI details: 8-year-old male child was outside playing flipping and struck his right hand now with diffuse hand pain and discomfort with small area of abrasion no obvious deformity closed injury right-hand-dominant just happened prior to arrival alert orient x3 [person, place, time].... Physical Examination ... mild diffuse tender to palpate right hand, active full range motion of all digits hand wrist and elbow and shoulder closed injury no obvious deformity [space] ... Results Diagnostic Interpretation: x-ray show no fracture dislocation, ... Impression: right hand contusion. ...Disposition Patient condition: stable.... ED Disposition: Home;” Radiology results were reviewed by the Radiologist [MD #3] at 1652 and revealed “Review of the “HAND; MINIMUM OF THREE VIEWS RIGHT ...Views: AP and oblique views of the right hand.... FINDINGS: Suboptimal evaluation without a true lateral view. BONES: No fracture or focal lesion ...IMPRESSION ...no evidence of acute osseous process ...” Interview on 06/05/2024 at 1037 with DED PA (Physician Assistant) #2 revealed he did not remember Patient #13. Interview revealed “ ...for this patient I added an ace wrap and advised to see the PCP (Primary Care Physician) in 5-7 days. ... anytime you’re close to the growth plate you should be looked at again. The sub-optimal view would not have changed the treatment plan. The radiologist would call if he had any changes, and I would have called the patient back by phone to update them if needed. I always go back in to speak with the patient and give the findings myself, go over discharge instructions also ...” The interview revealed that if the x-ray findings were indicated, a copy of the x-ray would be sent with the patient for follow-up. In summary, DED record review failed to show the provider correctly interpreted the physical examination which, even with a negative x-ray, pointed to a diagnosis of Salter-Harris type 1 fracture due to pain and tenderness over an open growth plate area. There was no evidence of an immobilizing splint or referral/ recommendation to see a pediatric orthopedist within one week. The hospital provider failed to provide stabilizing treatment to Patient #13.”