Cuba Memorial Hospital, Inc.

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 48506 Based on policy review, medical record review, observation, and interview, in one of one medical record reviewed, the facility failed to triage and conduct an emergency medical screening examination. Specifically, Patient #1 presented to the urgent care center with their legal guardian without legal guardianship paperwork. As a result, Patient #1 left prior to being triaged and an emergency medical screening examination. Findings Include: Review on 03/05/24 of policy “Emergency Medical Treatment and Labor Act (EMTALA) Guidelines for Urgent Care Center”, last reviewed February 2023, revealed “all patients shall receive a medical screening exam by the physician/physician extender to determine whether or not an emergency condition exists.” Review on 03/05/24 of policy “Triage”, last reviewed February 2023, revealed “it is the policy of Cuba Memorial Hospital to assess and triage all patients coming to the urgent care center for medical care. Evaluation and stabilization is provided to all patients regardless of age, race, or ability to pay according to need of care. Triage procedure includes assessing the patient based on chief complaint, obtaining other pertinent information such as past medical history/surgical history, and obtaining vital signs.” Review on 03/05/24 of policy “Admission to the Urgent Care Center”, last reviewed March 2023, revealed “triage shall be performed by the registered nurse on duty prior to patient registration. All patients are assessed by the physician assistant or nurse practitioner and registered nurse on duty. At time of initial assessment, the registered nurse will determine and prioritize the patient’s nursing care needs. The assessment of adolescents specifically includes the family’s and/or guardian’s expectations for involvement in the assessment, treatment, and continuous care or treatment of the patient.” Review on 03/05/24 of policy “Informed Consent”, last reviewed March 2023, revealed “Cuba Memorial Hospital will ensure patients receive the information necessary to give informed consent prior to the start of any non-emergency treatment or procedure. In an emergency situation, consent is not necessary. An emergency exists when the following elements are present: The patient has a life or health threatening condition requiring immediate care, the patient is incapable of participating in the consent process, and there is not time to obtain consent from a duly authorized representative.” Special circumstances apply for consents for patients under 18 years of age. These include: “the mother, father, or legal guardian must sign. Signature of a relative is permitted only if [they] are the legal guardian.” Review on 03/05/24 of Patient #1’s medical record, dated 01/15/24, revealed at 02:40 PM, Patient #1 arrived at the urgent care center with a chief complaint of a fall down the stairs with injury to the right hand, thumb, and wrist. At 02:42 PM, Staff (E), Patient Access Representative, documented Patient #1 “needs triage”. At 02:43 PM, Staff (E), Patient Access Representative, documented on the “Reason for Leaving without Being Seen Form” that Patient #1’s reason for leaving was: “did not have guardianship paperwork. Guardian decided to leave after being informed [the hospital] needed it”. At 02:48 PM, Staff (C), Physician Assistant documented an urgent care note with the primary impression of “Patient left before triage assessment.” At 02:49 PM, Staff (K), Registered Nurse documented Patient #1 was “discovered gone” at 02:45 PM, and the departure disposition was “left before triage “. Review of the registration form (no time) revealed Patient #1’s legal guardian signed the form and listed relationship to the patient as a “legal guardian”. Observations on 03/05/24 at 10:35 AM, at the urgent care center registration/check-in window revealed a sign stating, “proof of guardianship must be presented to get treated”. Interview on 03/05/24 at 01:16 PM with Staff (K), Registered Nurse, said they were the triage nurse on duty on 01/15/24 when Patient #1 presented to the urgent care but never spoke to them or their family and did not recall the reason for presentation. Staff (K) stated the Patient Access Representative (E) informed Patient #1 that they would not be seen without proof of guardianship. Interview on 03/05/24 at 03:00 PM with Staff (A), Chief Executive Officer and Staff (B), Clinical Services Director, verified these findings and both stated that Patient #1 should have been triaged and provided a medical screening exam prior to obtaining guardianship paperwork. Additionally, both Staff (A) and Staff (B) were unaware of the sign located next to the urgent care center registration/check- in window stating, “proof of guardianship must be presented to get treated.” Staff (A) stated that the sign would be removed.”

“PERIODIC REVIEW OF CLINICAL PRIVILEGES CFR(s): §485.631(d) Standard: Periodic review of clinical privileges and performance. The CAH requires that- (1) The quality and appropriateness of the diagnosis and treatment furnished by nurse practitioners, clinical nurse specialist, and physician assistants at the CAH are evaluated by a member of the CAH staff who is a doctor of medicine or osteopathy or by another doctor of medicine or osteopathy under contract with the CAH. (2) The quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by- (i) One hospital that is a member of the network, when applicable; (ii) One Quality Improvement Organization (QIO) or equivalent entity; (iii) One other appropriate and qualified entity identified in the State rural health care plan; (iv) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patient under an agreement between the CAH and a distant-site hospital, the distant-site hospital; or (v) In the case of distant-site physicians and practitioners providing telemedicine services to the CAH’s patients under a written agreement between the CAH and a distant-site telemedicine entity, one of the entities listed in paragraphs (d)(2)(i) through (iii) of this section. (3) The CAH staff consider the findings of the evaluation and make the necessary changes as specified in paragraphs (b) through (d) of this section. This Standard is not met as evidenced by: 48506 Based on policy review, document review, and interview, the hospital failed to ensure the quality and appropriateness of the diagnosis and treatment furnished by physicians are evaluated by an outside entity. Review on 07/30/24 of policy “Medical Staff Peer Review”, last reviewed January 2024, indicated “clinical staff and medical staff will review a representative sample of medical records annually. Should the peer review physician find an issue that [they] may be reluctant to address due to the small number of facility medical, the record will be forwarded to the performance improvement manager to send for an external peer review. If all the attending physicians/dentists are involved in a case that requires review, that case will be referred to the performance improvement manager to send for an external peer review. Results of the reviews will be shared with the attending provider and reviewed at the quarterly medical services committee meeting.” Review on 07/30/24 of the External Peer to Peer Review log, dated July 2016 to July 2018, revealed the last record sent for an external peer review was dated 07/05/2018. Interview on 07/30/24 at 10:00 AM and 11:00 AM with Staff (B), Clinical Services Director revealed the external peer review company previously used is no longer in existence. Efforts to contact the company in 2019 were unsuccessful as the telephone number was disconnected and there was no forwarding information. There is not a current external peer review process.”