Ns/Lij Hs Southside Hospital

“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: 47355 Based on medical record (MR) review, document review, interview, the hospital failed to provide an appropriate medical screening examination (MSE) within its capability and capacity, in one (1) of twenty-one (21) MRs (Patient #2). Findings: The facility policy and procedure (P&P) titled, “Emergency Treatment, Stabilization, Transfer of Patients, and EMTALA (Emergency Medical Treatment and Active Labor Act),” last reviewed 03/2022, stated, “Every person who comes to [hospital system’s name] Emergency Department [ED] for examination or treatment, or who presents elsewhere on the premises (within two-hundred fifty (250) yards of the hospital) stating that he/she has an emergency, will be given an appropriate MSE to determine whether an emergency medical condition (EMC) exists.” Review of Patient #2’s MR identified the following: This patient was brought to the ED by ambulance on 03/09/2025 at 3:39PM for a psychiatric evaluation. Patient #2 reported they had walked twenty-five (25) miles and felt as if someone was following them. Patient #2 was evaluated and diagnosed with Rhabdomyolysis (a breakdown of muscle tissue that releases a damaging protein into the blood) and left the ED against medical advice (AMA) on 03/09/2025 8:57PM. Review of the Pre-Hospital Care Report (PCR - ambulance report) dated 03/10/2025, revealed that Patient #2 was observed standing upright on the corner of the hospital’s north parking lot, and that Patient #2 was in the presence of police officers and a hospital security officer. As per the PCR, Patient #2 presented with a psychiatric emergency with agitation. The security officer informed EMS (emergency medical staff) that the hospital “refused to take the patient,” despite Patient #2 being on the hospital’s property. As per the PCR, the security officer was informed by EMS that this would be a potential EMTALA violation, and that the return of Patient #2 to the ED was still refused. Patient #2 was transferred to another nearby hospital. During the interview of Staff K (Security Officer) on 03/19/2025 at 1:47 PM, Staff K confirmed that they were assigned to patrol the perimeter of the hospital grounds on the night of 03/09/2025 and that they recalled the event involving Patient #2. Staff K explained they could not recall the exact or approximate times, but they had three (3) encounters with Patient #2 that night: (1) Patient #2 was observed standing in the rear of the building. When questioned, they indicated they were waiting for a ride. Staff K stated that they redirected Patient #2 to the “traffic circle” (an area near the hospital’s exit that is designated for patient pick-ups); (2) Patient #2 was later observed walking towards the ambulance bay. When questioned, Patient #2 again stated that they were waiting for their ride. Staff K stated that they again redirected Patient #2 to the traffic circle; (3) Approximately one hour later, Patient #2 was observed from a distance, standing near the parking garage. Staff K stated that when they approached Patient #2, two (2) police officers and an ambulance arrived at that time. Staff K stated that two EMS explained that they had been looking for Patient #2 for some time because Patient #2 had called 9-1-1 multiple times. Staff K explained that while speaking with EMS, they shared that Patient #2 had been seen in the ED earlier but had left AMA. Staff K denied refusing or discouraging Patient #2 from returning to the ED at any time. During interview of Staff A (Administrator), Staff B (Administrator), and Staff C (Administrator) on 03/19/2025 at 10:28AM, Staff A, B, and C explained that an executive leader of the hospital received an anonymous call late Tuesday evening (03/11/2025) informing them of a potential EMTALA violation involving security staff. Staff A, B, and C further explained that this information was placed on the Incident Log, and that a multidisciplinary investigation began on 03/12/2025. Staff A, B, and Staff C shared their investigation identified opportunities for improvement and that a corrective action plan was implemented on 03/17/2025, with an emphasis on in-person EMTALA re-education for security staff, and Teams® (video conferencing software) EMTALA re-education for nursing and medical staff. Review of the facility’s EMTALA re-education materials and respective attendance sheets with dates and timestamps for each session, revealed that security, nursing, and medical staff started to receive EMTALA re-education training on 3/17/2025, prior to the start of this survey, and that re-education training was still in progress. Re-education verification interviews were conducted during a re-tour of the ED 03/19/2025 at approximately 1:00PM. A sample of security officers, nursing, and medical staff were interviewed to verify the EMTALA re-education. During interview of Staff E (Security Officer) on 03/19/2025 at 1:05PM, Staff E confirmed they attended the in-person EMTALA re-education on 03/18/2025 (verified against the attendance sign-in sheet), and Staff E was able to speak to the EMTALA policy. During interview of Staff F (Security Officer) on 03/19/2025 at 1:10PM, Staff F confirmed they attended the in-person EMTALA re-education on 03/18/2025 (verified against the attendance sign-in sheet) and was able to speak to the EMTALA policy. During interview of Staff G (Registered Nurse) on 03/19/2025 at 1:16PM, Staff G confirmed they attended the Teams® EMTALA re-education on 03/17/2025 (verified against the Teams® attendance sheet) and was able to speak to the EMTALA policy. During interview of Staff H (Security Officer) on 03/19/2025 at 1:25PM, Staff H confirmed they attended the in-person EMTALA re-education on 03/17/2025 (verified against the attendance sign-in sheet) and was able to speak to the EMTALA policy. During interview of Staff I (Physician) on 03/19/2025 at 1:32PM, Staff I confirmed they attended the Teams® EMTALA re-education on 03/17/2025 (verified against the Teams® attendance sheet) and was able to speak to the EMTALA policy. During interview of Staff K (Security Officer) on 03/19/2025 at 1:47PM, Staff K confirmed they attended an in-person focused EMTALA re-education on 03/15/2025, and an in-person EMTALA re-education on 03/17/2025 (verified against the attendance sign in sheets). Staff K was able to speak to the hospital’s EMTALA policy. Surveyors verified, through interview and review of pertinent documents, that the facility initiated corrective actions on 3/17/2025, prior to this survey. All incident reports, adverse events, and complaints/grievances were reviewed from 10/2024 to 03/2025. No other similar events or complaints were identified. These findings were confirmed with Staff A (Administrator), Staff B (Administrator), and Staff C (Administrator) on 03/21/2025 at 2:45PM.”

“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: 16362 . Based on medical record (MR) review, document review, and interview, the facility failed to ensure nursing staff assessed patients at risk for hospital-acquired pressure injuries (HAPIs) as per facility protocol, in one (1) of four (4) medical records reviewed. This failure placed all patients at risk for adverse patient outcomes. Findings: Review of the facility’s policy and procedure (P&P) titled, “Pressure Injury: Prevention, Assessment, and Management System,” last approved 10/27/2022, stated, “ ... the nurse will assess and inspect skin daily and as indicated by patient’s condition. Assess for history of prior pressure injury (PI) and/or presence of current injury on admission to the health care setting. Assess and monitor pressure injury (s) on admission to health care setting, at minimum weekly, and with any signs of skin/wound deterioration.” The facility’s “Pressure Injury Process Map,” dated 8/2023, stated the following: “Pressure injury (PI) - Hospital Acquired: Stage 2, Stage 3, Stage 4, DTI [Deep Tissue Injury: A pressure-related injury to the subcutaneous tissue under intact skin], or Unstageable - two (2)-RN [Registered Nurse] assessment: Document with measurements. Refer to nurse driven wound management protocol, notify nurse manager and assistant nurse manager, and place wound care consult ...” Review of Patient #2’s MR identified that Patient #2 was evaluated for altered mental status in the Emergency Department (ED) on 1/11/2024 at 1:52 PM and placed in the ED holding area. On 1/11/2024, nursing staff documented that a pressure injury was present on admission. There was no documented evidence of an assessment or treatment of Patient #2’s pressure injury until 1/14/2024 at 12:11AM, when nursing staff performed an initial skin assessment (72 hours after arrival) which indicated Patient #2 had a Stage II pressure injury on the coccyx region. No wound measurements of the injury were documented. On 1/17/2024 at 8:15 AM, nursing staff documented “ ...Patient with sacral coccyx suspected DTI [deep tissue injury]. There is new pressure injury identified on left heel, Stage 1.” No wound measurements, two (2)-RN assessment/verification, or wound care consult were found for the new hospital-acquired pressure injury on the left heel. During interview of Staff K (Registered Nurse/RN) on 5/10/2024 at 10:41 AM, Staff K confirmed the 2-RN verification for skin assessment was not performed. On 1/19/2024, Patient #2 was admitted to the Medical-Surgical Unit. The Admission Assessment at 5:32PM stated Patient #2 had a “DTI [deep tissue injury] noted...and a Stage 4 to the sacrum area.” Nursing staff did not document a description of the pressure injury, nor complete wound measurements, as per facility policy. During interview of Staff M (Registered Nurse/RN) on 5/10/2024 at 11:33 AM, Staff M stated they received Patient #2 to the medical surgical unit. Staff M stated Patient #2 had a suspected deep tissue injury / Stage 4 to the coccyx region, and that the wound was measured in length and width, but not depth. Staff M was not able to provide an explanation why the full measurements were not completed and documented when the Stage 4 pressure injury on the coccyx area was assessed. On 1/24/2024 at 8:27 AM, nursing staff documented, “Pressure Injury #2: sacral/coccyx area Stage IV measuring length 10 cm x 8 cm width ...Pressure Injury #4 on left heel; Pressure Injury #5 on right heel. The documentation lacked pressure injury depth, wound characteristics, and an assessment of pressure injury #1 on the sacrum/coccyx. In addition, no wound care consults were found for the new hospital-acquired pressure injuries. During interview of Staff D (Quality Assurance Registered Nurse) and Staff E (Quality Assurance Registered Nurse) on 5/10/2024 at 2:25 PM, Staff D and E confirmed these findings.”