Chi Health Midlands

“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 review of the Emergency Department (ED) log, review of facility policy and staff interview the facility failed to follow facility policy for 1 (Patient (P)19) of 20 sampled patient records who presented to the facility seeking assistance were recorded on their central log. This failed practice has the potential to affect all patients presenting to the facility seeking assistance. According to facility provided information on average 1,216 patients are treated in the ED per month. See citation A2405 and A2406 that resulted in A2400 to not be met.”

“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: 46123 Based on review of the ED log, review of facility policy and staff interview the facility failed to ensure that 1 (P19) of 20 sampled patient records who presented to the facility seeking assistance were recorded on their central log. This failed practice has the potential to affect all patients treated by the facility. According to facility provided information on average 1,216 patients are treated in the ED per month. Findings include: A. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) (Emergency Medical Treatment and Labor Act) - (Midlands)”, approved 3/2023 revealed the Hospital’s EMTALA obligations are activated when, an individual (or someone on that individual’s behalf) requests and examination or treatment of a medical condition within a dedicated emergency department (DED). The Central Logs must contain, at a minimum, the name of the individual seeking assistance, whether the individual refused treatment, was refused treatment, was transferred, admitted, and treated, stabilized, and transferred, discharged, or expired. B. Review of the ED log during sample selection on 10/31/24 revealed that P19 was not listed on the ED log on 9/15/24 when P19 presented to the ED for chest pain. C. During an interview on 11/4/24 at 1:32PM, Patient Registration Manager (PRM) revealed, that she had been made aware of situation on 9/24/24. She spoke with P19 the same day who stated that [gender] presented to the ED on 9/15/24 between 12:00PM-2:00PM. P19 stated that they “spoke to the lady at window” and “she suggested I go somewhere else.” The PRM then revealed that she had spoken with Patient Registrar -A (PR-A) who stated “I wouldn’t tell anyone that” [meaning to go somewhere else]. The PRM then reviewed EMTALA with PR-A who voiced understanding. The PRM had security verify that P19 did present to the ED on 9/15/24 after phone call with P19. Security was able to verify that P19 had presented to the ED on 9/15/24. The contracted service then did their own investigation. The contracted service had on-site educators providing training to their staff 10/23 - 10/25/24. D. During an interview on 11/4/24 at 2:00PM, with Chief Medical Officer (CMO) revealed, P19 was in ED on 9/23/24 and informed the MD that they were instructed to go elsewhere on 9/15/24. The MD then notified CMO of concern. The contracted service for registration staff was also notified.”

“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 review of the ED log, review of facility policy and staff interview the facility failed to ensure that 1 (P19) of 20 sampled patient records who presented to the facility seeking assistance was not provided a medical screening exam (MSE). This failed practice has the potential to affect all patients that are treated in the ED. According to facility provided information on average 1,216 patients are treated in the ED per month. Findings include: A. Review of the ED log during sample selection on 10/31/24 revealed that P19 was not listed on the ED log on 9/15/24 when P19 presented to the ED for chest pain. B. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department - (EMTALA) (Emergency Medical Treatment and Labor Act) - (Midlands)”, approved 3/2023 revealed the Hospital’s EMTALA obligations are activated when, an individual (or someone on that individual’s behalf) requests an examination or treatment of a medical condition within a dedicated emergency department (DED). When the Hospital cannot immediately complete an appropriate MSE, it must still assess the individual’s condition upon arrival to ensure that the individual is appropriately prioritized, based on his/her presenting signs and symptoms, to be seen by a physician or other qualified medical provider (QMP) for completion of the MSE. The hospital will provide an MSE for an individual who comes to an on-campus DED, requesting examination or treatment for a medical condition or has such request made on his/her behalf, or if based on the individual’s appearance or behavior, the individual appears to need an examination or treatment for a medical condition. C. During an interview on 11/4/24 at 1:32PM, Patient Registration Manager (PRM) revealed, that she had been made aware of situation on 9/24/24. She spoke with P19 the same day who stated that [gender] presented to the ED on 9/15/24 between 12:00PM-2:00PM. P19 stated that they “spoke to the lady at window” and “she suggested I go somewhere else.” The PRM had security verify that P19 did present to the ED on 9/15/24 after phone call with P19. Security was able to verify that P19 had presented to the ED on 9/15/24. D. During an interview on 11/4/24 at 2:00PM, with Chief Medical Officer (CMO) revealed, P19 was in ED on 9/23/24 and informed the MD that they were instructed to go elsewhere on 9/15/24 when [gender] presented to the ED.”