United Memorial Medical Center

“SUPERVISION OF EMERGENCY SERVICES CFR(s): 482.55(b)(1) The emergency services must be supervised by a qualified member of the medical staff. This Standard is not met as evidenced by: 49420 Based on policy review, medical record review, document review, and interview, in seven of 15 medical records reviewed, the hospital does not have a consistent mechanism and/or protocol to ensure the supervising physician provides continuous supervision over the physician assistants (Patient #1, #3, #4, #5, #6, #7, #9). Findings Include: Review of the document “Bylaws of the Medical Staff of United Memorial Medical Center,” revised 01/26/26, revealed the physician assistant must have a supervising physician within the same scope of practice who holds clinical privileges and is in good standing. The physician assistant may perform medical services under the general supervision of the supervising physician or their designee, as outlined by their approved delineation of privileges. A physician assistant shall have authority to write medical orders and prescribe medications, subject to the scope of privileges granted to them within their delineation of privileges and New York State laws and regulations. Every health care provider at the hospital is only entitled to exercise those clinical privileges within the scope of privileges granted. Privileges granted are good for up to three years. Review of the New York State Regulation for Hospitals “Section 405.4 - Medical staff,” indicates it is medical staff responsibility to adopt, with governing body approval, bylaws, rules and regulations which provide formal procedures for the evaluation of the application and credentials of registered physician’s assistants and registered specialist’s assistants applying for employment or privileges in the facility for the purpose of providing medical services under the supervision of a physician; and the mechanism by which the supervising physicians shall exercise continuous supervision over the registered physician’s assistants or registered specialist’s assistants for whom he or she is responsible. “Section 40.19- Emergency Services,” indicates patient care services provided by licensed physician assistants shall be in accordance with section 405.4. Licensed physician assistants and the nurse practitioners shall meet the following standards: every person arriving at the emergency service for care shall be promptly examined, diagnosed and appropriately treated in accordance with triage and transfer policies and protocols adopted by the emergency service and approved by the hospital. All patient care services shall be provided under the direction and control of the emergency services director or attending physician. In no event shall a patient be discharged or transferred to another facility, unless evaluated, initially managed, and treated as necessary by an appropriately privileged physician, physician assistant, or nurse practitioner. Review of the ED medical record for Patient #1’s 2nd presentation to Hospital #1, dated 03/10/26, revealed the following: -At 06:16 PM, Patient #1 arrived at the ED via ambulance. -At 06:25 PM, the provider note by Staff (S), Physician Assistant (PA), revealed Patient #1 was in the Emergency Department (ED) on 03/08/26 and followed up with orthopedics outpatient on 03/09/26 where they aspirated the left knee. The fluid was bloody according to Patient #1’s spouse. Patient #1 stated that since the aspiration they had significantly more pain and the oral Morphine only gave temporary relief. The left knee was extremely warm, and Patient #1 lost a lot of range of motion. A physical assessment by Staff (S) revealed Patient #1 had nearly no flexion at the left knee with significant swelling, tenderness, bruising where the aspiration was performed, had significant warmth compared to the right knee, and had pain when attempting to ambulate. Staff (S) ordered a left knee x-ray, blood work including CBC with differential (complete blood count that provides detailed information about the different types of white blood cells in the blood), CMP (comprehensive metabolic panel that measures glucose, electrolytes, kidney and liver function), lactate (level of lactic acid in the blood, high levels can be toxic and can indicate infection, cardiovascular/respiratory issues, anemia, and disease), CPR (C-reactive protein is a marker of inflammation in the body), ESR sedimentation rate ((erythrocyte sedimentation rate measures inflammation in the body such as infection), urinalysis (urine test for diagnose conditions like urinary tract infections), and intravenous (in vein) Morphine pain medication. -At 06:36 PM, the left knee x-ray was completed, compared to the knee x-ray completed on 03/08/26 and resulted in no fracture, but severe degenerative changes of the tricompartmental knee joint (deterioration of cartilage), and a moderate sized suprapatellar (area on the knee just above the kneecap) effusion (fluid) was present. -At 07:12 PM, Staff (R), Registered Nurse, administered IV morphine to Patient #1. -At 07:32 PM, blood work results revealed, WBC (white blood cell-normal 4-11- an elevated result can indicated infection or inflammation) of 12.5; neutrophils (normal 45-75 %- body’ s response to infection, injury, or inflammation) was 80%; neutrophil number (normal 1.8-8- an elevated result can indicate infection and/or injury) was 10; monocyte number (normal 0.1-1.0- an elevated result can indicate infection and/or inflammation) was 1.4; CRP (C-reactive protein is a marker of inflammation in the body- normal 0-8. an elevated result can indicate severe inflammation, infection, and/or cardiovascular risk) was 100; ESR (erythrocyte sedimentation rate- normal 0-20- an elevated result can indicate infection and/or inflammation) was 48. -At 08:56 PM, Staff (S), Physician Assistant, documented the differential diagnosis was traumatic knee aspiration versus septic joint versus hemarthrosis versus ACL rupture. The CBC showed mildly elevated WBC of 12.5, urinalysis was noninfectious, ESR was elevated at 48, and the CRP was elevated at 100. The x-ray of the knee showed moderate sized suprapatellar effusion with severe degenerative changes of the tricompartmental knee joint. The case was verbally discussed with Staff (T), Orthopedic Physician Assistant, who advised that it was likely recurrent hemarthrosis (bleeding into the joint, causing pain, swelling, and limited movement) secondary to traumatic aspiration and ACL rupture. (Staff (T), Orthopedic PA was on-call and did not perform a physical assessment). Patient #1 was advised to rest, ice, and elevate the left knee, and walk with crutches. There was a low concern for antibiotics as there were no other infectious signs such as fever or increased erythema (redness of the skin). Patient #1 was discharged home and was advised to follow up with their orthopedic provider. (There was no evidence found that Staff (S) consulted and/or discussed Patient #1’s condition with their attending physician and/or another physician). -At 09:42 PM, Staff (R), Registered Nurse, documented Patient #1 had a pain level of zero out of ten. Vital signs were a temperature of 98.4 degrees Fahrenheit, a heart rate of 75 beats per minute, respirations of 20 breaths per minute, a blood pressure of 133/71 millimeters of mercury (normal 120/80 millimeters of mercury), and pulse oximetry of 99 percent on room air (no supplemental oxygen usage). -At 09:43 PM, Patient #1 signed their discharge instructions and left the ED. Review of the ED medical record, dated 03/06/26 at 09:00 AM, revealed Patient #2 presented to the ED after falling on ice at work and had left shoulder pain radiating to their neck. Staff (L), Physician Assistant, completed the medical screening exam and ordered a left shoulder x-ray. Staff (L), Physician Assistant documented “per protocol,” the case was discussed with Staff (FF), ED Physician, who agreed with the discharge. Staff (FF), ED Physician, documented an attestation in the medical record that they reviewed Patient #2’s presentation and plan of care with Staff (L), Physician Assistant. Patient #2 was discharged home due to the should x-ray being negative for fracture. Medical record review revealed no documentation or attestation indicating the attending physician was consulted on the case, reviewed patient presentation, agreed with the plan of care and/or discharge with the physician assistant for the following patients: -On 03/06/26 at 11:32 AM, Patient #3 presented to the ED for falling on ice on the steps of their home, had left rib pain, and hit their head on the stairs. Staff (S), Physician Assistant completed the medical screening exam and ordered x-ray of the lumbar spine (lower section of spine), computed tomography (CT-detailed cross-sectional images of the body) of the head and cervical spine (upper part of the spine near the neck) and all were negative for any acute findings. Patient #3 was discharged home by Staff (S), Physician Assistant. -On 04/11/26 at 04:23 PM, Patient #4 presented to the ED for left knee pain. Staff (S), Physician Assistant completed the medical screening exam and ordered left knee x-ray that showed a possible fracture so a CT of the left knee was completed and it was negative for fracture. Patient #4 was discharged home by Staff (S), Physician Assistant. -On 04/11/26 at 02:07 PM, Patient #5 presented to the ED for falling and injuring their right elbow, hitting their head, and had a left leg laceration. Staff (V), Physician Assistant, completed the medical screening exam and cleaned/dressed the left leg laceration. Staff (V), Physician Assistant, ordered a head and cervical spine CT scan which were negative for any acute findings. An x-ray of the right arm showed a fracture of the humerus (upper arm bone). Staff (V), Physician Assistant, consulted with an orthopedics physician assistant, but the humerus fracture was out of their scope of practice. Staff (V), Physician Assistant discharged Patient #5 home with an arm splint and to follow-up with their outpatient orthopedic provider as they may need surgery. -On 04/09/26 at 07:56 PM, Patient #6 presented to the ED for left toe injury. Staff (S), Physician Assistant, completed the medical screening exam and ordered left foot x-ray that was negative for fracture. Staff (S), Physician Assistant, discharged Patient #6 home. -On 04/08/26 at 01:40 PM, Patient #7 presented to the ED for chest and arm pain. Staff (BB), Physician Assistant completed the medical screening exam, ordered bloodwork which resulted within normal limits, and an EKG (electrocardiogram - test to record the electrical activity of the heart) which showed normal sinus rhythm. Staff (BB), Physician Assistant, discharged Patient #7 home. -On 04/04/26 at 03:26 PM, Patient #9 presented to the ED for left knee and hip injury. Staff (S), Physician Assistant completed the medical screening exam and ordered a left knee and hip x-ray that were negative for fracture. Staff (S), Physician Assistant, discharged Patient #9 home. Interview on 04/17/26 at 11:30 AM with Staff (D), Clinical Regulatory Compliance, verified the findings. Interview on 04/16/26 at 10:00 AM with Staff (F), Chief Medical Officer, revealed that if a patient in the ED was to be discharged, the physician assistant did not need to consult with the attending physician and had the ability to independently make that decision. If a patient in the ED disposition was to be admitted to the hospital or transferred to another hospital the physician assistant would consult with the attending physician to discuss the plan. Interview on 04/16/26 at 12:10 PM with Staff (S), Physician Assistant, revealed they cared for Patient #1 on 03/10/26. Patient #1’s knee was warm, had bruising, pain, decreased range of motion, and had difficulty walking. Blood work was performed and a repeat x-ray. Staff (S) spoke with Staff (T), Orthopedic Physician Assistant, regarding Patient #1 ’ s symptoms and blood work who recommended outpatient orthopedic follow-up with the team that aspirated the left knee and to ice and use the knee immobilizer. Staff (S) felt that Patient #1 did not need to be admitted to the hospital due to orthopedic recommendations, did not have a fever or high heart rate, and was walking with crutches. The WBC was only slightly elevated, and CRP and ESR inflammatory markers were elevated most likely secondary to the trauma of the knee aspiration. A physician assistant will consult an attending physician in the ED when there are questions regarding treatment, a transfer of a patient to a higher level of care, to admit a patient, and for a death. Attending physicians are in the ED 24 hours a day seven days a week. Physician assistants in the ED typically provide care for patients who need basic procedures similar to the care provided at an urgent care. If an attending physician co-signs a patient ’ s medical chart, they will document and complete an attestation. Interview on 04/16/26 at 12:55 PM with Staff (O), Physician, revealed physician assistants who work in the ED typically see less acute patients and do not always seek input from an attending physician. If a physician assistant needs help with the care of patients, an attending physician is present to collaborate with them. The attending physician would previously co-sign all patient charts that the physician assistant cared for but that is not the expectation at this time. Staff (O) reviewed Patient #1’s medical record for 03/10/26. If Staff (S). Physician Assistant, consulted with them, depending on their physical assessment, Staff (O) could have made a medical decision to either discharge or admit to the hospital depending on the information gathered collaboratively. Interview on 04/16/26 at 02:45 PM with Staff (X), System Medical Director Emergency Services, revealed that physician assistants are privileged to work independently. If a patient needs to be admitted or transferred to another facility, the physician assistant will discuss the patient with the attending physician. If the attending physician is involved in the care of the patient, they will document an attestation in the medical record. The hospital does not have a formal written policy or procedure for the oversight of physician assistants or advanced practice provider expectations. Interview on 04/17/26 at 10:10 AM with Staff (DD), Manager Medical Staff Office, revealed a physician assistant works at the directive of an attending provider. Physician assistants are not to work independently.”

“STAFF TRAINING CFR(s): Applicable staff, as identified by the hospital, must be trained annually on the protocols and provisions implemented pursuant to this section. (i) The governing body must identify and document which staff must complete such training. (ii) the hospital must document in the staff personnel records that the training was successfully completed. (iii) the hospital must be able to demonstrate staff knowledge on the topics implemented pursuant to this section This Standard is not met as evidenced by: 49420 Based on policy review, document review, and interview, in one of four registered nurse personnel files reviewed, the hospital failed to ensure that all mandatory training was completed before working independently (Staff R). Findings include: Review of the document “Emergency Medical Treatment and Active Labor Act COBRA/EMTALA, Mandatory Packet,” dated 08/22/25 revealed the mandatory education that all staff members of the ED receive including nursing staff. Review of the document “Enhanced Staffing Solutions Program Administration Team Operation Handbook (internal travel agency), “ dated 03/06/26 revealed all registered nurses must complete new employee orientation requirements including the EMTALA online module to work independently on their assigned unit. Review of the personnel file for Staff (R), Registered Nurse, revealed a date of hire of 01/05/26. The document “Health Stream Transcript, “ dated 04/17/26 indicated they have not completed EMTALA training. No other evidence was provided to indicate Staff (R) received EMTALA education. Interview on 04/17/26 at 09:35 AM with Staff (AA), Nursing Education Manager, revealed that Staff (R), Registered Nurse, was hired for the centralized float pool for ED services on 01/05/26. Staff (R) was assigned EMTALA mandatory training on 02/06/26 and was due to be completed on 03/08/26. Staff (R) had not completed the EMTALA at the time of the interview. Interview on 04/17/26 at 11:00 AM with Staff (FF), Enhanced Staffing Solutions Coordinator, revealed it is expected that all training will be completed prior to the first shift including EMTALA. Staff (R), Registered Nurse, first independent shift was 01/22/26 and should have had all required training completed including EMTALA. As of the time of the interview Staff (R) had not completed EMTALA training.”

“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: 48506 Based on policy review, medical record review, and interview, in one out of six record reviewed, the hospital failed to ensure nursing staff documented an initial skin check on admission (Patient #1). Findings Include: Review of policy “Skin Integrity Management Policy,” dated February 2024, indicated an initial skin check would be documented on admission and with transfer, where one nurse must be a registered nurse and another nurse must confirm. Review of the medical record of Patient #1 revealed on 11/25/24 at 10:23 AM, Patient #1 presented to the emergency department via ambulance with a complaint of a fall and was found lying on the ground for four to five hours. The registered nurse noted a skin tear on Patient # 1’s left lower leg, but no evidence was found to indicate an initial skin assessment was performed until 11/27/24 at 01:45 PM, when Staff (DD), Wound Care Nurse, documented a skin assessment for Patient #1 that identified one stage one pressure injury (reddened area of the skin) on the upper spine, a stage two pressure injury (skin breakdown where the top layer of skin has broken open) that measured 1.0 x 1.0 centimeter (cm), and a skin tear to the left lower leg measuring 3.6 x 3.1 x 0.1 cm deep. Interview on 03/05/25 at 12:21 PM with Staff (DD), Wound Care Nurse, revealed they became involved in Patient #1’s care on 11/27/24 when they performed a skin assessment for Patient #1. When Staff (DD) reviewed Patient #1’s medical record, there was no initial skin assessment documented.”