Children’s Nebraska

“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: 48575 Based on policy and procedure review, emergency room log review, patient interview and staff interviews, the facility failed to ensure 3 policies were followed for 1 (Patient 1) out of 20 emergency department (ED) sampled patients who presented to the ED with a chief complaint of chest pain. This failed practice has the potential to cause a delay in care and treatment to any patient who presents to the facility ED with an EMC. The facility ED sees an average of 3,592 patients per month for the past 6 months. See citations A2405, A2406, A2407 and A2409 that also resulted in A2400 to be not 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: 48575 Based on policy and procedure review, dedicated emergency department (DED)-A central log review, patient interview and staff interviews, the facility failed to ensure 1 (Patient 1) of 20 sampled emergency department (ED) patients were placed on the central ED log and whether treatment was refused or stabilized and transferred on 12/2/2025. This failed practice has the potential to cause a delay in emergent care and treatment to any patient who presents to the facility ED with an emergency medical condition (EMC). The facility ED sees an average of 3,592 patients per month for the past 6 months. See citations A2400, A2406, A2407 and A2409 that also resulted in A2405 to be not met. Findings Include: A. Review of facility policy, Unidentified Patients Policy, last approved 2/21/2023 revealed in the event a patient arrives at the ED and is unable to be identified will be registered by first name as letter of the alphabet, and last name gender. Once identified the patient will continue to have the same patient identification number and changed to the legal name. Review of facility policy, Medical Retention and Destruction Schedule Policy, last approved 5/14/2025 revealed the ED log retention period is 22 years. B. Review of the facility dedicated emergency department (DED-A) central log from December 2, 2025, revealed Patient 1 was not entered on the ED log. A dedicated ED is defined as providing emergency care to the public. C. During an interview on 2/5/2026 at 1:53PM, Patient 1 revealed they drove to a hospital they thought was DED-B, saw the red sign and pulled in. Patient 1 stated, “I walked in, said I was having bad chest pain and not feeling well at the ED front desk.” The person sitting at the desk asked Patient 1 if they knew they were at DED-A, and Patient 1 replied no. The person at the desk asked Patient 1 if they meant to go to DED-B, and Patient 1 replied yes. The person at the desk told Patient 1 it’s across the street. Patient 1 left the DED-A and checked into DED-B on 12/2/2025 around 9:30AM. Patient 1 revealed the person at the DED-A front desk did not ask their name. During an interview on 2/5/2026 at 10:15AM, Staff B revealed an adult who presents to the DED-A is registered on the board (ED log). Staff B revealed if the patient doesn’t give a name they’re registered as a doe. During an interview on 2/5/2026 at 11:06AM, Registered Nurse (RN)-A revealed they were the quick view nurse (QVN) assigned in the triage role on 12/2/2025 from 7:00AM until 11:00AM. RN-A revealed around 3 adults per week present to the DED-A.”

“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: 48575 Based on policy and procedure review, dedicated emergency department B (DED-B) medical record review, patient interview and staff interviews, the facility failed to ensure 1 (Patient 1) of 20 sampled emergency department (ED) patients were provided a medical screening exam (MSE) to rule out an emergency medical condition (EMC) for a patient who presented to the dedicated ED (DED-A) with a chief complaint of chest pain. This failed practice has the potential to cause a delay in emergent care and treatment to any patient who presents to the facility ED with an EMC. The facility ED sees an average of 3,592 patients per month, and 40 transfers per month for the past 6 months. See citations A2400, A2405, A2407 and A2409 that also resulted in A2406 to be not met. Findings Include: A. Review of facility policy, Medical Screening Exam, last approved 1/20/2025 revealed an MSE will be performed on any individual who presents to the ED or another area of the hospital and either requests emergency treatment or is in apparent need of emergency treatment. In the event the patient needs transferred from the ED to another facility, refer to the Transfer and Transport of Patient policy. Review of facility policy, Transfer or Transport of Patients, last approved 1/13/2026 revealed an EMC is defined as a medical condition with acute symptoms without immediate medical attention could result in placing the health of the individual in serious jeopardy. A dedicated ED is defined as providing emergency care to the public. Stabilized is defined as no deterioration of the medical condition is likely during transfer of the patient or the physician has determined the EMC has been resolved. Transfer is defined as relocation of an individual outside the hospital’s facility. B. Review of Patient 1’s medical record from DED-B revealed, P1 presented to DED-B on 12/2/2025 at 9:34AM with a chief complaint of chest pain that started 30 minutes prior while exercising at the gym. P1 was provided an MSE that revealed an EMC of an inferior STEMI (a serious, time-sensitive heart attack caused by a total blockage in the artery that supplies blood to the bottom portion of the heart) which required emergent heart catheterization (the doctor guides a thin tube through a blood vessel from the groin, neck or arm to the heart) with two stents (a mesh tube placed inside a narrowed or weakened artery to hold it open and improve blood flow) placed. P1 was admitted and remained inpatient until discharged on 12/4/2025 at 10:30AM. C. During an interview on 2/5/2026 at 10:15AM, Staff B revealed an adult who presents to the DED-A is registered on the board (ED log). Staff B revealed if the patient doesn’t give a name they’re registered as a doe. During an interview on 2/5/2026 at 11:06AM, Registered Nurse (RN)-A revealed they were the quick view nurse (QVN) assigned in the triage role on 12/2/2025 from 7:00AM until 11:00AM. RN-A revealed around 3 adults per week present to the DED-A. During an interview on 2/5/2026 at 1:53PM, Patient 1 revealed they drove to a hospital they thought was DED-B, saw the red sign and pulled in. Patient 1 stated, “I walked in, said I was having bad chest pain and not feeling well at the ED front desk.” The person sitting at the desk asked Patient 1 if they knew they were at DED-A, and Patient 1 replied no. The person at the desk asked Patient 1 if they meant to go to DED-B, and Patient 1 replied yes. The person at the desk told Patient 1 it’s across the street. Patient 1 left the DED-A and checked in to DED-B on 12/2/2025. Patient 1 revealed the person at the DED-A front desk did not ask their name.”

“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: 48575 Based on policy and procedure review, dedicated emergency department (DED)-A central log review, dedicated emergency department B (DED-B) medical record review, patient interview and staff interviews, the facility failed to ensure 1 (Patient 1) of 20 sampled emergency department (ED) patients were provided stabilizing treatment for a patient who presented to the dedicated ED (DED-A) with a chief complaint of chest pain emergency medical condition (EMC). This failed practice has the potential to cause a delay in emergent care and treatment to any patient who presents to the facility ED with an EMC. The facility ED sees an average of 3,592 patients per month, and 40 transfers per month for the past 6 months. See citations A2400, A2405, A2407 and A2409 that also resulted in A2406 to be not met. Findings Include: A. Review of facility policy, Medical Screening Exam, last approved 1/20/2025 revealed an MSE will be performed on any individual who presents to the ED or another area of the hospital and either requests emergency treatment or is in apparent need of emergency treatment. In the event the patient needs transferred from the ED to another facility, refer to the Transfer and Transport of Patient policy. Review of facility policy, Transfer or Transport of Patients, last approved 1/13/2026 revealed an EMC is defined as a medical condition with acute symptoms without immediate medical attention could result in placing the health of the individual in serious jeopardy. A dedicated ED is defined as providing emergency care to the public. Stabilized is defined as no deterioration of the medical condition is likely during transfer of the patient or the physician has determined the EMC has been resolved. Transfer is defined as relocation of an individual outside the hospital’s facility. B. Review of dedicated emergency department (DED)-A central log on 2/4/2026 lacked evidence of Patient 1 being registered, triaged or provided a medical screening exam to rule out an emergency medical condition on 12/2/2025 at approximately 9:00AM. C. Review of Patient 1’s medical record from DED-B revealed, P1 presented to DED-B on 12/2/2025 at 9:34AM with a chief complaint of chest pain that started 30 minutes prior while exercising at the gym. P1 was provided an MSE that revealed an EMC of an inferior STEMI (a serious, time-sensitive heart attack caused by a total blockage in the artery that supplies blood to the bottom portion of the heart) which required emergent heart catheterization (the doctor guides a thin tube through a blood vessel from the groin, neck or arm to the heart) with two stents (a mesh tube placed inside a narrowed or weakened artery to hold it open and improve blood flow) placed. P1 was admitted and remained inpatient until discharged on 12/4/2025 at 10:30AM. D. During an interview on 2/5/2026 at 1:53PM, Patient 1 revealed they drove to a hospital they thought was DED-B, saw the red sign and pulled in. Patient 1 stated, “I walked in, said I was having bad chest pain and not feeling well at the ED front desk.” The person sitting at the desk asked Patient 1 if they knew they were at DED-A, and Patient 1 replied no. The person at the desk asked Patient 1 if they meant to go to DED-B, and Patient 1 replied yes. The person at the desk told Patient 1 it’s across the street. Patient 1 left the DED-A and checked into DED-B on 12/2/2025 around 9:30AM. Patient 1 revealed the person at the DED-A front desk did not ask their name. During an interview on 2/5/2026 at 10:15AM, Staff B revealed an adult who presents to the DED-A is registered on the board (ED log). Staff B revealed if the patient doesn’t give a name they’re registered as a doe. During an interview on 2/5/2026 at 11:06AM, Registered Nurse (RN)-A revealed they were the quick view nurse (QVN) assigned in the triage role on 12/2/2025 from 7:00AM until 11:00AM. RN-A revealed around 3 adults per week present to the DED-A.”

“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: 48575 Based on policy and procedure review, dedicated emergency department (DED)-A central log review, dedicated emergency department B (DED-B) medical record review, patient interview and staff interviews, the facility failed to ensure 1 (Patient 1) of 20 sampled emergency department (ED) patients were provided an appropriate transfer for a patient who presented to the dedicated ED (DED-A) with a chief complaint of chest pain emergency medical condition (EMC). This failed practice has the potential to cause a delay in emergent care and treatment to any patient who presents to the facility ED with an EMC. The facility ED sees an average of 3,592 patients per month, and 40 transfers per month for the past 6 months. See citations A2400, A2405, A2406 and A2407 that also resulted in A2409 to be not met. Findings Include: A. Review of facility policy, Medical Screening Exam, last approved 1/20/2025 revealed an MSE will be performed on any individual who presents to the ED or another area of the hospital and either requests emergency treatment or is in apparent need of emergency treatment. In the event the patient needs transferred from the ED to another facility, refer to the Transfer and Transport of Patient policy. Review of facility policy, Transfer or Transport of Patients, last approved 1/13/2026 revealed an EMC is defined as a medical condition with acute symptoms without immediate medical attention could result in placing the health of the individual in serious jeopardy. A dedicated ED is defined as providing emergency care to the public. Stabilized is defined as no deterioration of the medical condition is likely during transfer of the patient or the physician has determined the EMC has been resolved. Transfer is defined as relocation of an individual outside the hospital’s facility. B. Review of dedicated emergency department (DED)-A central log on 2/4/2026 lacked evidence of Patient 1 being registered, triaged or provided a medical screening exam to rule out an emergency medical condition on 12/2/2025 at approximately 9:00AM. C. Review of Patient 1’s medical record from DED-B revealed, P1 presented to DED-B on 12/2/2025 at 9:34AM with a chief complaint of chest pain that started 30 minutes prior while exercising at the gym. P1 was provided an MSE that revealed an EMC of an inferior STEMI (a serious, time-sensitive heart attack caused by a total blockage in the artery that supplies blood to the bottom portion of the heart) which required emergent heart catheterization (the doctor guides a thin tube through a blood vessel from the groin, neck or arm to the heart) with two stents (a mesh tube placed inside a narrowed or weakened artery to hold it open and improve blood flow) placed. P1 was admitted and remained inpatient until discharged on 12/4/2025 at 10:30AM. D. During an interview on 2/5/2026 at 1:53PM, Patient 1 revealed they drove to a hospital they thought was DED-B, saw the red sign and pulled in. Patient 1 stated, “I walked in, said I was having bad chest pain and not feeling well at the ED front desk.” The person sitting at the desk asked Patient 1 if they knew they were at DED-A, and Patient 1 replied no. The person at the desk asked Patient 1 if they meant to go to DED-B, and Patient 1 replied yes. The person at the desk told Patient 1 it’s across the street. Patient 1 left the DED-A and checked into DED-B on 12/2/2025 around 9:30AM. Patient 1 revealed the person at the DED-A front desk did not ask their name. During an interview on 2/5/2026 at 10:15AM, Staff B revealed an adult who presents to the DED-A is registered on the board (ED log). Staff B revealed if the patient doesn’t give a name they’re registered as a doe. During an interview on 2/5/2026 at 11:06AM, Registered Nurse (RN)-A revealed they were the quick view nurse (QVN) assigned in the triage role on 12/2/2025 from 7:00AM until 11:00AM. RN-A revealed around 3 adults per week present to the DED-A.”