Memorial 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: 49835 Based on record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) to ensure a medical screening exam was done all patients that present to the Emergency Department. This deficient practice is likely to lead to poor outcomes related to patients not being evaluated when seeking medical care. The findings are: A. The facility failed to perform a medical screening exam. Refer to tag A-2406.”

“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: 49835 Based on record review and interview the facility failed to provide a medical screening examination that ensured an emergency medical condition was not present for 1 (P (patient) 3 out of 20 (P1-P20) patients reviewed. This deficient practice could likely result in patients not receiving medical treatment for an emergency medical condition. The findings are: A. Record review of the Emergency Room Activity log , for dates 09/01/2024 through 04/28/2025, P3 came to the Emergency Room (ER) on 09/03/2024 at 7:36am via Emergency Medical Service (EMS) with nausea (feeling of vomiting) and vomiting, for 4 days since P3 has had no alcohol. P3 had vomited blood once. B. Record review of P3’s provider note under historical section, dated 09/03/2024 at 7:38 am the provider documented that P3 has a history of hypertension (the pressure in your blood vessels is too high), diabetes (when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces), dependency of alcohol with daily use and gastroesophageal reflux (when stomach acid flows back up into the esophagus and causes heartburn). Under immunization history it revealed P3’s last tetanus immunization status unknown. 1. Under exam it revealed the provider ordered blood to be drawn for testing, NT-proBNP (a lab to assess heart failure), complete blood cell count with differential (a lab that counts each different type of white blood cell and not fully developed blood cell to assess for anemia and infection), complete metabolic panel (a lab that measures proteins, enzymes, electrolytes, minerals and other substances in the body), partial thromboplastin time (a lab to assess how long it takes for blood to clot) and troponin test (a lab to assess protein, troponin, which can increase when there is damage to the heart muscle cells indicating a heart attack). The provider did not order a D-Dimer (blood test to assess possible pulmonary embolism, a condition where a blood clot travels to the lungs and blocks one of the pulmonary arteries) or a computed tomography angiography scan (CT scan, a noninvasive medical imaging procedure that uses X-rays and computer technology to create detailed images of the blood vessels in the body) for P3’s complaint of shortness of breath to assess for a possible pulmonary embolism. 2. Under exam, it also revealed that at 7:28 am P3’s cardiovascular status (heart) was assessed and the assessment was negative for abnormalities, the patient’s respiratory status was assessed and was negative for abnormality, and the patient’s abdomen was assessed and found to be negative. There was no mention of possible detoxification from alcohol with P3’s history of drinking daily until 4 days prior to ER visit. C. Record review of P3’s nurse’s notes dated 09/03/2024 it is documented that P3 had a laceration to the occipital area that measured 2.6 centimeters by 7.5 centimeters with no bleeding. The laceration occurred 6 to 12 hours prior to ER visit. There is no documentation of care to this wound and no Tetanus Immunization shot being given with documentation of the last Tetanus shot as unknown. E. Record review of P3’s provider note dated 09/03/2024 at 2:12pm the provider discussed findings of tests and examination with P3 with the final diagnoses of dehydration, acute kidney failure, alcohol dependence with Propranolol (antihypertension) a medication used for rapid heartbeat and alcohol withdrawal to be ordered at discharge. P3 agreed to the plan and to be discharged home. The provider did not document assessment or care of P3’s laceration noted in the nurse’s note. F. During an interview with S(staff)4 (clinical) on 04/30/2025 at 3:45pm about P3’s visit to the emergency room. S4 stated that P3 came to emergency room for nausea and vomiting, having blood in the vomit, and a fall. S4 stated that there were no more tests or examinations to be completed that were not done. S4 also confirmed that the emergency room provider assesses the patient’s complaints which would have been nausea and vomiting, alcohol withdrawal, and injuries after a fall. S4 explained that this provider did that with blood tests, chest x-ray, CT-scan of the head and hydration for the dehydration and acute kidney injury.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 49835 Based on record review and interviews, the facility failed to provide a safe discharge for 1(P1 (Patient)] out of 26 (P1-P26) patients. This deficient practice could likely result in harm to the patients that are discharged from the facility. The findings are: A. Record review of P1’s medical chart under Emergency Department Record dated 03/31/2025 at 11:15 pm stated P1 lives in Lordsburg New Mexico, presented to the ER (Emergency Room) via helicopter on 03/31/2025 at 2:56 pm after passing out at a store in Lordsburg, New Mexico and had complaints of a fall and chest pain 3-4 days ago. Under physician documentation it stated that a full cardiac work-up in the emergency room, with 2 electrocardiograms (electrical activity of the heart) the first on 03/31/2025 at 3:36 pm and 6:09 pm. Under Nurses Notes dated 03/31/2025 at 2:56 pm stated that P1 was alert and oriented to person, place and time. P1’s chart did not contain an address or phone number and the patient did not know them. It was noted by S (staff)4 (clinical) that EMS (emergency medical service) reported P1 lives in a hotel. Medical record review noted that P1 on 04/01/2025 at 1:52 am “patient left the ED”. B. During an interview on 04/30/2025 at 3:45 pm with S3 (clinical) confirmed there was no address listed or a phone number for P1, for the staff to use for discharge planning. S3 confirmed that EMS in the chart stated that P1 lives in a hotel. Confirmed that discharging this patient without a ride back to Lordsburg, New Mexico could cause harm and there was no documentation of a discharge plan or an attempt to come up with a safe discharge plan. S3 confirmed the emergency room staff should have found a way to get home and not left at the bus stop for hours at night and the bus does not run through the night. C. During an interview with S1 (clinical) on 04/30/2025 at 6:20 am it was confirmed that P1 did not know where he lived or had a phone number to call for a ride and told S1 that he just moved in with a friend. S1 stated “his story sounded good”. S1 confirmed that the record was not read for further information for a safe discharge. D. During an interview with S2 (clinical) on 04/30/2025 at 7:00 am it was confirmed that S2 took care of P1 and P1 did not know his address or phone number. S2 stated the staff could have called the EMS company to find where he lived and get a possible phone number to call for a ride back to his home. S2 stated that the police came into the ER on 04/01/2025 at 7:00 am when she came on shift and stated the patient had sat at the bus stop all night. E. During an interview with S4 (clinical) on 04/30/2025 at 10:30 am confirmed P1 was confused and did not know his address or phone number, had no money to call for transport home. S4 confirmed that the discharge of this patient was not safe.”

“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: 50656 Based on record review and staff interviews, the facility failed to ensure that Emergency Department (ED) staff properly assessed and monitored pain levels for 4 (Patient (P)1, P3, P4 and P6) of 6 (P1-P6) patient charts reviewed. This deficient practice could result in inadequate pain management, delayed pain interventions, affect patient outcomes and satisfaction for all patients in the facility ED. The findings are: A. Record review of the facility’s policy titled: “Pain Management, ADM POL 14-18” Effective date 01/2022 through 01/2025 stated the following: 1. “All patients admitted as inpatients and presenting to the emergency department shall be questioned as whether or not they are experiencing pain. 2. An age and ability-appropriate comprehensive initial pain assessment shall be conducted for any patient reporting or suspected of having moderate or severe pain. The comprehensive assessment shall include, to the extent relevant, intensity (using an age-appropriate pain scale when practical and available), site(s) quality (e.g. dull, sharp, throbbing, stabbing), radiation, onset (e.g. when did the pain start, is it increasing or decreasing). The details of the initial pain assessment may vary depending on the clinical presentation and the nature of the interaction. For example, a physician’s note addressing the patient’s pain as part of medical screening or a physical examination is considered a comprehensive pain assessment. 3. A reassessment for the presence and intensity of pain shall be performed at least once every shift for inpatients and extended-stay outpatients and following any intervention intended to lessen the patient’s pain (for example, administration of pain medications, applications of cold packs, repositioning). The reassessment and documentation of the reassessment shall take place within the hour of the intervention that was performed to lessen the patient’s pain (for example, administration of pain medications, applications of cold packs, repositioning). The documentation may be as simple as “patient sleeping comfortably following pain intervention.” B. Record review of P1’s medical record revealed P1 arrived at the ED on 03/26/24 at 7:26 pm with complaints of severe abdominal pain at a level of 8 out of 10, (utilizing a numeric standardized adult pain scale of 0 to 10, with 0 being no pain, and ten being the worst possible pain) at 7:47 pm. Despite the patient reporting severe pain upon arrival to the ED, no documentation of a pain intervention was found in P1’s medical record until 10:31 pm, several hours later, when P1 was given IV (a medical method that administers fluids, medications and nutrients directly into a person’s vein) pain medication at 10:31 pm. C. Record review of P3’s medical record revealed P3 presented to the ED on 02/04/24 at 6:42 am with reports of abdominal epigastric (upper abdominal area) pain at a level of 7 out of 10 at 6:42 am, then at 7:01 am the patient reported an increased pain level of 8 out of 10, but no documentation of pain-relieving interventions was found in P3’s medical record, nor did the medical record contain any documentation of a pain reassessment, and P3 left the facility against medical advice (AMA) on 02/04/24 at 8:44 am. D. Record review of P4’s medical records revealed P4 arrived at the ED on 08/01/24 at 9:17 pm with complaints of abdominal pain. The medical record did not contain any documentation of a pain assessment, or any pain-relieving interventions offered or provided to the patient. E. Record review of P6’s medical records revealed the P6 arrived at the ED on 04/14/24 at 1:31 pm and reported severe pain at a level of 8 out of 10 at 1:37 pm. P6 was reevaluated for pain at 1:39 pm, again reporting severe pain of 8 out of 10. P6’s medical record did not contain any documentation of any pain-relieving interventions while P6 was in the ED or that a pain reassessment was completed despite P6 reporting severe pain shortly after arriving to the ED. F. During an interview on 12/11/24 at 2:51 pm with S (staff) 4, clinical staff member, S4 stated the pain assessment policy requires an initial comprehensive pain assessment at each initial nursing assessment and again after one hour following any pain-relieving interventions to determine if the intervention was effective. G. During an interview on 12/11/24 at 3:41 pm with S5, clinical staff member stated that the facility pain assessment policy requires an initial pain assessment during triage soon after patient arrives to the ED, using a standardized numeric scale, and a reassessment for pain one hour after the patient has been given pain relief interventions.”

“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: 49193 Based on record review and interview the facility failed to ensure the Registered Nurse monitored and documented every two hours on patients while being restrained for 1 (P (patient) P3) of 10 (P1-P10) patients. This deficient practice could likely lead to, serious injury, harm or death for all patients restrained at this facility. The findings are: A. Record review of facility’s policy title “Restraint/Seclusion in Patient Management, ADM POL 14-7” dated 08/2022, on page 5 under section 5. Monitoring and Reassessment stated, “Will be monitored and documented every 2 hours for: recognizing and providing for nutritional and hydration needs, checking circulation and range of motion in the extremities, addressing hygiene and elimination, addressing physical and psychological status and comfort including skin Integrity and neurovascular condition [condition that affects the blood supply in the brain or spinal cord], recognition of readiness for discontinuing restraint, recognition of signs of any incorrect application of restraints and the removal of same with ROM [the movement potential of a joint].” B. Record review of P3’s medical records revealed that patient was restrained from 01/20/24 through 01/23/24, no documentation regarding monitoring of restraints was conducted from 01/21/24 at 6:00 PM till 01/22/24 at 08:00 AM. C. During an interview on 02/27/24, at 3:55 PM, with Staff (S)10, Registered Nurse (RN) Quality Coordinator confirmed there was no documentation regarding monitoring of restraints on P3’s medical record from 01/21/24 at 6:00 PM till 01/22/24 at 08:00 AM. D. During an interview on 02/28/2024, at 12:34 PM, with S12, Emergency Department Nurse confirmed that when the patient is first restrained, they monitor and document every 15 minutes for the 1st hour then every hour after.”