Jamestown Regional 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: 42397 Based on complaint information, policy review, record review, and review of Medical Staff Rules and Regulations, the Critical Access Hospital (CAH) failed to enforce policies to ensure compliance with 42 CFR 489.24, special responsibilities of Medicare hospitals in emergency cases, and the related requirements at 42 CFR 489.20 for 1 of 1 sampled patient (Patient #1) who presented to the CAH for leg numbness. Hospitals are required to adopt and enforce a policy to ensure compliance with the requirements at §489.24. Failure of the CAH to enforce their Emergency Medical Treatment and Labor Act policy limited the CAH’s ability to determine if the patient had an emergency medical condition. Findings include: The CAH failed to ensure an Emergency Department (ED) provider conducted an appropriate medical screening examination within the capability of the CAH’s ED (Refer to C2406).”

“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: 42397 Based on information from the complainant, record review, policy review, and review of Medical Staff Rules and Regulations, the Critical Access Hospital (CAH) failed to provide an appropriate medical screening examination (MSE) for 1 of 1 sampled patient (Patient #1) who presented to the emergency department (ED) for leg numbness. Failure to provide patients who present to the emergency department with an appropriate medical screening examination limited the CAH’s ability to determine if the patient had an emergency medical condition. Findings include: Review of the facility policy titled “EMTALA Requirements (Emergency Medical Treatment and Labor Act)” occurred on 06/26/25. This undated policy stated, “The Emergency Medical Treatment and Labor Act (EMTALA) serves to provide structure to the proper examination, treatment and transfer of emergency patients. . . . documentation of each aspect of care and communication is central to compliance . . . each patient presenting for care through a medical screening exam (MSE) must be evaluated by trained and qualified personnel to determine the presence or absence of an emergency medical condition. . . . The purpose of the examination is to determine if an emergency medical condition is present. . . . . EMTALA establishes specific responsibilities for physicians attending to the Emergency Department patient. The provisions of the law apply to patients who present, on hospital property, for purposes of examination and treatment of medical complaint. . . . describes the need for an examination of each patient for the purpose of determining if that patient possesses an ‘emergency medical condition’ . . . An emergency medical condition is defined as a medical condition manifesting itself by symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in . . . serious impairment of bodily functions/or . . . serious dysfunction of any bodily organ or part. . . .” Review of the facility policy titled “Standards of Care, Emergency Department” occurred on 06/26/25. This undated policy stated, “Every Emergency Department patient . . . can expect to receive the following . . . Triage and assessment of all patients on arrival with appropriate intervention. . . . Triage and assessment for life threatening conditions and initiation of appropriate intervention without delay. . . All patients entering the ED are seen by a physician and receive a medical screening exam. . . .” Review of the “Medical Staff Rules and Regulations” occurred on 06/26/25. These regulations, dated April 2024, stated, “. . . F. General Rules Regarding Emergency Services . . . 3. An appropriate medical record shall be kept for every patient receiving emergency service and be incorporated into the patient’s hospital record. The record shall include . . . pertinent history of the injury or illness . . . diagnostic and therapeutic orders . . . a description of significant clinical, laboratory and radiological findings . . . treatment given and clinical observations . . . diagnostic impression . . . the condition of the patient on discharge or transfer; and . . . the final disposition, including instruction given to the patient and/or his/her family . . . in regards to follow-up care. . . .” Review of Patient #1’s ED record from 05/23/25 occurred on 06/23/25. The record identified Patient #1 arrived at the ED at 2:38 a.m. with complaints of “leg numbness.” An “ED Triage Note”, dated 05/23/25 at 2:43 a.m., stated, “Pt [patient] has a tumor at T3-T7 [thoracic vertebrae 3-7] level, compressing on her spine. Pt has surgery scheduled in [tertiary hospital name/town] on Tuesday 5/27. Pt is taking oxycodone [narcotic pain medication], last dose at 2200 [10:00 p.m.]. . . . is also taking gabapentin [nerve pain medication] and flexeril [muscle relaxer]. Pt noticed increasing numbness in . . . left leg in the early evening yesterday. Pt is started to lose feeling in her torso.” A “Fall Risk Assessment”, dated 05/23/25 at 2:48 a.m., stated, “Patient immobile: No . . . Muscle weakness/balance problems/unsteady gait/assist of person or device (WC [wheelchair], walker, crutches): 0 - No Problem . . .” Provider #1’s “ED Provider Note”, dated 05/23/25 at 3:12 a.m., stated, “. . . DIAGNOSIS 1. Thoracic spine tumor . . . ASSESSMENT/PLAN/DECISION MAKING: Follow up at [tertiary hospital name] Hospital . . . HPI [history of present illness] Pt presents with numbness to left side Pt has hx/o [history of] malignant tumor T3-8 is scheduled for surgery and further treatment next week at [tertiary hospital name] Is on Prednisone [steroid medication] 4 mg [milligrams] a day No falls or acute trauma . . . Review of Systems Neurological : Positive for numbness . . . Physical Exam vitals and nursing note reviewed. Neurological: Comments: left sided numbness in lower extremities and trunk . . . ED COURSE Pt given Solu-medrol [steroid medication] 125 mg IM [intramuscular] Patient and family are traveling to [tertiary hospital name] currently Procedures: [none] . . .” Patient #1’s ED record identified the patient was discharged home on 05/23/25 at 3:17 a.m. The medical record lacked an appropriate medical screening exam to evaluate for an emergency medical condition.”