Jefferson Community Health & Life

“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 Emergency Department (ED) Log review, facility policy and procedure review, staff and provider interviews the Critical Access Hospital (CAH) failed to follow their policies and provide 1 of 20 sampled patients (Patient 20) a Medical Screening Exam (MSE) within the hospitals capabilities to rule out an Emergency Medical Condition (EMC), stabilized and transferred with in the facilities capabilities then include patient 20 on the ED Log. This failed practice has the potential to affect all patients treated in the ED. On average the facility treats 200 patients per month in the ED. Also see 2405 and 2406”

“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 Emergency Department (ED) log, review of facility Emergency Medical Treatment and Labor Act (EMTALA) guidelines, and staff interviews, the facility failed to ensure all patients that present to the ED are entered into the ED log. This failed practice has the potential to affect all patients that present to the ED. The facility treats 200 ED patients per month on average. Findings are: A. Review of the ED log (6/22/2026 at 12:00 PM) revealed that the facility failed to enter Patient 20 in the ED log after presenting to the ED via ambulance on 5/21/2026 at 11:40 PM. B. Review of facility policy EMTALA Guidelines (last review 9/24/25) revealed, the MSE should include at a minimum the ED log entry including disposition of patient. C. During an interview with the Chief Nursing Officer (CNO) (6/25/2026 at 8:25AM) she confirmed that Patient 20 was not entered in the ED log nor does the facility have a policy that includes the required information in the ED log.”

“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: 46123 Based on review of facility policy and procedure, nurse and provider interview the facility failed to provide 1 of 20 ED patients (Patient 20) an appropriate medical screening examination (MSE) within the capability of CAH-A’s ED to determine if patient 20 had an emergency medical condition (EMC). This failed practice has the potential to cause harm to all patients that present to the ED seeking care. The facility treats 200 patients per month on average in the ED. Findings are: A. Review of facility policy EMTALA Guidelines (last review 9/24/25) revealed, all patients shall receive an MSE that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis. Review of facility policy Medical Screening Exam (last review 9/24/25) revealed, the MSE shall include a history and physical examination, diagnostic evaluation, and consultation to the extent necessary, within the capability of facility staff to detect an emergency medical condition. B. During an interview (6/23/26 at 1:00 PM) Nurse Practitioner-C (NP-C) revealed that CAH-A had lost phone and internet services on 5/21/26 prior to Patient 20 arrival. The ambulance was here with patient 20 before we could notify them of our limited resources. Patient 20 was sitting up on the cot with a cervical collar (a neck brace used to keep the spine in proper alignment and limit head movement). I did a quick assessment of patient 20 no visible injuries. Discussed with the ambulance our limited resources. The ambulance then took patient 20 to CAH-B 27.5 miles away. When asked if NP-C had notified CAH-B of patient 20 NP-C responded, “I thought the nurse had called them.” NP-C confirmed that documentation of assessment was not completed in the medical record. CAH-A was unable to complete radiologic testing due to internet service being down and unable to transmit images to radiologist to be interpreted. C. During an interview (6/23/26 at 1:45 PM) Registered Nurse-D (RN-D) revealed everything “crashed” lost phone and internet service, only my phone was working as it is on a different service carrier. I was able to call out with my phone. RN-D was on the phone with ED manager when ambulance arrived. ED manager asked that NP-C to see patient 20. NP-C and another RN went to see patient 20. RN-D was asked if they notified CAH-B of patient 20 being sent to them. RN-D responded, “no I did not call them.” D. During an interview (6/25/26 at 8:25 AM) the Chief Nursing Officer (CNO) revealed Patient 20 did not have a medical record created for ED visit on 5/21/26. Patient 20 was not transferred to CAH-B according to policy.”