Eastern New Mexico 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: 51995 Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) to ensure stabilizing treatment was provided to patients that present to the Emergency Department. This deficient practice is likely to lead to poor outcomes related to patients not receiving adequate ongoing monitoring when seeking medical care. The findings are: A. The facility failed to provide ongoing monitoring and stabilizing treatment prior to transferring the patient to an outside facility. Refer to tag A-2407.”

“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: 51995 Based on interview and record review, the facility failed to provide ongoing monitoring and stabilizing treatment after completing a medical screening examination and prior to transferring 1 (P[ patient] 1) of 20 (P1-P20) patients reviewed for compliance with all Emergency Medical Treatment and Labor Act (EMTALA) requirements. This deficient practice could possibly result in patients not receiving adequate ongoing monitoring of the emergency conditions identified prior to an appropriate transfer, which could result in emergency condition progression without stabilizing interventions. The findings are: A. Record review of the facility’s Policy “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy,” version 6, published 07/14/2022, under definitions, “Stable for transfer: A patient is stable for transfer if the treating physician has determined, within reasonable clinical confidence, that the patient is expected to leave the hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes that the receiving facility has the capability to manage the patient’s medical condition and any reasonable foreseeable complications of that condition.” Under “III. Stabilizing treatment” reads “If it is determined through an MSE [Medical Screening Examination] that an EMC [Emergency Medical Condition] exists . . . ED (Emergency Department) personnel shall: (1) provide such further medical examination and treatment as may be required to stabilize the medical condition. . . within the capabilities of the staff and facilities available at the hospital or (2) transfer the individual to another appropriate facility that can meet the patient’s needs, in accordance with the transfer procedures contained in this policy.” Under IV. Transfer of Individuals under “B. Transfer procedures” stated “1. Stabilizing medical treatment: the hospital shall provide stabilizing medical treatment within its capacity to minimize the risk of transfer to the individual’s health.” B. Record review of P1’s medical record titled “ED Physician note” dated 12/14/2024 at 4:53 AM, revealed P1 arrived with family at the facility’s emergency department on 12/12/2024 at 3:08 AM with a chief complaint of continued new onset blindness to the left eye and meeting sepsis (infection) criteria. P1’s medical screening examination (MSE) was performed on 12/12/2024 at 3:13 AM. Screening included new imaging and labs, including blood cultures. Treatments were provided to P1, including a 1.6 Liter Normal Saline bolus (a mixture of salt and water placed into a vein, commonly given when patients meet infection criteria) performed at 4:02 AM, 1000 mg (milligrams) of ceftriaxone (a broad-spectrum antibiotic to help kill bacterial infections) administered intravenous push (by vein) at 9:43 AM, and 50 mg of diphenhydramine (commonly called Benadryl - indication not specified) intravenous push at 12:51 PM. C. Record review of P1’s medical record titled “Vital Signs” (Vital signs measure the body’s most essential functions including heart rate, body temperature, respiratory rate, blood pressure, and oxygen saturation.) revealed abnormal vitals upon triage on 12/12/2024 at 3:24 AM including heart rate (how fast the heart is pumping, noted in beats per minute) at 141 beats per minute (too fast, normal is 60-100); Respiratory rate (breathing rate, noted in breaths per minute) as 22 breaths per minute (too fast, normal is 12-20). Continued inspection of section titled “Vital Signs” revealed there were no vital signs recorded from 6:15 AM through 4:37 PM. The last full set of vital signs was performed at 5:57 PM. There were no vitals documented for P1 at discharge. Additionally, there was no documentation informing the physician about abnormal vital signs. D. Record review of P1’s medical record, dated 12/12/2024 section titled “Respiratory” under Oxygen therapy and oxygenation, revealed that P1 required no oxygen assistance upon arrival at 3:24 AM. P1 was placed on 2 liters of oxygen per minute by nasal cannula to maintain safe blood oxygen levels on 12/12/2024 at 3:43 AM. No oxygenation or oxygen therapy recordings were charted between 6:15 AM through 4:37 PM, despite requiring oxygen assistance to keep blood oxygen levels above 90%. E. Record reviews of P1’s medical record from 12/12/2024 revealed the only nursing assessment documented was performed during triage at 3:24 AM. It was noted that S(staff) 10, clinical gave a report to the transportation team, but does not note the specifics of what was reported. F. Record review of P1’s medical record revealed a transfer to an accepting facility was initiated on 12/12/2024 at 9:36 AM. Transfer via fixed wing airplane occurred on 12/12/2024 at 8:35 PM. G. During an interview on 03/19/2025 at 11:50 AM with S(Staff) 1, non-clinical, S1 stated P1 required adult life support measures (chest compressions, breathing tube placement, and other lifesaving measures) in transit to the accepting facility and expired on 12/13/2024. H. During an interview on 03/18/2025 at 11:50 AM with S1, nonclinical, S1 stated there is currently no policy or procedure for staff to reference regarding frequency of monitoring patients in the Emergency Department. I. During an interview on 03/19/2025 at 4:21 PM with S10, clinical who was familiar with P1’s baseline status, stated upon transfer to the accepting facility, P1 appeared ill, not vitally stable, and not alert. S10 could not recall charting vitals nor direct communication with provider prior to transferring P1 to the accepting facility. J. During an interview on 03/19/2025 at 4:50 PM with S9, clinical, S9 stated the expectation was for staff to report heart rates outside of normal parameters of 60-100 beats per minute to the emergency department physician. S9 could not recall the specific clinical presentation of P1 upon transfer to accepting facility.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 47302 Based on record review and interview the facility failed to ensure that patient’s on high alert medications (medications that may have an increased risk of causing significant patient harm) were monitored according to established procedures for 1 (P[patient]1) of 10 (P1-P10) patients reviewed for seeking acute care at the hospital. This deficient practice could likely lead to patients suffering adverse outcomes that can include but are not limited to: tissue damage, irregular heartbeat, allergic reactions, chest pain. The findings are: A. Record review of the facility’s policy titled, “High Alert Medication Policy” dated 11/16/2021 revealed the purpose of the policy was, “To designate ‘high alert’ medications at [facility name] and provide standardized drug safety procedures for these ‘high alert’ medications to enhance their safe use.” The policy defines high alert medications as. “medications that may have an increased risk of causing significant patient harm when they are used incorrectly.” Under “Policy” it is stated, “d. The medication process shall also include verification of appropriate indication, appropriate lab values, calculations, and pump settings as well as the review of potential contraindications, medication administration record verification, calculations of preparation, and visualization of the medication in the form it is delivered.” Under “Procedure:. . .b. Independent Verification” it is stated, “i. Certain high alert medications require additional verification safeguard checks during either or both the medication or medication administration processes. . .” This policy included an attachment - high alert medication list and this list included norepinephrine (medication used to increase blood pressure in critically ill patients). B. Record review of the facility’s “Standard drip preparation guidelines” for norepinephrine (medication given for severely low blood pressure) under “Patient Monitoring” it stated, “Cardiac Monitoring of HR [heart rate], and BP [blood pressure]. . .” C. Record of P1’s medical record for ICU admission date 03/14/2024 revealed the following: 1. Under “Provider Order Summary” on 03/14/2024 at 5:29 AM a norepinephrine drip was ordered with the following instructions: “Goal: (SBP [systolic blood pressure - pressure of heart beating] or MAP [mean arterial pressure - measurement of the bodies ability to supply organs with blood flow] (or both). . . Maintain SBP between 90-100 mmHg [millimeters of Mercury, method of measurement] Maintain MAP between 65-75 mmHg” 2. Review of nurse’s notes for date 03/14/2024 revealed that the norepinephrine drip was last adjusted on 03/14/2024 at 4:10 PM with a blood pressure recording of 77/66 (low blood pressure indicating patient had continued need for norepinephrine and would warrant follow-up based on adjustment to medication). 3. Review of blood pressures recorded in patient’s chart for 03/14/2024 revealed staff did not monitor blood pressure from 4:10 PM until 7:15 PM. D. During an interview on 05/29/2024 at 4:45 PM with S(Staff)9, RN (Registered Nurse), S9 explained that vital signs (clinical measurements like pulse and blood pressure) are monitored every 15 minutes while a patient is on norepinephrine. E. During an interview on 05/29/2024 at 4:50 PM with S3, RN, S3 confirmed that vital signs are monitored every 15 minutes while a patient is on norepinephrine. S3 also explained that this has been passed down verbally, it is not written anywhere for reference.”

“PATIENT RIGHTS: GRIEVANCES CFR(s): 482.13(a)(2) The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. This Standard is not met as evidenced by: 47480 Based on record review, observation, and interview, the facility failed to inform all patients in the [Name of Unit] the name and telephone numbers for whom to contact to file a grievance. This deficient practice will likely prevent all patients from exercising their right to file a grievance The findings are: A. Record review of facility’s policy title “Complaints Grievance Policy” “Category: Patient Safety” “Revision Date: 04/13/2023”: “The patient/patient representative shall be informed of whom to contact to file a complaint/grievance. This may be done a variety of mechanisms [sic]: Patient Information Guide; Admission Packet ....” B. Record review of facility’s policy title “Patient Rights” “[Name of Unit] Mental Health Program” “04/16”. “You have the right to be informed of the name and telephone number of the patient advocate. Contact the patient advocate to file a formal complaint any time you think your patient rights have been violated. The patient advocate for [Name of Unit] is either the Unit Director [telephone number] or the Unit Social Worker [telephone number].” (Area code provided by Staff (S)6 Unit Director of Behavioral Health). C. During an observation on 11/28/2023 at 10:47 am, surveyor called phone number for Unit Director and the call went directly to voicemail without a message greeting. Surveyor called phone number for social worker and the call rang at the nurse station. Call was answered at nurse’s station and call was transferred to unknown extension that went directly to voicemail without a message greeting. There was no indication that either phone number was to the patient advocate to file a grievance. D. During interview on 11/28/2023 at 1:20 pm with Patient (P)11, when asked if someone has gone over the grievance process or explained how the patient can file a complaint, P11 stated “No...” E. During interview on 11/28/2023 at 1:50 pm with S (Staff) 6 Unit Director of Behavioral Health, S6 confirmed the phone numbers for their office is incorrect. S6 confirmed the phone number for the Unit Social Worker does not have a voice message”