Providence 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: 46123 Based on record reviews, policy review, dispatch log review and staff interviews the Critical Access Hospital (CAH) failed to follow their Emergency Medical Treatment and Labor Act (EMTALA) policies for 2 (Patient (P) 9, and P18 (P18 presented to ED on 3 occasions) of 20 selected Emergency Department (ED) medical records. This failed practice has the potential to cause harm or even death to all ED patients of the CAH. According to facility provided information the ED treats on average 249 patients per month. Findings include: See citation C2406 and C2409, that also resulted in C2400 to not be met. A. Review of facility policy “EMTALA: Medical Screening Exam”, effective 8/1/2019 revealed, Patients are to be provided written discharge instructions and discharge education detailing the proper use of any medication they are provided and the potential hazards and side-effects of the medication. Discharge instructions will contain the instructions for the plan of care. The patient will demonstrate improvement in their condition prior to discharge and that improvement will be documented. Where improvement is not achieved, it may be an indication that additional assessment or specialty care is required. B. Review of medical records from ED-A revealed P18 presenting to the ED on 10/9/24 at 8:22 AM with complaints of shortness of breath, cough and increased oxygen needs. P18 was diagnosed with pneumonia. Discharge instructions included: - It does appear that you have pneumonia. We have treated you with a dose of Rocephin here in the ER. I have sent a prescription for Augmentin twice daily for 5 days and azithromycin 500mg x 3 days. You may need to increase your usage of your nebulizer treatments as well as your oxygen use until this improves. You may follow-up with your primary care provider if you are not improving or if things worsen. The medical record lacks orders that include medication, dose, route and frequency of any medication changes desired by NP-B.”

“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 policy review, dispatch log review, record reviews, and staff interviews the CAH failed to provide a medical screening exam to 1 (P18B) of 18 ED patient medical records once by cancelling the CAH owned EMS for transport to the Emergecy Department (ED) and, failure to provide a complete MSE when P18B presented to the ED after requesting EMS transport again. This failed practice has the potential to cause harm or even death to all patients treated by the CAH ED. According to facility provided information the ED treats on average 249 patients per month. Findings include: A. Review of facility policy “EMTALA: Medical Screening Exam”, effective 8/1/2019 revealed, the CAH will provide an appropriate medical screening examination (MSE) to any individual who comes to the emergency department and requests examination or treatment. The MSE must be the same on every individual presenting with comparable conditions. B. Review of the dispatch log for CAH owned ambulance revealed, 10/9/24 at 20:34:41 (8:34 PM) incident initiated at Nursing Facility -A (NF-A). Caller advised that patient is [gender] with shortness of breath. At 20:55:53 (8:55 PM) PM (CAH) advised NF-A called them and canceled the call. Incident closed. 21:16:07 (9:16PM) NF-A called back and did want the ambulance now. 21:21:41 (9:21PM) Ambulance enroute to NF-A. Ambulance arrived at NF-A 21:22:40 (9:22 PM), 21:40:52 (9:40 PM) Ambulance enroute to ED-A and arrives to ED-A at 21:42:53 (9:42 PM). C. Review of P19’s medical records from NF-A revealed, Res (P19) was having difficulty breathing with respiratory retraction observed. Res (P19) disoriented, voiced seeing people that were not present in the room and reports having double visions. Coarse crackles auscultated to bilateral lungs; skin slightly paler than usual. Vitals: oxygen saturation (SpO2) 92% on 8liters(L) per nasal canula (NC), blood pressure (BP) 169/82, respirations (R) 21, Pulse (P) 89, temp (T) 97.4. P19’s daughter was concerned with worsening condition and requested for P19 to go to the ED to be evaluated. The on-call provider for P19’s primary care provider (PCP) was notified of patient status. Order received to transport P19 to CAH ED (closest facility). 911 was called by registered nurse A (RN-A) for transport to the ED. RN-A then called the CAH ED to give nurse to nurse report. RN-A was transferred to nurse practitioner B (NP-B) who stated that P19 does not need to be seen since [gender] was already there today and there was not much they could do for resident at ER. Then stated to keep him (P19) at this facility and initiate breathing treatment every 20 minutes x3 and to change prn (as needed) breathing treatment to every 2 hours. NP-B also canceled the EMT (emergency medical technician) transportation to the ER. Breathing treatments x 2 every 20 minutes were completed. P19 continually stated [gender] shortness of breath was worsening and requested to go to ED-B (CAH facility 25 minutes away) if ED-A would not accept him. RN-A then notified ED-B and spoke with on-call provider who advised that P19’s condition is urgent and needs to go to closest ED. RN-A calls ED-A and speaks with NP-B regarding P19’s condition worsening and breathing treatments being ineffective. NP-B then gave the okay to transport P19 to ED-A. RN-A again called 911 to request transport to ED-A RN-A receives call from NP-B at 2215 (10:15PM) to inform nurse that P19’s condition is stable for diagnosis of pneumonia, significant COPD (chronic obstructive pulmonary disease - a condition that makes it difficult to breath) and sleep apnea. There is not much they [ED-A] could for him at the ED that this facility [NF-A] can’t provide. P19 will be returning to NF-A with no new orders. P19 returns to NF-A at 2345 (11:45 PM), vital signs on return T 97.8, P114, R22, BP 119/83 SpO2 95% on 4L. P19 vomits upon return to NF-A with continued shortness of breath and respiratory retraction noted. As needed Zofran (medication that helps with nausea) was given. D. Review of P19’s medical records from ED-A revealed, P19 admitted to ED-A via EMS 10/9/24 at 21:46 (9:46 PM) with complaints of worsening symptoms, feeling more short of breath. P19 had completed 2 breathing treatments every 20minutes prior to arrival as ordered. Initial vital signs on admit to the ED were T 97.9, R18, P77, BP 110/56, SpO2 97% on 4L/NC. NP-B arrived at the bedside for assessment at 2158 (9:58PM). Lung sounds documented as faint wheeze bilat upper lobes, bilat diminished lobes on auscultation and percussion, non-labored respiration. NP-B called NF-A at 22:24 (10:24PM) to inform that P19 would be discharged back to NF-A. NF-A will work on finding a ride for P19. NF-A arrived to pick up P19 from ED-A at 2325 (11:25PM) discharge instructions reviewed with P19 who voices understanding of instructions given. Discharge instructions included Patient continues on 4L per nasal cannula sating at 98%. This O2 sat may actually be more than what he is normally used to and could potentially tolerate his 2L per nasal cannula with rest and 4L per nasal cannula with activity which is his baseline. Patient should continue with the antibiotic and nebulizer treatments as prescribed earlier today. No further lab work or imaging was completed at this time. Patient can follow up with his PCP as needed. The medical record lacks documentation of continued physical assessment monitoring prior to discharge. E. During an interview on 11/20/24 at 10:55AM, Medical Doctor C (MD-C) revealed that the CAH does not have a policy that allows a provider to cancel a 911 call the ambulance should go and bring the patient to the ED.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 46123 Based on policy review, record reviews, and staff interview the CAH failed to provide stabilizing medical treatment within its capabilities to 1 (P9) of 5 transferred patients. This failed practice has the potential to cause harm or even death to all ED patients treated at the CAH. According to facility provided information the ED transfers on average 19 patients per month. Findings include: A. Review of facility policy “EMTALA: Emergency Treatment and Transfer Policy”, effective date 8/1/2019 revealed, individuals with an emergency medical condition must be stabilized or, if the medical benefits exceed the risks, transferred to an appropriate alternative facility according to the prescribed processes. - Alternate facility must have special or additional resources and capabilities not available at this facility. - The provider (physician or non-physician certifying/ordering the transfer) will explain the risks and benefits of transfer to the individual. - The individual will be treated within the capabilities available to the emergency department prior to transfer to minimize, to the extent possible, the risks of transfer. - A physician will certify the need for transfer. - Qualified personnel, appropriate equipment and vehicle will be utilized to effect transfer. B. Review of ED-A’s medical record revealed, P9 presented to the ED on 8/20/24 at 7:25PM with a complaint of choking on some food and now is having trouble swallowing. P9 states that [gender] was eating a piece of pork tenderloin and felt like it got stuck in [gender] throat. Attempted to drink water but was unable to swallow water. Now feels like it is stuck mid chest. Admits to having pain/difficulty breathing and is not able to swallow much saliva. Patient has been constantly spitting up saliva and phlegm. Inspiratory stridor (a sound made when breathing in that indicates a partial obstruction in the upper airway.) noted on physical exam by Physician Assistant D (PA-D). PA-D ordered a cat scan of chest high resolution without contrast (imaging test that uses a higher dose of x-rays to produce detailed images of the lungs) and Toradol 30mg (pain medication) intramuscular (IM) for pain control. CT report revealed a dilated fluid-filled esophagus with concern for possible impacted food bolus in the mid esophagus and they are recommending endoscopy to further evaluate (the tube that goes from mouth to stomach is filled with liquid and a suspicion that a piece of food is stuck in the middle section that could be blocking the tube). P9 did admit to feeling a little better after the Toradol. P9 thought [gender] might have coughed it up. Attempted to give P9 some fluids but P9 was still unable to swallow them. PA-D consulted with surgeon MD-E regarding P9. The MD-E felt P9 needed to present to the ED at Acute Care Facility-D (ACF-D) as soon as possible. MD-E stated he is okay with the P9 driving themselves, noting stable vital signs. MD-E did advise that P9 not stop prior to coming. MD-E wanted alerted to when the patient would be 30 minutes out and he would meet P9 in the ED at ACF-D. The patient transfer form was completed. The patient condition is marked as the patient may be at risk for deterioration from or during transport. The mode of transport is marked as private vehicle. P9 signed consent to transfer and refusal of ambulance transport. On P9’s discharge instructions included statement: It is imperative that you go to the ED at [name of ACF-D]. Do not stop along the way. If there are any concerns during your drive continue towards the hospital and call 911. The medical records lack documentation to attempt to treat the food bolus in the ED. Glucagon available and noted during ED tour. C. Review of ED-A’s medical record revealed, P18C presented to ED-A 10/10/24 at 6:18AM via EMS after going unresponsive at NF-A and having CPR (cardiopulmonary resuscitation) initiated prior to 911 call. Upon arrival to the ED P18C was in ROSC (return of spontaneous circulation). P18C was evaluated by NP-B and decision to transfer was made. NP-B completed the patient transfer form indicating that P20 may be at risk of deterioration from or during transport. NP-B had a physician backup of MD-F. D. During an interview on 11/20/24 at 10:40AM, MD-C revealed that P9 did have an EMC on dismissal/transfer to ACF-D. MD-C did agree that the medical record lacked documentation of if pharmacological intervention was discussed or if it should be attempted prior to transfer. E. During an interview on 11/20/24 at 12:40PM, MD-F revealed that NP-B did not notify her of the code or transfer of P18C that morning.”

“42 CFR 482.41 The facility must meet the applicable provisions of the 2012 Edition of the Life Safety Code of the National Fire Protection Association. This facility is governed by Chapter 19, “Existing Health Care Occupancies” of the 2012 Edition of the National Fire Protection Association [NFPA], Chapter 101: Life Safety Code. Providence Medical Center received construction approval in 1975. The construction is classified as Type II (000) and includes one stories and a basement. Patients occupy the first floor only. There is a two hour fire/smoke barrier on the main level separating the Physical Therapy / Clinic area from the Health Care occupancy. The building is fully fire sprinkler protected and includes a fire alarm system with smoke detection in all corridors and spaces open to the corridors. The facility has a capacity of 21 and a census of 6 at the time of the survey. Providence Medical Center was found to be not in compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 482.41 Life Safety from Fire, and the related National Fire Protection Association (NFPA) Standard 101 - 2012 edition.”

“Hazardous Areas - Enclosure CFR(s): NFPA 101 Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322) This Standard is not met as evidenced by: 41670 Based on observation and staff interview, the facility failed to provide smoke resistant enclosures for hazardous areas to separate them from the rest of the facility. This deficient practice would allow fire, smoke and gases to migrate into the exit corridors. Facility census was 6 and licensed for 21 at the time of the survey. Finding are: Observation and staff interview on 8-6-2024 at 10:45 AM, 11:45 AM and 12:00 PM revealed the following: 1. Open conduit penetrations were found in the 1-hour fire wall located inside of Electrical Room B123. 2. Open conduit penetrations were found in the 1-hour fire wall located inside of Electrical Room A135. 3. Open conduit penetrations were found in the 1-hour fire wall located inside of Electrical Room A260. During interview on 8-6-2024 at 12:00 PM, Maintenance Staff A confirmed the open fire wall penetrations.”

“Corridor - Doors CFR(s): NFPA 101 Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc. This Standard is not met as evidenced by: 41670 Based on observation and staff interview, the facility failed to ensure that corridor doors would resist the passage of fire and smoke. This deficient practice would allow fire, smoke and gases to migrate into the adjoining exit corridors. Facility census was 6 and licensed for 21 at the time of the survey. Finding are: Observation and staff interview on 8-6-2024 at 11:15 AM revealed the following: 90-minute fire rated cross corridor door located nearest to room B131 failed to seal and latch when in the closed position. During interview on 8-6-2024 at 11:15 AM, Maintenance Staff A confirmed the fire door failed to seal and latch.”

“Maintenance, Inspection & Testing - Doors CFR(s): Maintenance, Inspection & Testing - Doors Fire doors assemblies are inspected and tested annually in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Non-rated doors, including corridor doors to patient rooms and smoke barrier doors, are routinely inspected as part of the facility maintenance program. Individuals performing the door inspections and testing possess knowledge, training or experience that demonstrates ability. Written records of inspection and testing are maintained and are available for review. 19.7.6, 8.3.3.1 (LSC) 5.2, 5.2.3 (2010 NFPA 80) This Standard is not met as evidenced by: 41670 Based on record review and staff interview, the facility failed to ensure that fire rated doors are inspected and tested annually. This deficient practice would allow fire smoke and gases to migrate outside of the effected space. Facility census was 6 and licensed for 21 at the time of the survey. Finding are: Observation and staff interview on 8-6-2024 at 10:30 AM revealed the following: Record review found that fire doors were not being inspected or tested annually. During interview on 8-6-2024 at 10:30 AM, Maintenance Staff A confirmed fire door inspections were not being performed.”