Great Plains Health

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 48575 Based on policy and procedure review, medical record review, administration interview and medical staff interview, the facility failed to ensure adequate supervision by nursing to perform and document an abdominal reassessment for 1 (Patient 2) of 10 sampled inpatients that had a change of condition related to abdominal pain, and rigidity per facility policy. This failed practice has the potential to cause a delay in care and treatment for inpatients with a change in condition. The facility inpatient census on entrance was 55. Findings are: A. Review of facility policy, Nursing Assessment Reassessment, last reviewed 5/2024 revealed the reassessment of patient’s needs are determined throughout the course of care, treatment and services. The nursing practice is to define the scope of screening content, assessment and reassessment information collected that may indicate the need for further assessment or reassessment of the patient. Reassessment is determined by the patient’s diagnosis, complexity of care, and patient response to care and treatment. Nursing clinical judgement and critical thinking may result in increased frequency or monitoring. Medical surgical reassessment are to be completed for systems not within defined limits with interventions or change in condition. B. Review of the medical record (12/2/2025 at 11:24AM) revealed Patient 2 presented to the facility emergent department on 9/22/2024 at 7:08PM with a chief complaint of right lower abdominal pain with nausea and vomiting that started 48 hours prior to arrival. Abdominal imaging was obtained, and a general surgeon was consulted that planned surgery for a dilated cecum greater than 12 centimeters (normal size of the cecum is less than 9 centimeters, it is a pouch that forms the first part of the large intestines) consistent with cecal volvulus (the large intestine twists around itself and causes a bowel obstruction that detaches from the abdominal wall and requires emergency surgery.) Patient 2 was agreeable to the plan and taken to the operating room for a laparotomy with ileo right colectomy, ileotransverse colostomy (the surgeon removes the compromised ascending colon and the end of the ileum and then reconnects the remaining ends of the small and large intestines). Patient 2 was admitted to the medical surgical unit after surgery on 9/23/2024 at 12:44AM for continued care, treatment and monitoring of bowel function, abdominal incision, vital signs, and oral intake as ordered by the physician. Timeline of Patient 2’s increased heart rate (tachycardia), increased pain frequency of 10/10, and nursing abdominal assessments on: 9/25/2024: -At 12:21 AM: Pain 6/10 -At 4:52 AM: Pain 2/10. -At 5:14AM: Pain 6/10. -At 6:32AM: Blood pressure (BP) 131/85, Heart Rate (HR) 70. -At 9:28AM: Pain 6/10. -At 11:23AM: Pain 7/10. -At 1:06PM: BP 140/88, HR 102 (tachycardia). -At 3:08 PM: Pain 10/10, IV dilaudid (pain medicine) given. -At 4:30 PM: BP 138/80, HR 87. -At 6:38PM: Pain 10/10 severe to abdomen, radiates to back, cramping, IV dilaudid (pain medicine) given. -At 6:59 PM: Nursing abdominal assessment new finding of rigidity documented. -At 8:12 PM: BP 148/95, HR 79. -At 8:56 PM: Pain 10/10 severe to lower back new onset, continuous, IV dilaudid given. -At 11:46PM: BP 136/97, HR 104 (tachycardia). -At 11:48PM: Pain 8/10 severe to the back, aching, continuous, IV dilaudid given. 9/26/2024: -At 3:57AM: BP 132/97, HR 109 (tachycardia) -At 4:02 AM: Pain 10/10 severe new onset to abdomen and back cramping, continuous. -At 6:04 AM: Pain 10/10 severe new onset to abdomen, cramping, continuous. -At 6:45 AM: Nursing abdominal assessment rigid, and nausea documented. -At 7:12 AM: Nursing reached out to notify on call general surgery for patient 2 “pain scale too high.” -At 8:30AM: BP 74/39, HR 141, MAP 46. A rapid response was called for low blood pressure and abdominal pain 10/10. The patient required levophed (an emergency medication given for low blood pressure.) Patient 2 was taken to the OR for emergent abdominal surgery at 8:48AM. Patient 2 had gastric fluid in the abdomen, stomach perforation (hole) and ischemia (tissue death). Patient 2’s medical record lacked evidence of nursing increasing the frequency of nursing abdominal reassessments with a change in condition 9/25/2024 that started at 6:59PM per policy, confirmed by CNO. Patient 2’s medical record lacked evidence of notification to the physician for the change in condition of tachycardia, abdominal assessment new findings of rigidity and abdominal increased pain frequency and management on 9/25/2024 from 6:38 PM until 9/26/2024 at 07:45AM, confirmed by Physician-A and CNO. C. Interview (12/2/2025 at 3:31PM) with Physician-A confirmed there was no notification from nursing regarding patient 2 change in abdominal assessment on 9/25/2024 at 6:59PM until notified of change in condition of diffuse abdominal pain on 9/26/2024 at 7:45AM. Physician-A confirmed the after hours general surgery on call did not contact regarding patient 2, and would have if there was communication from nursing overnight on 9/25/2024 6PM - 6AM. Interview (12/3/2025 at 9:37AM) with CNO confirmed no documentation of nursing notification to the physician for change in patient 2 condition on 9/25/2024 from 6:38PM until 9/26/2024 at 7:45AM.”

“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: 46123 Based on policy and procedure review, medical record review, and medical staff interview the facility failed to follow their policy regarding medical screening exams for 1 (Patient (P)2) of 20 sampled medical records. This failed practice has the potential cause harm or even death to all patients who present to the Emergency Department (ED). According to facility provided information the ED averages 1,675 patients in the ED monthly. See citation A2406 and A2407 that resulted in A2400 not being met.”

“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: 46123 Based on record review, facility call schedules, policy and procedure review and staff interviews the facility failed to provide 1 (P2) of 20 sampled patient records a complete medical screening exam (MSE) to rule out an emergency medical condition (EMC). This failed practice has the potential to cause harm or even death to all patients presenting to the ED. According to facility provided information the ED averages 1,675 patients in the ED monthly. Findings include: A. Review of facility policy “EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening”, approved 2/24/2023 revealed, a MSE is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to discharge or transfer. Psychiatric MSE - Patients presenting with both psychiatric and other medical signs or symptoms shall receive a MSE broad enough to rule out both psychiatric and other medical EMCs. The medical record documentation should specifically address any psychiatric complaint, culminating in an evaluation of the complaint resulting in a finding of no EMC, or establishing an appropriate plan of care. B. Review of Patient (P)2’s medical record revealed, P2 presented to the ED on 9/4/24 at 12:16PM with the police per P2’s guardian request for suicidal ideation. P2 had a piece of porcelain with a plan to cut their own neck. P2 admitted to increasing marijuana use to help numb the suicidal ideation. On 9/3/24 P2 laid down on the train tracks and called the police. Medical Doctor (MD)-A evaluated P2 in the ED and discussed admitting P2 to psychiatric service, however P2 refused and would prefer to be admitted at Behavioral Health Facility (BHF) - B. P2 states if I go home, I will attempt to commit suicide and perhaps will be successful. P2 had 1:1 (1 staff member per 1 patient) during the ED stay. Labs ordered and completed included, Complete blood count (CBC, a blood test that measures the number and types of blood cells in your body.), comprehensive metabolic panel (CMP, a blood test that measures electrolytes, kidney and liver function, protein levels and provides information about your body’s chemical balance and metabolism.), both were with in normal limits. Other labs included a pregnancy test that was negative, acetaminophen and salicylate levels (measure the levels of medication in body to rule out an overdose of medication) both in normal limits and a urine drug screen that was positive for marijuana. Transfer communication with BHF-B was initiated at 3:24PM. The last phone call to follow up on referral for transfer was made at 8:09PM. BHF-B state they have been busy and are looking at referral. At 8:14PM P2 was requesting to go home. MD-C notified of the request. P2 was discharged from the ED at 8:29PM to home. Discharge instructions included that P2 has chosen to go home tonight. Please return if having thoughts of self-harm. Continue to take medications as prescribed. Follow a healthy lifestyle including exercising regularly and eating a healthy diet. Consider volunteer opportunities in the community. P2 was to follow up with a family medicine provider (no appointment scheduled prior to discharge), and education regarding suicide and depression. The medical record lacks evidence of the MSE evaluation documentation prior to discharge by MD-C. The medical record lacks evidence of psychology consultation. C. During an interview on 10/17/24 at 11:45AM, MD-D revealed “we had a team meeting (Behavioral Health Services Providers) regarding P2.” As a team it was decided to not admit P2 for inpatient stay in Behavioral Health as it was not beneficial for P2. However, we do expect to the ED to call us to assist in P2’s plan of care.”

“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: 46123 Based on record review, policy and procedure review and staff interviews the facility failed to provide 1 (P2) of 20 sampled patient records stabilizing treatment for an EMC prior to discharge. This failed practice has the potential to cause harm or even death to all patients presenting to the ED. According to facility provided information the ED averages 1,675 patients in the ED monthly. Findings include: A. Review of facility policy “EMTALA (Emergency Medical Treatment and Labor Act) Medical Screening”, approved 2/24/2023 revealed, Psychiatric MSE - Patients presenting with both psychiatric and other medical signs or symptoms shall receive a MSE broad enough to rule out both psychiatric and other medical EMCs. The medical record documentation should specifically address any psychiatric complaint, culminating in an evaluation of the complaint resulting in a finding of no EMC, or establishing an appropriate plan of care. B. Review of Patient (P)2’s medical record revealed, P2 presented to the ED on 9/4/24 at 12:16PM with the police per P2’s guardian request for suicidal ideation. P2 had a piece of porcelain with a plan to cut their own neck. P2 admitted to increasing marijuana use to help numb the suicidal ideation. On 9/3/24 P2 laid down on the train tracks and called the police. Medical Doctor (MD)-A evaluated P2 in the ED and discussed admitting P2 to psychiatric service, however P2 refused and would prefer to be admitted at Behavioral Health Facility (BHF) - B. P2 states if I go home, I will attempt to commit suicide and perhaps will be successful. P2 had 1:1 (1 staff member per 1 patient) during the ED stay. Transfer communication with BHF-B was initiated at 3:24PM. The last phone call to follow up on referral for transfer was made at 8:09PM. BHF-B state they have been busy and are looking at referral. At 8:14PM P2 was requesting to go home. MD-C notified of the request. P2 was discharged from the ED at 8:29PM to home. Discharge instructions included that P2 has chosen to go home tonight. Please return if having thoughts of self-harm. Continue to take medications as prescribed. Follow a healthy lifestyle including exercising regularly and eating a healthy diet. Consider volunteer opportunities in the community. P2 was to follow up with a family medicine provider (no appointment scheduled prior to discharge), and education regarding suicide and depression. C. During an interview on 10/17/24 at 11:45AM, MD-D revealed “we had a team meeting (Behavioral Health Services Providers) regarding P2.” As a team it was decided to not admit P2 for inpatient stay in Behavioral Health as it was not beneficial for P2. However, we do expect to the ED to call us to assist in P2’s plan of care.”