University Medical Center

“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: 39418 Based on interview, record review and document review, the facility failed to ensure triage protocol laboratory tests were completed and critical vital signs were addressed during the emergency department (ED) visit for 2 of 20 sampled patients (Patient 17 and 18). The deficient practice had the potential for not establishing stability and the need for further medical interventions. Findings include: 1) Patient 17 (P17) presented to the Emergency Department (ED) via ambulance on 11/10/2025 at 5:42 PM. Emergency Medical Service (EMS) narrative documented the patient admitted taking Fentanyl. The patient did not know quantity or the time the Fentanyl was taken. During the transport at 5:07 PM, P17’s blood pressure (BP) was 120/82 and heart rate (HR) 100. At 5:39 PM, (still in the ambulance) BP 120/86, HR 86. The Emergency Medicine Resident Note Adult Emergency Department dated 11/10/2025. Document the chief complaint per nursing was “Patient on a legal 2000 (mental health crisis hold) for bizarre behaviors. Patient just keeps saying ‘Yes’ and ‘Yes Daddy’. Patient continues to make weird noises.” The History of Present Illness (HPI) indicated the patient was 32 years old with a past medical history of bipolar disorder, schizophrenia, asthma and anxiety who presented to the emergency department with a chief complaint of psychiatric evaluation and bizarre behavior. According to the Mental Health Crisis document and EMS, law enforcement responded to a call of a female running naked around a tourist area. When law enforcement arrived, the patient was acting erratic, bizarre behavior, stated multiple times “yes” and “yes daddy”. While waiting for EMS to respond, the patient began staring at the ground and was in the street, almost being hit by cars. The patient began to knock on random doors in the neighborhood. There was no visual trauma that was witnessed. The patient was repeatedly complaining about itching, stated had genital herpes and it was causing her some distress, however, would not answer any further questions. The patient was not answering questions about any traumatic injury or event. Unknown last menstrual cycle. The Patient Care Timeline documented the following vital signs: - 11/10/2025 at 5:47 PM: Blood Pressure (BP) 120/80 and Heart Rate (HR) 100 - 11/10/2025 at 5:48 PM: BP 113/77 and HR 115 - 11/11/2025 at 2:00 AM: BP 96/67 and HR 89 - 11/11/2025 at 3:18 AM: BP 97/68 and HR 129 The Medical Decision Making (MDM) note signed by the physician on 11/10/2025 at 11:48 PM, documented the patient was 32 years old who presented for psychiatric evaluation. Triage vital signs, tachycardic otherwise unremarkable. On evaluation, the patient was in the exam room and was repeatedly taking off the green hospital gown stating, “prefers to be naked”. The patient had bizarre behavior, continually scratching around their body. The patient was intermittently answering questions. The patient was given a dose of Zyprexa, Benadryl as well as Droperidol. The examination was remarkable for a hematoma to the left forehead; the patient had no recollection of the events which took place. No other signs of trauma on physical examination. Computerized Tomography (CT) scan of the head will be ordered in addition to toxicology screen and pregnancy test. Upon review of the diagnostics obtained, CT of head without hemorrhage, midline shift, mass effect and vasogenic edema. Soft tissue swelling was seen without a skull fracture. The patient continues to present with behaviors and continues to remove garments. Review of previous records revealed the patient was seen at another acute care hospital and was admitted for schizophrenia. Given the continued bizarre behavior, patient meets criteria for Legal 2000 hold. There was no evidence of emergent medical condition at this time, other than the patient’s underlying psychiatric condition. The patient will be observed in the hospital until such time as a bed becomes available for inpatient psychiatric evaluation and management. The Attestation signed by the Attending ED Physician on 11/11/2025 at 3:57 PM, documented the attending physician performed a face-to-face history and physical examination of P17, including key aspects of their history and physical exam. The patient’s evaluation and management plan was discussed with the Resident Physician and agreed with the history, physical, assessment, and plan of care. The Patient Care Timeline documented the following: - 11/10/2025 at 6:25 PM, orders were placed for a lab toxicology screen, urine and a pregnancy, urine. - 11/10/2025 at 9:21 PM, the urine toxicology screen and pregnancy test collection was completed. - 11/11/2025 at 1:45 AM, the result of the serum qualitative HCG (pregnancy) test was completed with a negative result. The ED record lacked documented evidence that the Registered Nurse (RN) had notified the physician of the critical HR and the trending down BP of the patient. There was lack of documented evidence that the urine toxicology was completed by the laboratory department and if the physician was made aware of the lack of results of the ordered laboratory test. The ED record lacked documented evidence a re-assessment was completed by the physician after the initial MDM at 11:48 PM, and if the physician was notified of P17’s critical HR prior to discharge. The physician addressed P17 triage tachycardia as unremarkable with no correlation to patient’s current medical status, history or diagnostic data to determine if P17’s tachycardia was benign. 2) Patient 18 (P18) presented to the ED on 11/22/2025 at 2:20 AM via ambulance with a chief complaint of acting abnormal and only answering name appropriately, admitting to recent methamphetamine use. The ED record documented the patient was 29 years old with a history of schizoaffective disorder and methamphetamine use presenting for psychiatric evaluation. Per EMS, the patient wandered into a dispensary, stating owning the store and was requesting a medical exam. Once arriving at the emergency department, the patient stated the intent to take own life. When asked if P18 had a plan, the patient stated it was to commit murder. The patient had no somatic complaints at this time. The patient denied chest pain, shortness of breath, fevers or chills. Denied abdominal pain, nausea or vomiting. Patient indicating taking Risperdal daily. The attending physician documented agrees with physical exam findings as discussed/documented by an Advance Practice Practitioner (APP). FOCUSED EXAM: On exam the patient was tachycardic. The patient was awake and alert. The patient was responding to internal stimuli. The patient was alert oriented x 3. The patient had pressured speech. The patient had good eye contact. Head was atraumatic. Neck was supple. Normal gait. Intact motor to all 4 extremities. No evidence of respiratory distress speaking to me in full complete sentences. The Patient Care Timeline documented the following: - 11/22/2025 at 2:28 AM: Heart Rate 117 and the BP 140/79 - 11/22/2025 at 4:59 AM: Heart Rate 111 and BP 144/97 - 11/22/2025 at 6:38 AM: Heart Rate 109 and BP 124/86 - 11/22/2025 at 7:43 AM: P18 was discharged. The Patient Care Timeline documented the following: - 11/22/2025 at 2:59 AM: orders placed for a urine toxicology screen and a urine pregnancy test. The ED records lacked documented evidence that the RN had informed the physician of the critical HR of the patient. Lacked documented evidence the urine toxicology and pregnancy test was completed by the laboratory department and if the physician was made aware of the lack of results of the laboratory test ordered. The ED record lacked documented evidence the physician was notified of P18’s consistent critical HR even when the Patient Attendant Log documented P18’s activity to be awake, calm and relaxed. The physician mentioned P18 had tachycardia with no correlation to patient’s current medical status, history or diagnostic data to determine if P18’s tachycardia was benign. On 01/15/2026 at 12:27 PM, the Quality and Regulatory Coordinator reviewed P17 and P18’s medical record and agreed the HR being greater than 100, and per policy was a vital sign (VS) critical value. Typically, the physician would have ordered an electrocardiogram (EKG - a non-invasive test used to diagnose heart conditions) especially with the patients’ history of drug use. The coordinator confirmed there was lack of documentation the nurses had notified the physician of the critical HR for both patients. The Quality and Regulatory Coordinator confirmed there was lack of documentation that the physician was made aware the laboratory tests ordered were not completed. On 01/15/2025 at 1:50 PM, the Director of ED indicated any critical value for laboratory results, imaging or VS should be relayed to the physician and documented. The Director indicated tachycardia would be a reason for an EKG test. The Director stated the protocol was so broad wherein the test was almost done for most of the ED admissions. The Director confirmed urine pregnancy and toxicology was part of the ED standard orders for psychiatric triage protocol, if any of the tests where not completed the physician should be notified. On 01/15/2025 at 2:10 PM, an ED physician indicated the unreported HR of 129 would have changed the plan of care for P17. The Physician stated knowing the results of the patient’s urine toxicology might provide correlation to a patient’s tachycardia although may have not changed the plan of care. The facility policy titled “Adult Emergency Department (ED) Triage Protocol” dated 2/2024, documented the purpose was to establish initial patient level of care, and initiate immediate interventions. The protocol orders would improve safety, facilitate timely interventions, and foster efficiency in care delivery. For Medical Clearance/Psychiatric Evaluation: i. Urine toxicology screen; ii. Urine pregnancy in females less than 55 years old. The facility policy titled “Vital Signs Frequency and Addressing Abnormal Vital Signs in the Adult Emergency Department” dated 12/2025, documented Abnormal Vital Signs: a. Vital signs outside of what was normal to the patient’s baseline or showing a worrisome trend were reported to the patient’s physician or advanced practice provider. b. Newly discovered abnormal vital signs were reported to the physician or advanced practice provider. Critical vital signs: Heart Rate: 1. Greater than 100 beats per minute at rest. 2. Less than 60 beats per minute and new to patient or clinically significant.”

“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: 39418 Based on interview, record review and document review, the facility failed to ensure critical vital signs were reported to the physician prior to a patient’s discharge for 1 of 20 sampled patients (Patient 17). The deficient practice had the potential for a patient to be discharged even with an emergency condition and has not been stabilized. Findings include: Patient 17 (P17) presented to the Emergency Department (ED) via ambulance on 11/10/2025 at 5:42 PM. Emergency Medical Service (EMS) narrative documented the patient admitted taking Fentanyl. The patient did not know quantity or the time the Fentanyl was taken. During the transport at 5:07 PM, P17’s blood pressure (BP) was 120/82 and heart rate (HR) 100. At 5:39 PM, (still in the ambulance) BP 120/86, HR 86. The Patient Care Timeline documented the following vital signs: - 11/10/2025 at 5:47 PM: Blood Pressure (BP) 120/80 and Heart Rate (HR) 100 - 11/10/2025 at 5:48 PM: BP 113/77 and HR 115 - 11/11/2025 at 2:00 AM: BP 96/67 and HR 89 - 11/11/2025 at 3:18 AM: BP 97/68 and HR 129 - 11/11/2025 at 3:20 PM: P17 was discharged The ED record lacked documented evidence that the Registered Nurse (RN) had notified the physician of the critical HR and the trending down BP of the patient. The Medical Decision Making (MDM) note signed by the physician on 11/10/2025 at 11:48 PM, documented P17 was 32 years old who presented for psychiatric evaluation. Triage vital signs, tachycardic otherwise unremarkable. The ED record lacked documented evidence that a re-assessment was completed by the physician and if the physician was notified of P17’s critical HR prior to discharge. On 01/15/2026 at 12:27 PM, the Quality and Regulatory Coordinator reviewed P17’s medical record and agreed the triage HR being greater than 100, and per policy was a vital sign (VS) critical value. Typically, the physician would have ordered an electrocardiogram (EKG - a non-invasive test used to diagnose heart conditions) especially with the patients’ history of drug use. The coordinator confirmed the large gap of time a set of VS was completed for the patient and there was a lack of documentation the nurse had notified the physician of the critical HR prior to discharging the patient. On 01/15/2025 at 1:50 PM, the Director of ED indicated any critical value for laboratory results, imaging or VS should be relayed to the physician. The director indicated VS at a minimum should be taken at least every 4 hours as part of establishing patient’s stability. 01/15/2025 at 2:00 PM, an ED nurse indicated for a patient waiting to be transported, frequency of VS signs had to be taken depending on the patient’s condition and at least every four hours. VS were to be done prior to discharge or transport. Abnormal VS, high or low BP, HR issues, fever, anything out of the range; had to be relayed to the MD and documented. Depending on the physician order, further treatment or testing would be provided. The patient would need to be re-assessed after interventions. The patient would not be discharged if deemed unstable. On 01/15/2025 at 2:10 PM, the ED physician indicated P17’s HR was in the 80’s the last time the physician had evaluated the patient. The physician acknowledged not being aware of P17’s HR of 129 prior to discharge. The physician indicated that the patient would have had additional work up if the critical HR was conveyed, and the patient’s transfer would not have occurred. The facility policy titled “Vital Signs Frequency and Addressing Abnormal Vital Signs in the Adult Emergency Department” dated 12/2025, documented vital signs were reassessed no less than the frequency required for the anticipated level of admission, or no less than 4 hours with no anticipated admission. Abnormal Vital Signs: a. Vital signs outside of what was normal to the patient’s baseline or showing a worrisome trend were reported to the patient’s physician or advanced practice provider. b. Newly discovered abnormal vital signs were reported to the physician or advanced practice provider. Critical vital signs: Heart Rate: 1. Greater than 100 beats per minute at rest. 2. Less than 60 beats per minute and new to patient or clinically significant.”

“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: 37718 Based on observation, interview and record review, the facility failed to provide an evaluation of the needs related to discharge planning for 1 of 96 sampled patients (Patient 40). The deficient practice may create adverse health consequences for patients at risk, who did not receive adequate discharge planning. Findings include: Patient 40 (P40) arrived by ambulance to the Emergency Department (ED) on 09/16/2023 with chief complaints of dizziness and worsening right sided extremity weakness. The ED Medical Provider Note dated 09/17/2023 included a history and physical exam (H&P). The H&P indicated the patient reported a recent history of a stroke with symptoms of right-sided weakness of the arm and the leg. The patient reported vision loss to both eyes over the past several years. The patient reported using insulin to treat diabetes. The note indicated P40’s past medical history included back pain, stroke, diabetes, and high blood pressure. The record indicated current medications for P40 included Lisinopril orally for high blood pressure, and insulin by injection for diabetes. The note indicated the patient reported losing all medications and had not taken any over the past week, and the patient had become homeless. The ED Provider Notes regarding medical decision making documented P40 was homeless and presented to the ED due to dizziness and weakness. The note indicated P40 would need case management support for medication care. The note indicated the patient stated having no resources and was homeless. The note indicated the patient spoke with case management. The note documented the case manager furnished P40 with options for the patient to navigate to acquire housing, medications, and other social support services. Discharge follow up recommendations provided to P40 included to schedule an appointment at the hospital outpatient clinic in one day. The note documented P40 was discharged on 09/17/2023 in stable condition with diagnoses of dizziness and homelessness. The note lacked the mode of transportation, destination, or mobility status of the patient. A Case Management note dated 09/17/2023 at 9:26 AM documented, met with patient at bedside. Patient did not know the name of medications currently taking and does not know the daughter’s phone number to verify. Patient’s phone does not turn on at this time, no battery life and no charger available. Primary RN (Registered Nurse) aware. Discount medication recourses {sic} given to patient. P40’s record lacked a case management assessment. A Nurse’s Note dated 09/17/2023 at 10:29 AM, indicated the patient was given discharge information, along with a taxi voucher and community resources that included possible discounts for prescription medications. The note indicated P40 left the ED on 09/17/2023 at 10:45 AM. The record lacked the mode of transportation the patient used upon discharge. The record lacked an address the patient was discharged to. On 07/26/2024, in the morning, the Case Management Manager verbalized case management staff visited for discharge needs for all patients in all areas of the hospital. The Case Management Manager revealed case management screened patients within 24 hours, including all patients in the ED. The Case Management Manager revealed providers and nurses could order a case management consultation at any time. The Case Manager stated nurses could also prepare a discharge plan if case management did not prepare the discharge plan. The Case Management Manager verbalized if the nurse identified a need, then it triggered a consultation and assessment to address the need. The Case Management Manager reported, social deterrents of health which were not medical conditions but affected the patient’s well-being, would trigger a consultation. The Case Manager verbalized homelessness was a social deterrent of health. On 07/26/2024, in the morning, the Case Management Manager reviewed P40’s medical record and verbalized the following: - P40’s medical record lacked a case management assessment to determine the patient’s need. The case management assessment should have been completed due to the patient being homeless and the provider having indicated a need for the consultation. -Case management tasks included obtaining family member phone numbers from the past record on file. The hospital practice was to reach out to family members for input on discharge planning. P40’s record lacked documentation this had been done. -The hospital discharge process included assisting patients to obtain prescription medications. P40’s record lacked documentation the patient had been assisted to obtain prescription medications including insulin. The medications should have been called in to the patient’s pharmacy of choice, and transportation provided to the pharmacy to pick up the medications. -P40’s record documented the patient was given a taxi voucher. Taxi vouchers were issued to patients who needed transportation to a destination. A taxi voucher would only be given if the patient had an address to be sent to. The provider notes indicated the patient was homeless. A copy of the taxi voucher would be maintained in the patient’s record. P40’s record lacked a copy of a taxi voucher. -The discharging planning process should include an assessment of the patient’s mobility. P40’s record lacked documentation the patient’s mobility was assessed, for instance as to whether the patient could walk or propel self in a wheelchair. -The hospital discharge options included referring homeless patients to a specific shelter which offered many support services upon discharge. P40’s record lacked evidence of a referral to this shelter. The Case Management Manager verbalized the hospital failed to perform a case management assessment per the hospital policy and procedure. The Case Management Manager indicated the lack of the assessment resulted in an unsafe discharge for P40 which carried a risk for an adverse outcome. On 07/26/2024 at 2:20 PM, an Emergency Department Registered Nurse (RN) verbalized, upon discharge the RN must assess and document each patient’s mobility status to ensure the patient was safe to discharge. The hospital policy and procedure titled Transition of Patients, final approval date of 05/2022, indicated the transition planning process utilized an interdisciplinary team approach, began upon admission and continued throughout the hospitalization. A patient’s specific needs and outcome goals would be identified by the team through assessments on admission. Transition Planning Criteria included patients who expressed concern over financial and/or environmental problems. Case Management Responsibility included: -Screen daily admissions for Transition Planning needs, barriers, and plans. -Collaborate with all members of the healthcare team, develop a realistic timely discharge plan based upon input from medical staff, nursing staff, and other members of the hospital and patient/family. -Arrange non-medical support services as needed or requested. Transition Planning Procedure included -Primary responsibility for screening for transition planning rests with Case Management. -At the time Case Management responds to the referral, he/she would evaluate for the need to complete and assessment and evaluate the need for post hospitalization services. -All transition planning should include input from the patient and family prior to implementation -The plan should be recorded in the Case Management section of the patient’s medical record. The policy and procedure titled Discharging Patients from the Adult Emergency Department dated 02/2024, indicated to ensure all patients were discharged from the Emergency Department in stable condition and to provide for patient safety upon discharge, for all patients being discharged, the primary care nurse will ensure the patient can ambulate or move at baseline. The policy and procedure titled Ambulation on Discharge in the Adult Emergency Department, dated 07/2023, indicated ED staff shall test and document patient ambulation status upon discharge from the Emergency Department to minimize patient morbidity and mortality. The policy indicated patients discharged from the ED would be assessed for their ability to ambulate independently or with the assistive device prescribed (i.e. crutches) or present during triage. The patient being discharged from the Emergency Department would be asked to ambulate to assure their ability to stand and walk independently. During the discharge process, the nurse should assure there was a sufficient, unobstructed area for the patient to use, ask the patient to walk 5-10 steps (may use a mobility device such as a walker, cane, or crutches). Document the patient’s ability to ambulate (note any assistive devices). If any unexpected difficulties in ambulating, the nurse must interrupt the discharge process and immediately notify the physician of the patient’s ambulation status.”