Ellis Hospital

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 21072 Based on document review and medical record review, in 1 of 21 (Patient #1) medical records reviewed, Patient #1 had a a chest x-ray and received a nebulizer treatment on 2/5/2024, but there is no documentation of a provider or nursing assessment related to these interventions. Findings include: -- Per medical record review, Patient #1 arrived to the ED on 2/4/2024 at 4:24 pm. Patient #1 was triaged at 4:26 pm with a chief complaint, “brought by daughter who is concerned about pt’s (patient’s) weight loss of greater than 10 pounds in 3 weeks. Hasn’t been sleeping. Patient’s wife died 7 weeks ago. Patient. is tearful. Daughter requesting a crisis evaluation as well.” Acuity level assigned was 3 on Emergency Severity Index (ESI) (is a 5-level triage system that categorizes emergency department patients by evaluating both patient acuity and the patient care resource needs. Acuity is determined by the stability of vital functions and potential for life, limb, or organ threat).Vital signs were temperature 98.4 degrees Fahrenheit, heart rate 84, respirations 22 (lungs clear, respirations unlabored), oxygen saturation on room air 95 %. A physician assistant saw Patient #1 at 5:27 pm. Physical exam revealed Patient #1 was alert and tearful, with normal respiratory effort and no respiratory distress. A physician saw Patient #1 at 7:15 pm. Review of systems revealed “positive for insomnia, decreased appetite, depression.” Medical Decision Making indicated “... Urinalysis not consistent with urinary tract infection. ... “ Patient was provided 50 milligrams (mgs) of oral hydroxyzine and 6 mg of oral Melatonin for sleep. Patient was still agitated, needs something else for sleep. Five mgs of intramuscular Haldol provided. Crisis stated that they were able to evaluate the patient and patient will receive a physician evaluation in the morning. Patients disposition is pending crisis recommendations. ED physician’s diagnosis was normal grief reaction, insomnia, anxiety, depression and failure to thrive. On 2/5/2024 at 2:35 am vital signs were temperature 97.5 degrees Fahrenheit, heart rate 80, respirations 18, blood pressure 110/60, and oxygen saturation 96%. At 4:41 pm: Patient #1 was accepted at Hospital B for transfer for inpatient psychiatric care. At 5:54 pm: a chest x-ray revealed “Findings suggestive of congestive heart disease with mild bibasilar atelectasis or less likely pneumonia.” At 7:55 pm Patient #1 received Albuterol 3 milliliters (mls) nebulizer. At 9:51 pm vital signs were: temperature 97.5 degrees Fahrenheit, heart rate 86, respirations 18, blood pressure 125/64, and oxygen saturation 97%. Patient #1 was transferred to Hospital B for a higher level of care. -- Per review of hospital policy and procedure titled “Patient Assessment & Reassessment: Documentation and Plan of Care,” (revised 10/2023), “the purpose of this policy is to provide a process for patient assessment/reassessment to determine the level of care required to meet the patient’s initial needs as well as his/her needs as they change in response to care or disease process. ...” - Per interview of Staff F on 11/5/2024 at 2:00 pm, they acknowledged the above findings.”

“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: 35159 Based on observation, medical record review and review of facility policy, the facility failed to implement all requirements of their policy for EMTALA Medical Screening Examinations for 1 of 20 patients (#16) in the medical record sample. Findings: The facility failed to provide necessary stabilizing treatment prior to discharging patient #16 on 8/9/2023. (See findings at A2407). The facility’s “Emergency Department and EMTALA” policy (Policy # 9307, Rev. Date 10/21) reviewed by the State Agency (SA) on 11/15/2023 states, “an individual who comes to the emergency department will receive an MSE, performed by a physician or a QMP, appropriate to the individuals presenting signs and symptoms”. It also states, “If the treating physician determines that the individual has an emergency medical condition, the hospital will provide: 1) further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the staff and facilities, or 2) for transfer of the individual to another medical facility in accordance with EMTALA obligations”.”

“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: 35159 Based on observation and record review, the facility failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) requirement for sign posting. Findings: The “Ellis” site Emergency Department (ED) was toured by the State Agency (SA) on 11/14/2023 at 1040. There was only one EMTALA sign in the waiting room, which could not be seen from all areas of the waiting room. There was no EMTALA signage in the non-urgent area of the ED and no EMTALA signage in any of the patient rooms in the main ED. A sign posted at the ED registration desk read: “The Emergency Department is for serious and life-threatening emergencies ONLY.” This sign indicated to patients and visitors when it is appropriate to come to the Emergency Department, when to go to a primary care physician and when to go to an urgent care. The facility’s “Emergency Department and EMTALA” policy (Policy # 9307, Rev. Date 10/21) reviewed by the SA on 11/15/2023 indicates that “The hospital will post signage conspicuously in lobbies, waiting rooms, admitting areas, and treatment rooms where treatment and examination occurs in the form required by CMS that specifies the rights of individuals to examination and treatment for emergency medical conditions and whether the Hospital participates in the Medicaid program. Signage will be posted in each dedicated emergency department. The hospital will not post any sign that discourages an individual from remaining for an appropriate medical screening examination.” “In general, the sign should be visible from anywhere in the area or at a reasonable distance (e.g. 20 feet) or whichever is less.””

“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: 35159 Based on medical record review, the facility failed to provide necessary stabilizing medical treatment for 1 of 20 patients (patient #16) in the medical record sample. Findings: Patient #16 was brought to the Emergency Department (ED) on 8/8/2023 at 1908 accompanied by police after the patient attempted to hang self at a juvenile detention facility. The patient was seen by behavioral health crisis staff at approximately 1945 on 8/8/23. It was determined that the patient would stay in the ED and be re-evaluated by a psychiatrist in the morning. (8/9/2023). The patient verbalized suicidal ideation and that they would try to hang self or cut their neck. Per the Staff H’s assessment/Behavioral Health note for 8/9/23 at 1454, entered on 8/18/23 at 1515 indicated the patient was in need of psychiatric hospitalization, and needed a forensic facility. Staff H wrote a letter dated 8/9/23, to the detention facility that indicated the patient needed a forensic mental health facility due to the patient being in the custody of the criminal justice system. The documentation further revealed a transfer to a forensic unit would not be possible at this time, as it requires going through the court system. The facility discharged the patient on 8/9/23 at 1758 indicating that the patient was to be maintained on constant observation at the detention facility. The facility policy entitled “Emergency Department and EMTALA” policy (Policy # 9307, Rev. Date 10/21) reviewed by the SA on 11/15/2023 indicates “If the treating physician determines that the individual has an emergency medical condition, the hospital will provide: 1) further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the staff and facilities, or 2) for transfer of the individual to another medical facility in accordance with EMTALA obligations”.”