Presbyterian Santa Fe Medical Center

“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: 49844 Based on record review and interview the facility failed to provide stabilizing treatment to 1 (P6 (patient)) out of 10 (P1-P10) patients being reviewed for stabilizing treatment. This deficient practice is likely to lead to patients leaving the emergency department (ED) in unstable condition. The findings are: A. Record review of facility’s undated procedure titled “Nursing CAUTI [Catheter Associated Urinary Tract Infection] Prevention Protocol” stated “Discontinue the catheter [tube that drains urine], document and perform the following assessment and interventions: Ensure the patient is spontaneously voiding [urinating on their own]: record on intake and output time and amount of each void [urine output] for 24 hours following the removal of the catheter or as ordered by a patients physician” B. Record review of facility’s policy titled “EMTALA Stabilization” dated 03/05/2021 under the section “Policy “ stated “Patients being transferred or discharged will be stabilized as required under EMTALA.” C. Record review of P6’s medical record under “ED Events” indicated that P6 arrived to the emergency department on 09/08/24 at 4:31 AM by ambulance with a chief complaint of abdominal pain. Review of the section “Provider note” indicated P6 had urinary retention (when a person cannot urinate and the urine is retained) requiring a catheter. A foley catheter (indwelling tube that drains urine) was ordered for insertion at 4:45 AM. This order stated “Acute urinary retention (requires providers order to remove).” P6’s flowsheets revealed at 8:46 AM, P6 had 2500 mL (milliliters) of output from the Foley catheter. The provider note stated “Patient is hopeful did not need the Foley catheter but understands that he does need this.” Indicating that the Foley catheter is needed. The sections titled “Flowsheets” indicated that the catheter was removed at 10:31 AM. The record did not contain any documentation of urinary output following the removal of the Foley catheter. The section “ED events” revealed P6 was discharged at 10:33 AM, 2 minutes after the removal of the Foley catheter. The record did not contain any order in place for discontinuation of the Foley catheter. The record did not contain any assessment of the patients ability to void following the removal of the foley catheter. D. Record review of P6’s discharge instructions under “Acute Urinary Retention” stated “Acute Urinary Retention is when a person cannot pee (urinate) at all, or can only pee a little. This can come on all of a sudden. If it is not treated, it can lead to kidney problems or other serious problems. E. During an interview on 09/12/24 at 11:10 AM with S(staff)4, Clinical Staff member, when asked how soon after the removal of a Foley catheter a patient can be discharged, S6 explained that he would wait until the patient can “urinate on their own” to discharge them.”

“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: 47302 Based on observations, record review and interview the facility failed to meet the Emergency Medical Treatment and Labor Act (EMTALA) of conspicuously posting the appropriate EMTALA sign failed to provide an adequate Medical screening exam and failed to have a process in place for patients that choose to transfer via private vehicle. This deficient practice could lead to unfavorable outcomes while patient is en route to accepting hospital. The findings are: A. Failed to post signs informing patients of their rights to seek medical care. Refer to tag A-2402. B. Failed to provide a medical screening exam. Refer to tag A-2406 C. Failed to have a process in place for patients that choose to transfer via private vehicle. Refer to tag A-2409.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 47302 Based on observation and interview the facility failed to post appropriate EMTALA (Emergency Medical Treatment and Labor Act) signs in English for the population served by the hospital informing patients of their rights presenting to the emergency department (ED). This deficient practice can lead to all patients not being aware of their rights as a patient in the emergency department. The findings are: A. During an observation on 04/02/2024, at 10:00 AM, in the ambulance bay where patients are brought in to the ED there was not an English sign posted that explained patients right to be seen for any emergency condition and stated whether the facility participated in the Medicaid program. B. During an interview on 04/02/2024 at 10:50 AM with Staff (S)4, Emergency Department Director confirmed that an English sign should be posted in the ambulance bay.”

“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: 47302 49844 Based on record review and interview the facility failed to provide an appropriate medical screening exam for 1 (P[patient]1) out of 20 (P1-P20) patients reviewed for seeking emergency care. This deficient practice could possibly lead to patient’s medical conditions being untreated, resulting in harm. The findings are: A. Record review of P1’s medical record revealed the following: 1. Under “ED (Emergency Department) events,” P1 arrived to the ED on 01/12/24 at 12:56 PM and P1 was discharged from the emergency department on 01/12/24 at 10:17 PM. 2. Under “Provider Notes”, at 9:30 PM, P1 was assessed by S(staff)11 for a chief complaint of leg swelling, a thorough review of systems (an assessment of patient that includes each body organ system) was not done by the provider. S11 did not assess P1’s pedal pulses (pulse felt in foot, used to determine the blood flow to the extremity). 3. Under “Clinical Lab Results”, P1 had an elevated D-dimer of 732 at 7:52 PM (Normal range is 0-500; a blood test used to measure the level of D-dimer protein which is released when clots dissolve in the body). 4. Under “Imaging Results”, P1 had a left lower extremity ultrasound at 3:50 PM that revealed no acute deep or superficial clot. There was no evidence that an ultrasound was done for the right lower extremity. 5. There was no evidence that a Chest CT Angiogram (computed tomography, x-ray scan that shows the blood vessels in the chest) was done to check for a pulmonary embolism (Blood clot in the lung). 6. Under vital sign flow sheets, P1 had initial vital signs on 01/12/24 at 1:32 PM with an oxygen saturation level of 96% respirations (Number of breathes per minute) 18 (Normal respirations in adults is 12-20), blood pressure (Measure of pressure or force of blood inside arteries) 175/85 . The final vital signs taken prior to discharge at 10:00 PM revealed an oxygen saturation that was trending downward. P1 was discharged with an oxygen level of 93%, respirations 22, and blood pressure of 174/98. The decreased oxygen level, increased respirations and elevated blood pressure were not addressed in the provider’s note. 7. Under the section “Flowsheets”, in the pain assessment section, P1 reported a pain level of 7.5 on a rating scale of 1-10 at 9:03 PM. P1’s pain remained untreated when discharged from the emergency department. 8. Under the section “Imaging Results,” P1 had a chest X-ray (a scan that produces images of your internal organs), that revealed “air distention of the bowel suggesting ileus [The inability of the intestine to contract normally]”. The ileus was not mentioned on the providers note or assessment and was not addressed in the emergency department. B. During an interview on 04/03/2024 at 5:45 PM with S11, when asked how she completes a review of systems, S11 explained that they no longer have to chart a full review of systems, but the way she assesses a patient is dependent on the complaint. S11 explained that if a patient presented with a concern for DVT (deep vein thrombosis or blood clot) she would look for leg swelling, leg pain, and pitting edema (swelling). S11 did not mention doing a chest CT Angiogram (computed tomography, x-ray scan that shows the blood vessels in the chest).”

“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: 47302 Based on record review and interview the facility failed to have a process in place for patients that choose to transfer by a private vehicle for 1 (P [Patient] 20) of 20 (P1-P20) patients reviewed for seeking emergency medical care. The deficient practice could lead to patients not being monitored and not receiving medical care while they are en route to accepting hospital. The findings are: A. Record review of facility’s policy titled, “EMTALA Transfer” dated 03/05/2021, on page 4, number 9 stated; “A transfer to another facility will be appropriate only in those cases in which: . . . 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.” B. Record review of P20’s emergency department note for visit on 11/15/2023, under “Medical Decision Making” stated, “[Patient] presents for approximately 24 hours of right lower quadrant abdominal [right lower area of the abdomen] pain. With nausea [the feeling of needing to vomit] and vomiting. And decreased urine output. No fevers. CT [computed tomography, an imaging procedure] shows distal ureteral stone on the right [kidney stone that has moved out of the kidney and is in the tube connecting the kidney to the bladder], 7 to 8 mm [millimeters]. White blood cell count 13.8 [value high and can reflect various medical issues such as inflammation or infection]. urinAlysis [sic] shows trace blood [urine sample that is showing blood in the urine, an abnormal finding]. Urology [medical service that deals with issues related to the urinary system] consulted to see if admission is warranted. Patient aware and willing to do what is ever necessary. Pain currently controlled after 1 dose of morphine [medication given for pain management]. Urology [doctor’s name] recommends transfer to [name of facility]. [doctor’s name] is the admitting doctor. Stable for transfer.” C. Record review of P20’s transfer paperwork under “RN [Registered Nurse] Documentation” dated 11/17/2023, stated, “Transport by - Car”, “Ambulance Company [blank]”, and “Transported by (If not by Ambulance) - Spouse.” There was no evidence that patient was offered an ambulance and no evidence of the reason why patient was transported by private vehicle. D. During an interview on 04/03/2024 at 2:30 PM, with Staff (S)10, MD (Medical Doctor), it was asked what the risks are associated with a patient transferring to another hospital by private vehicle. S10 explained that patients are not monitored, medical professionals are not available, and if an ambulance gets a flat tire or there is a car accident they already have a network setup to assist the patient.”