Washington County Hosp Inc.

“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: 26622 Based on policy review, medical record review, central log review, staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings include: Based on hospital policy and procedure review, medical record review, physician and staff interviews, the hospital’s DED (Dedicated Emergency Department) physician failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for two of 21 reviewed patients who presented to the DED. (Patient #13 and #14). ~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag C2406”

“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: 26622 Based on hospital policy review, EMTALA central log review, and interviews, the hospital failed to maintain a central log on each individual who presented to the emergency department seeking medical care as to whether or not the patient refused treatment, or whether the patient was transferred, admitted and treated, stabilized and transferred or discharged for two of 21 sampled patients (#13 and #14). Findings include: Review of the hospital policy titled “Dedicated Emergency Department Functions” revised 05/2023 revealed “Policy Statement: ... Any individual who comes to the ‘Hospital’ seeking an examination and treatment of a potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition ... Definitions: ...E. Documentation: C. Emergency Patient Log. The Hospital will maintain a central log on each individual who comes to a DED seeking assistance ...” Review of the ED Registration Policy last effective 04/2023 revealed “Policy: All individual presenting to Hospital A seeking medical treatment through the Emergency Department shall be registered and logged into the ED Log ...” Review of the DED Triage Policy last reviewed 03/01/2021 revealed “ ... Policy: A. All patients presenting to the emergency department will be seen by a registered nurse. ... Procedure: A. Upon presentation to the emergency department the patient will be greeted by the registration clerk and his/her name, demographics, and phone number will be obtained. B. The registration clerk will notify the emergency department personnel ...” Review of the hospital’s central log for 07/10/2023 revealed Patient #13 and #14 were not listed/logged on the central EMTALA log. No medical records available for review at Hospital A. Patient #13 and #14 presented via private vehicle. Interview on 01/09/2024 at 0900 with the CEO (chief executive officer revealed the hospital had conducted and documented the investigation concerning the EMTALA violation in July 2023. Interview revealed that the Patients (#13 and #14) were never registered and/or placed on the ED Central EMTALA log. Interview revealed there were no hospital ED records available to review for the Patients (#13 and #14). Interview revealed the EMTALA violation was self-reported by Hospital A.””

“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: 26622 Based on hospital policy review, medical record review, and staff interview, the hospital’s DED (Dedicated Emergency Department) provider failed to provide an appropriate medical screening examination (MSE) within the capability of the hospital’s DED, including ancillary services routinely available to the DED, to determine whether or not an emergency medical condition (EMC) existed for two of 21 reviewed patients who presented to the DED. (Patient #13 and #14) Findings include: Review of the hospital policy titled “Dedicated Emergency Department Functions” revised 05/2023 revealed “Policy Statement: ... Any individual who comes to the ‘Hospital’ seeking an examination and treatment of a potential emergency medical condition will receive a screening examination to determine the existence of any emergency medical condition ... Definitions: ...H. Medical Screening Examination (‘MSE’): An examination conducted by a physician or Qualified Medical Personnel, with the ‘capability of the Hospital’, to determine whether an individual has an EMC. I. Qualified Medical Personnel (‘QMP’); An individual other than a licensed physician designated by the Board of Trustees (‘Board’) as qualified to conduct MSEs and provide stabilizing treatment ... Procedure: A. Examination and Treatment: a. A MSE will be offered to all patients presenting to the Emergency Department of the hospital ...” Review of the EMTALA Policy” last revised 04/2023 revealed “... Medical Screening Exams and Stabilization: *Any individual who presents to Hospital A ED for care will receive an appropriate MSE within the capability of the facility. *The MSE will be performed by a physician or qualified medical personnel. The PA/NP (physician assistant/nurse practitioner) may not transfer a patient from the hospital to another facility until the following has been completed: ...Completed and signed the transfer form.” Review of the hospital policy “Transfer of Patients to Other Acute Facilities” last reviewed 12/2019 revealed “Policy ...5. An EMTALA Transfer Form will be completed for all transfers. ...” Review of the DED Triage Policy last reviewed 03/01/2021 revealed “ ... Policy: A. All patients presenting to the emergency department will be seen by a registered nurse. ... Procedure: A. Upon presentation to the emergency department the patient will be greeted by the registration clerk and his/her name, demographics, and phone number will be obtained. B. The registration clerk will notify the emergency department personnel ...” No medical records for Patients #13 and #14 were available for review at Hospital A. Patients #13 and #14 presented to the Emergency Department via private vehicle. Review of the Emergency Department Diversion Report for Hospital A revealed documented diversion status for Radiology availability (X-ray and CT not available) on 07/10/2023 at 1921. Review of medical records for documented radiology diversion dates revealed the patients requiring radiology (x-ray and/or CT) services received a medical screening exam at Hospital A and transfer arrangements were made with other local facilities that had availability of needed radiology services. Review of the Radiology Staff Schedule for July 10, 2023 revealed there was radiology staff coverage for the 7a-7p shift and the 7p-7a shift on July 10, 2023. Interview on 01/09/2024 at 0900 with the CEO (chief executive officer revealed that Patients #13 and #14 did not receive a medical screening exam in the Dedicated Emergency Department on 07/10/2023. Interview revealed the ED nurses (RN and LPN) and Nurse Practitioner (NP) allowed Patients #13 and #14 to leave the DED prior to receiving a Medical Screening Examination. Interview on 01/09/2024 at 1605 with RN #1 revealed she worked the 7p-7a shift in the ED 07/10/2023. The interview revealed that the outside ED entrance door buzzed and two elderly ladies, late 60’s, 70’s entered the ED hallway. The patients informed the ED staff that they had been involved in a car accident 2 days ago and needed x-rays. RN #1 indicated that other ED staff informed the patients that x-ray services were not available. The interviewee informed the patients that the ED would be glad to see them and that if x-rays were needed the ED Provider would either transfer the patients to another facility and if not urgently needed would ask the patients to return when the x-ray system was back up. RN #1 indicated that the hospital went on diversion status after the x-ray system went down. The nurse indicated that education had been provided to all ED staff after the July 2023 incident. Interview on 01/10/2024 at 1450 with Nurse Practitioner (NP) #4 working in the ED on 07/10/2024 during the time the patients arrived, revealed that the NP did not see the patients. The NP did not witness any staff or overhear any staff telling the patients that the ED could not see them. The NP revealed that the NP had overheard the staff telling patients that the ED was glad to see them but that the facility did not have x-ray services available. Interview on 01/10/2024 at 1615 with LPN #2 revealed she worked the 7p-7a shift on 07/10/2023. Interview revealed there were two elderly ladies that presented to the ED with a chief complaint of vehicle accident 1-2 days ago, requesting x-rays. The LPN indicated the patient’s were greeted and directed to the registration area. The patients were informed that the hospital did not have radiology services available and could not do x-rays but told the patients that the ED staff would be happy to treat. The interview revealed that the patients stated “No” and left the hospital. The nurse indicated that education had been provided about bringing patients into the ED, obtaining a medical screening exam and completing registration of patients. The LPN was educated that all patient should be seen in the ED and then informed of unavailable services by the provider and if the patient decided to leave it would be their choice. The LPN had received EMTALA follow-up education since the event in July 2023. Interview on 01/10/2024 at 1540 with the NM #3 revealed the patients should have been registered and a medical screening exam should have been completed in the ED by the Provider. The nurses should have notified the Provider that the patients were leaving the ED.”