Capital Health Regional Medical Center

“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: 48965 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure patients are monitored by nurses in the Emergency Department (ED) according to facility policy. (Patient (P)1). Findings include: Facility policy titled, “Documentation in the Emergency Department: Guidelines,” last revised January 2023, states, “ ...V. Procedure: A ...3. The nursing documentation will include an initial set of vital signs, reassessment of the vital signs and patient condition as per patient acuity, and a final set of vital signs within one hour of discharge ...C. Reassessments (including a complete set of vital signs) shall be performed as often as is required by the patient’s condition, but at least every two hours with the findings documented. On 3/11/2025 at 10:04 AM, P1’s medical record was reviewed with Staff (S) 2, Director of ED Services. The medical record revealed the following: On 2/27/25 at 8:52 AM, P1 presented alone to the ED with a chief complaint of “sore on chest.” At 8:57 AM, P1 had an initial assessment completed by the triage nurse. Vital signs were taken at this time. At 9:58 AM, S19, P1’s primary nurse, performed a reassessment. At 12:00 PM, P1’s vital signs were taken. At 12:25 PM, P1’s vital signs were taken. At 1:23 PM, P1 left against medical advice (AMA). On 3/11/25 at 1:34 PM, when asked how frequently neurological assessments must be completed on patients, S2 reported that all patients should be assessed every 2 hours. According to S2, since both the nurse and doctor were working the substance use route for P1, more frequent assessments were not indicated. S2 confirmed there were no nursing reassessments for P1 after 9:58 AM. S2 confirmed that reassessments should have been completed every 2 hours until an admission or transfer order was placed. Then the assessments would be completed based on the level of care ordered (such as Intensive Care Unit (ICU) or telemetry). S2 also confirmed that P1’s vital signs were not taken every 2 hours as the policy dictates.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 48965 Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to maintain accurate medical records, in two of 20 medical records reviewed (Patients (P) 1 and P6). Findings include: Facility policy for Medical Staff Services titled, “Medical Record Documentation,” last revised December 2024, states, “ ...IV. Policy ...4. Medical Record Entries ...b. All medical record entries are to be promptly completed, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided ...” On 3/11/2025 at 10:04 AM, P1’s medical record was reviewed with Staff (S) 2, Director of Emergency Department (ED) Services. The medical record revealed the following: On 2/27/25 at 9:09 AM, P1 was seen by S18, ED Provider. The ED physician note was electronically signed by S18 on 3/4/25 at 8:11AM. On 3/11/25 at 11:16 AM, an interview was conducted with S18. S18 was shown the nursing note which indicated that P1 had a change in mental status, and asked S18 to clarify if his/her own note reassessed P1’s neurological status. According to S18, his/her note states P1 was stable for discharge. When asked what time this assessment was completed, S18 stated that his/her note is a rolling note, and there is an internal timestamp in the electronic medical record (EMR). S18 stated the Informatics team could get the timestamps of his/her documentation. At the conclusion of the interview with S18, S2 was asked to retrieve timestamps for each entry in S18’s ED physician note in P1’s medical record. He/she contacted the Informatics team to determine if this information could be obtained. On 3/11/25 at 1:45 PM, S2 reported that the video recordings from the Electronic Medical Record (EMR) that could reveal documentation timestamps could only be done within 7 days of charting. S2 explained they were out of the window for timestamp retrieval for this medical record, including the ED physician note by S18. 51555 On 3/11/2025 at 1:00PM, P6’s medical record was reviewed and revealed the following: On 11/3/2024 at 7:59 AM, an ED Physician note completed by S18 states, “ ... Reexamination/Reevaluation: [P22’s name] 21 Years F [female] DOB [Date of Birth]: 04/02/2003...” The name, age, and DOB documented in P6’s medical record belonged to P22. On 3/11/2025 at 1:10 PM, when asked why P22’s name, age, and DOB was documented in P6’s medical record, S1, ED Nurse Manager, stated, “I am not sure. That should not be in this chart, that is very strange.””

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 33556 Based on observation and staff interview, it was determined the facility failed to ensure a defect-free environment is maintained for patients, staff, and the general public. Findings include: During a building tour conducted at 11:00 AM on 3/11/25, with Staff (S)17, Facility Manager, the following were noted: Two (2) open windows in the emergency department waiting room did not have insect screens. The lack of window screens would allow for the intrusion of insects and/or vermin into the building. The delayed egress lock mechanism on the ambulance bay doors was broken, permitting unsupervised entering and exiting to and from the emergency department treatment area. The above was confirmed by S17 upon discovery.”

“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: 38289 Based on medical record review, staff interview and review of facility documents, it was determined that the facility was not in compliance with §489.24 by 1.) failure to provide stabilizing treatment for a patient who presented to the emergency department (ED) with an emergency medical condition (EMC) (Refer to A2407); 2.) failure to ensure that all patients seeking medical treatment receive a Medical Screening Exam (MSE) (Refer to A2406). Cross Reference: 489.24(d)-Necessary Stabilizing Treatment for Emergency Medical Conditions 489.24 (a)(1)(i) - Medical Screening Exam”

“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: 38289 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to ensure a patient presenting to the emergency department (ED) for an emergency medical condition, was provided with a medical screening exam (MSE) appropriate to his/her presenting condition prior to leaving the emergency department, in one of 21 medical records reviewed (Patient (P) 1). Findings include: Facility policy titled, “Triage Policy,” effective May 2024, states, “... The purpose of ED triage is to prioritize patient care in standardized, safe, comprehensive, and efficient method ... Level 2 patients are defined as patients with life, limb, or sight threatening illness which, if not treated immediately, may result in permanent functional loss or mortality; patients with new onset confusion, disorientation or lethargy; patients in severe pain or distress, or patients with a high risk situation ...” Facility policy titled, “Emergency Department - RMC,” effective May 2024, states, “... The ED provides emergency care and stabilization to those patients presenting with acute illness or injury ... The ED fosters a coordinated and collaborative relationship between all disciplines caring for the patient in order to achieve the best possible outcomes that meet our patients and family’s needs to their satisfaction ... ED Discharge ... Discharge from the ED occurs: -After stabilization and treatment and if it is determined that an emergency medical condition does not exist. -After stabilization, treatment and referral to an appropriate health care facility or provider ...”. Facility policy titled, “Emergency Care,” effective September 2022, states, “ ... [name of facility] provides an appropriate Medical Screening Examination and stabilizing treatment within its capacity to all individuals who present to its Dedicated Emergency Departments (“DEDs”) and request examination or treatment of an Emergency Medical Condition ... A Medical Screening Examination is an examination conducted by a Qualified Medical Person that is sufficient to determine. with reasonable clinical confidence, whether an Emergency Medical Condition Exists ... 3. Documentation The Qualified Medical Person performing the Medical Screening Examination records in the medical record: ... c. Continued monitoring according to the individual’s needs until it is determined whether the patient has an Emergency Medical Condition and, if they do, until they are stabilized or appropriately transferred; and, d. If the patient is determined to be stable, a notation certifying this, with additional evaluation prior to discharge ... E. Stabilization of Patients ... 3. With respect to discharge, ‘stabilized’ means that the Emergency Medical Condition has been resolved, and the treating physician has determined, within reasonable clinical confidence, that the individual has reached the point where their continued care, including diagnostic work-up or treatment, could be reasonably performed as an outpatient or later as an outpatient ...” P1 presented to the facility ED with local police on 5/21/24 at 1:39 PM for a crisis evaluation. P1 was triaged, by Staff (S) 15, a Triage Nurse, at 2:15 PM, with an ESI (Emergency Severity Index) level 2 - emergent, noting the chief complaint as “Brought in by [name of police department] from [name of outpatient behavioral health (BH) facility] for assaulting another patient at [name of outpatient BH facility] at random. Pt [patient] only states, ‘I’m tired.’ Pt not answering this RN’s [registered nurse] questions for triage.” Additional triage documentation, by S15, stated “Diagnoses (Active) Crisis Evaluation ... Is the patient able to answer BH Concerns questions appropriately: No ...” A note, written by S15 at 2:20 PM, stated, “[name of police department] were called to [name of outpatient BH facility] due to an assault on another patient. Per PD [police department] patient was walking at [name of outpatient BH facility] and randomly attacked another patient ‘unprovoked’ ... When attempting to locate a proper room for patient ... patient seen by this RN pacing the hall ... Pt turned around and assaulted the patient in chair 140 ... Pt placed into room 113 in order to restrain patient and ensue [sic] safety in the ED ... Security placed patient in four point restraints at this time ...” A note written by S16, an ED Physician, at 2:03 PM, stated, “... History of present illness ... Patient denies any complaints at this time ... the patient subsequently punched another patient in the ER [emergency room]. Pt declines to say why at this time ... Physical exam ... Psychiatric: [cooperative], [flat affect] ... Reexamination/Reevaluation 05/21/2024 15:01:00 [3:01 PM] ... Patient’s [sic] does not need to see crisis at this time, not suicidal and denies any homicidal ideation. Will discharge from the ER. Assessment/Plan 1. Encounter for general adult medical examination without abnormal findings Patient education Health Maintenance, Male Follow Up with [local health center] ... additional instructions: [blank] ...” P1 was discharged on 5/21/24 at 3:37 PM. S15’s discharge note written at 3:45 PM, stated, “...Discharge to Care of: Self ... Home Caregiver Present: No ... Discharge comments: Pt provided d/c [discharge] instructions by Charge RN. Pt removed from restraints and escorted out of ED by security for safety reasons ...” S15 noted an addendum at 3:44 PM, that stated,”... Pt escorted out of ED with security due to patient’s history of unprovoked violent behavior ...” A late entry nursing note written by S17, the ED Charge RN, on 5/22/24 at 11:28 AM, stated, “... Nursing supervisor and nursing manger got in touch with our legal department to ensure proper release of this patient. The patient was discharged and escorted off property by security to ensure staff and patient safety ...” P1’s medical record lacked reference to the patient’s history of anxiety and depression, and medications including fluoxetine and zyprexa, as documented during P1’s previous visit to the facility’s ED on 5/21/24 at 8:29 AM visit 2. P1’s medical record lacked evidence of further evaluation being conducted prior to his/her discharge. P1’s discharge instructions lacked evidence of instructions to follow-up with an outpatient behavioral health facility. The medical record lacked evidence that P1 was stable for discharge. The above findings were shared with S18, an ED Physician on 6/7/24 at 10:18 AM. S18 stated that S17, as an ED physician, would have been qualified to treat BH concerns. S18 confirmed that a full BH assessment had not been completed in light of the presenting complaint to the ED. S18 confirmed that the medical record lacked documentation of the determination that P1 did not need a crisis evaluation. When asked for the algorithm an ED physician uses when determining which patients should be screened by a crisis screener, S18 stated that there is no algorithm, the determination is decided by the ED physician. S16 was not available for interview during the time of the survey. An interview with S12, BH Screener, was conducted on 6/7/24 at 11:10 AM. S12 was asked how screeners determine a safe discharge for a patient who is in crisis. S12 stated that there would be an assessment of whether the patient was at risk for harm to self or others, and whether it was related to a pattern of chronic personal mental illness or if the patient was at risk of decompensation and could not be stabilized as an outpatient. S12 stated that for discharge there would be a safety plan with the patient to determine what is helpful versus what may trigger the patient. S12 stated that outpatient BH resources would be provided. S12 stated, that his/her department has a good relationship with local BH organizations and that upon discharge an appointment would be established for the patient for the organization that would get them in quickly. On 6/7/24 at 2:38 PM, the above findings were shared with S5, the Associate Chief Nursing Officer, S6, the Manager of Regulatory, S7, the Director of Regulatory, S8, the Staff Attorney, and S19, the Chief Legal Counsel. When asked what the process was in determining the proper release of P1 from the ED, S8, and S19 were unable to provide information regarding the determination of the proper release of the patient. S5, S6, and S7 validated the concerns of a safe discharge and the lack of stabilization of an emergency medical condition prior to discharge for P1. A review of a random sample of five additional medical records of patients seen in the ED for a crisis evaluation was completed (P6, P7, P8, P10, and P20). Five of five patients received a crisis evaluation by a psychiatric screener prior to being discharged from the ED.”

“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: 38289 Based on medical record review, staff interview, and review of facility documents, it was determined that the facility failed to provide treatment to stabilize a patient that presented to the emergency department with suicidal ideation in one of 21 medical records reviewed (Patient (P) 1). Findings include: On 5/21/24 at 11:56 PM, P1 presented to the facility Emergency Department (ED) with local police requesting a crisis evaluation and psychiatric clearance for incarceration, after allegedly stabbing [family member] on that same day. ED provider evaluated the patient and documented on 5/22/24 at 12:29 AM, that P1 refused to talk or interact with the ED provider. On 5/22/24 at 1:27 AM, the Behavioral Health (BH) Screener documented that P1 consulted with psychiatry for an evaluation of suicidal thoughts. The BH screener documented, “...eye contact was inconsistent ... When asked if [patient] has been having suicidal thoughts, patient stated that ‘I’ve been thinking about it.’ ... Patient does endorsed [sic] visual hallucinations of ‘shadows’ ... Patient report [sic] history of inpatient psychiatric hospitalization and suicide attempt in the past ... patient does show risk of violence and risk of harm to others ... Wuld [sic] recommend to discharge patient to custody of police ... Patient is very guarded. Patient with poor insight, patient with poor ability to adhere to treatment plan ...” P1 was diagnosed with adjustment disorder and conduct disorder, aggressive type, moderate and was provided discharge instructions for the diagnosis of adult adjustment disorder. P1 was discharged to police custody on 5/22/24 at 1:38 AM. The medical record lacked evidence of interventions provided to P1 to address his/her emergency medical condition. On 6/7/24 at 10:18 AM, an interview was conducted with S18, an ED physician. S18 stated that the BH provider would determine if acute care was needed or if outpatient treatment could be completed when in jail. When asked if other treatments were needed for P1 or what was done for P1 prior to the release of the patient to police custody, S18 confirmed that the medical record lacked documented evidence of interventions, and stated, “ I understand your concerns. We are reviewing it from that standpoint.” Facility policy titled, “Emergency Department - RMC,” effective May 2024, states, “... The ED provides emergency care and stabilization to those patients presenting with acute illness or injury ... The ED fosters a coordinated and collaborative relationship between all disciplines caring for the patient in order to achieve the best possible outcomes that meet our patients and family’s needs to their satisfaction ... ED Discharge ... Discharge from the ED occurs: -After stabilization and treatment and if it is determined that an emergency medical condition does not exist. -After stabilization, treatment and referral to an appropriate health care facility or provider ...” Facility policy titled, “Emergency Care,” effective September 2022, states, “ ... [name of facility] provides an appropriate Medical Screening Examination and stabilizing treatment within its capacity to all individuals who present to its Dedicated Emergency Departments (“DEDs”) and request examination or treatment of an Emergency Medical Condition ... A Medical Screening Examination is an examination conducted by a Qualified Medical Person that is sufficient to determine, with reasonable clinical confidence, whether an Emergency Medical Condition Exists ... 3. Documentation The Qualified Medical Person performing the Medical Screening Examination records in the medical record: ... c. Continued monitoring according to the individual’s needs until it is determined whether the patient has an Emergency Medical Condition and, if they do, until they are stabilized or appropriately transferred; and, d. If the patient is determined to be stable, a notation certifying this, with additional evaluation prior to discharge ... E. Stabilization of Patients ... 3. With respect to discharge, ‘stabilized’ means that the Emergency Medical Condition has been resolved, and the treating physician has determined, within reasonable clinical confidence, that the individual has reached the point where their continued care, including diagnostic work-up or treatment, could be reasonably performed as an outpatient or later as an outpatient ...””