Saint Rose Dominican Hospitals - Siena Campus

“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: 21794 Based on interview, document review, and record review, the facility failed to provide a thorough medical screening exam for 1 of 30 sampled patients (Patient 23). The failure to provide a thorough medical screening exam for this patient had the potential to place the patient at increased risk of further harm or illness. Findings include: Patient 23 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 09/03/2024 with a chief complaint of history of vertigo and falls. The Emergency Department Physician Notes dated 09/04/2024 at 4:44 PM, revealed Patient 23 became dizzy after walking out of the garage and fell to the ground and was unable to get up. Patient 23 reported sustained burns to buttocks and right arm from the hot pavement. The Skin Assessment conducted by the attending ED physician revealed the patient had approximately 4 cm (centimeters) cyst and superficial thermal burn to right arm and approximately 3 cm diameter thermal burn to right buttock which was superficial but contained 1 cm area of partial thickness with intact blister. Assessment of the left lower extremity revealed no documentation the patient had incurred thermal burns to the left lower extremity, with no mention the right lower extremity was assessed. The Medical Decision Making (MDM) section of the ED Physician Notes described the skin examination demonstrated small areas of mostly superficial burns with a single area of partial thickness burn. It was determined the patient did not require to be transferred to a burn center. The final diagnosis did not contain evidence of a single burn diagnosis. The Discharge Summary dated 09/04/2024, revealed no evidence of prescribed wound treatment, including no evidence of a topical ointment, antibiotic, or wound bandages/gauze to address the two areas of thermal burns sustained from the fall and the inability to get up off the hot ground. On 04/09/2025 at 12:35 PM, the patient’s Attending ED Physician (Physician) confirmed an assessment of the patient’s lower extremities was conducted during the medical screening exam (MSE) and acknowledged no discovery of additional thermal burns to the patient’s lower extremities. The Physician confirmed no orders for treatments to the thermal burns to the upper arm and buttocks were prescribed. The Physician acknowledged the Lidocaine patch, which was prescribed, was to be applied to the patient’s back due to pain. On 04/09/2025 at 3:10 PM, ED Registered Nurse (Employee 2) confirmed there was no documented evidence of burns on the lower extremities of Patient 23. Employee 2 confirmed there were no treatments ordered that addressed the patient’s burns at the time of the ED visit and none prescribed following the patient’s discharge. On 04/10/2025 at 6:30 PM, ED RN (Employee 4) acknowledged her role as a chaperone during the patient’s skin assessment. Employee 4 confirmed the Physician conducted a visual examination of the patient’s lower extremities during the MSE. Employee 4 acknowledged there was documentation the Physician assessed the left lower extremity of Patient 23, but no documented evidence the right lower extremity was a part of the MSE. Clinical records were obtained from another local hospital, which revealed Patient 23 was treated in the hospital’s ED on 09/05/2024. The ED Physician Record dated 09/05/2024 at 10:53 PM revealed one of the patient’s chief complaints were burns from the asphalt with blisters and pain (10/10 pain scale). It was documented in the ED Physician Record that the patient’s current skin status was “Warm, burns to lateral aspect right arm, lateral aspect right lower leg, medial aspect left lower leg, right buttocks and lateral hip.” The ED Physician Record noted the status of the burns as 1st degree 3% and partial and 2nd degree 3 %. A third set of partial clinical records were obtained regarding an admission to a local Burn Center following the patient’s hospital admission and short engagement at a local outpatient burn clinic, Patient 23 was referred to another local burn clinic. The History and Physical, dated 09/18/2024, revealed the patient was diagnosed with “5% TBSA (Total Body Surface Area) full thickness hot pavement burns to right buttocks to hip and BLE (bilateral lower extremity)”. In the Assessment/Plan dated 09/18/2024, Patient 23 was admitted, and surgery was scheduled for 09/19/2024 “due to severity of burn”. A facility policy entitled, Emergency Medical Treatment and Labor Act (EMTALA), revealed that for the hospital to comply with EMTALA, the hospital will provide an individual with an appropriate medical screening examination (MSE) and stabilizing treatment once that individual presents at the hospital and requests an examination. Complaint NV00073503”

“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: 21794 Based on interview, document review, and record review, the facility failed to provide stabilizing treatment for 1 of 30 sampled patients (Patient 23). The failure to provide stabilizing treatment for this patient had the potential to place the patient at increased risk of further harm or illness. Findings include: Patient 23 presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 09/03/2024 with a chief complaint of history of vertigo and falls. The Emergency Department Physician Notes dated 09/04/2024 at 4:44 PM, revealed Patient 23 became dizzy after walking out of the garage and fell to the ground and was unable to get up. Patient 23 reported sustained burns to buttocks and right arm from the hot pavement. The Skin Assessment conducted by the attending ED physician revealed the patient had approximately 4 cm (centimeters) cyst and superficial thermal burn to right arm and approximately 3 cm diameter thermal burn to right buttock which was superficial but contained 1 cm area of partial thickness with intact blister. Assessment of the left lower extremity revealed no documentation the patient had incurred thermal burns to the left lower extremity, with no mention the right lower extremity was assessed. The Medical Decision Making (MDM) section of the ED Physician Notes described the skin examination demonstrated small areas of mostly superficial burns with a single area of partial thickness burn. It was determined the patient did not require to be transferred to a burn center. The final diagnosis did not contain evidence of a single burn diagnosis. The Discharge Summary dated 09/04/2024, revealed no evidence of prescribed wound treatment, including no evidence of a topical ointment, antibiotic, or wound bandages/gauze to address the two areas of thermal burns sustained from the fall and the inability to get up off the hot ground. On 04/09/2025 at 12:35 PM, the patient’s Attending ED Physician (Physician) confirmed an assessment of the patient’s lower extremities was conducted during the medical screening exam (MSE) and acknowledged no discovery of additional thermal burns to the patient’s lower extremities. The Physician confirmed no orders for treatments to the thermal burns to the upper arm and buttocks were prescribed. The Physician acknowledged the Lidocaine patch, which was prescribed, was to be applied to the patient’s back due to pain. On 04/09/2025 at 3:10 PM, ED Registered Nurse (Employee 2) confirmed there was no documented evidence of burns on the lower extremities of patient 23. Employee 2 confirmed there were no treatments ordered that addressed the patient’s burns at the time of the ED visit and none prescribed following the patient’s discharge. On 04/10/2025 at 6:30 PM, ED RN (Employee 4) acknowledged her role as a chaperone during the patient’s skin assessment. Employee 4 confirmed the Physician conducted a visual examination of the patient’s lower extremities during the MSE. Employee 4 acknowledged there was documentation the Physician assessed the left lower extremity of Patient 23, but no documented evidence the right lower extremity was a part of the MSE. Clinical records were obtained from another local hospital, which revealed Patient 23 was treated in the hospital’s ED on 09/05/2024. The ED Physician Record dated 09/05/2024 at 10:53 PM revealed one of the patient’s chief complaints were burns from the asphalt with blisters and pain (10/10 pain scale). It was documented in the ED Physician Record that the patient’s current skin status was “Warm, burns to lateral aspect right arm, lateral aspect right lower leg, medial aspect left lower leg, right buttocks and lateral hip.” The ED Physician Record noted the status of the burns as 1st degree 3% and partial and 2nd degree 3 %. A third set of partial clinical records were obtained regarding an admission to a local Burn Center following the patient’s hospital admission and short engagement at a local outpatient burn clinic, Patient 23 was referred to another local burn clinic. The History and Physical, dated 09/18/2024, revealed the patient was diagnosed with “5% TBSA (Total Body Surface Area) full thickness hot pavement burns to right buttocks to hip and BLE (bilateral lower extremity)”. In the Assessment/Plan dated 09/18/2024, Patient 23 was admitted, and surgery was scheduled for 09/19/2024 “due to severity of burn”. A facility policy entitled, Emergency Medical Treatment and Labor Act (EMTALA), revealed that for the hospital to comply with EMTALA, the hospital will provide an individual with an appropriate medical screening examination (MSE) and stabilizing treatment once that individual presents at the hospital and requests an examination. Complaint NV00073503”