Genesis Hospital

“SELF-ADMINISTRATION - DRUGS FROM HOME CFR(s): 482.23(c)(6)(ii) [The hospital may allow a patient (or his or her caregiver/support person where appropriate) to self -administer both hospital-issued medications and the patient’s own medications brought into the hospital, as defined and specified in the hospital’s policies and procedures.] (ii) If the hospital allows a patient to self-administer his or her own specific medications brought into the hospital, then the hospital must have policies and procedures in place to: (A) Ensure that a practitioner responsible for the care of the patient has issued an order, consistent with hospital policy, permitting self-administration of medications the patient brought into the hospital. (B) Assess the capacity of the patient (or the patient’s caregiver/support person where appropriate) to self-administer the specified medication(s) and also determine if the patient (or the patient’s caregiver/supplier person where appropriate) needs instruction in the safe and accurate administration of the specified medication(s). (C) Identify the specified medication(s) and visually evaluate the medication(s) for integrity. (D) Address the security of the medication(s) for each patient. (E) Document the administration of each medication, as reported by the patient (or the patient’s caregiver/support person where appropriate), in the patient’s medical record. This Standard is not met as evidenced by: 33019 Based on record review, staff interview, and policy review, the hospital failed to ensure that a practitioner issued an order permitting self-administration of a patient’s home medication which was to be brought into the hospital. This affected one (Patient #4) of 26 medical records reviewed. The hospital census was 180 patients. Findings include: Review of the medical record for Patient #4 revealed he arrived to an outlying emergency department (ED) on 02/05/25 at 12:32 P.M. with a chief complaint of shortness of breath. His visit diagnoses were influenza, hypoxia, immunocompromised state, and acute hypoxic respiratory failure. The resident was admitted for acute hypoxia respiratory failure which required high flow oxygen via nasal cannula and was transferred on 02/05/25 at 5:52 P.M. to the main hospital for further care. Review of Patient #4’s medication list reviewed in the ED by Registered Nurse (RN) (Staff #S) revealed Patient #4 received dolutegravir (Tivicay) 50 milligrams (mg) by mouth daily. Review of Patient #4’s History and Physical (H and P) completed by admitting Physician #R, dated 02/05/25, revealed the patient had the diagnosis of Human Immunodeficiency Virus (HIV). He was to continue his home regimen when able to get it from his spouse the following day. His antiviral home medications included emtricitabine-tenofovir (Truvada) 200-300 mg one tablet by mouth daily and dolutegravir (Tivicay) 50 mg one tablet by mouth daily. Review of Patient #4’s medication administration record (MAR) revealed he was administered emtricitabine-tenofovir (Truvada) 200-300 mg one tablet daily during his hospitalization, 02/06/25 through 02/13/25. There were no doses of dolutegravir (Tivicay) 50 mg administered or received during Patient #4’s hospitalization. During an interview on 04/21/25 at 12:29 P.M., Pharmacy Director #J confirmed Patient #4 did not receive his antiviral medication dolutegravir (Tivicay) during his hospitalization. Pharmacy Director #J stated he believed the issue was that the medication was listed as “non-formulary” and possibly the admitting physician, Physician #R, assumed it wasn’t available and did not order it. Pharmacy Director #J confirmed that although a medication may be listed as “non-formulary” the pharmacy would have been able to obtain and provide this medication to the patient. Pharmacy Director #J stated if Patient #4’s spouse had brought in his home medication, the physician would have put an order in for the medication and pharmacy would verified the medication. During subsequent interview on 04/25/25 at 2:16 P.M. with Pharmacy Director #J revealed the definition of non-formulary in the inpatient hospital setting means that a medication may not be stocked, however, that does not mean that the medication cannot be obtained. Pharmacy Director #J stated the use of the word “non-formulary” is what he thinks started the entire situation and why the medication was not ordered, as the admitting physician may have assumed the medication was not available. Pharmacy Director #J confirmed there were no notes in the medical record indicating that Patient #4’s spouse ever brought in his home medications to the hospital. During an interview on 04/24/25 at 12:13 P.M.. Registered Nurse (RN) (Staff #Q) revealed she did not recall Patient #4’s spouse bringing in his home medications during his hospitalization, but if she had, the process prior to administering those medications would have required both pharmacy and physician verification. During an interview on 04/24/25 at 2:35 P.M., RN/Director of Acute Care Services (Staff #K) revealed Patient #4’s medical record did not reveal he received dolutegravir (Tivicay) 50 mg during his hospitalization, nor that his spouse brought in his home medications. Staff #K stated there was no documentation of any follow-up with the patient’s spouse regarding his home medications. During an interview on 04/24/24 at 12:50 P.M., Regulation Program Specialist/RN (Staff #A) stated her expectation was that there should have been a follow-up with Patient #4’s spouse regarding his home medications. During an interview on 04/24/25 at 2:58 A.M. with the Medical Director of Hospital Medicine/Physician #T revealed admitting Physician #R was currently working and was unable to be interviewed, however, he had reviewed Patient #4’s medical record could answer any questions. Physician #R stated that the admitting physician reviews all medications upon admission and it was charted by Physician #R that Patient #4’s home HIV medications would be brought to the hospital by his spouse. Medical Director of Hospital Medicine/Physician #T confirmed there was no evidence that Patient #4’s spouse brought in his home medications or that he received Tivicay 50 mg once per day. Review of the facility’s policy titled, “Medications: Use of a Patient’s Home Supply,” dated 08/01/24, revealed Genesis HealthCare Systems strongly discourages the use of the patient’s home supply of medication. In the event that a patient’s home medication supply is to be utilized during the patient’s hospital stay, an order must be obtained to utilize the patient’s medication supply. Prior to administration, all medications for home use must be verified by the pharmacist and labeled to ensure barcode scanning and patient safety. The medications cannot be provided to the patient until verified by Pharmacy.”

“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 33019 Based on record review, staff interview, and policy review, the hospital failed to ensure Patient #4’s medical record contained complete information/documentation of patient care. This affected one (Patient #4) of three medical records reviewed for discharge. The hospital census was 180 patients. Findings include: Review of the medical record for Patient #4 revealed he arrived to an outlying emergency department (ED) on 02/05/25 at 12:32 P.M. with a chief complaint of shortness of breath. His visit diagnoses were influenza, hypoxia, immunocompromised state, and acute hypoxic respiratory failure. The resident was admitted for acute hypoxia respiratory failure which required high flow oxygen via nasal cannula and was transferred on 02/05/25 at 5:52 P.M. to the main hospital for further care. Review of a Patient Feedback form, dated 02/14/25, revealed Patient #4 called the Nurseline and left a voicemail with a complaint alleging that his spouse waited outside for almost two hours prior to his discharge and that he was not offered a wheelchair and had to walk out of the hospital on his own while wearing oxygen. There were no discharge notes documented so patient safety was unable to determine how the patient left the facility or if he was required to set up his portable oxygen. Nurse Manager RN (Staff #N) reviewed the concern and stated that he witnessed Patient #4 attempting to leave and did not want to wait on staff to remove his intravenous (IV) line. Staff #N stated he clearly overheard the bedside RN offer the patient a wheelchair on discharge and spoke with staff who informed him the patient left as soon as his discharge was ready. Review of Patient #4’s After Visit Summary (AVS), dated 02/13/25, revealed durable medical equipment (DME) was ordered for continuous oxygen to be infused at 4 liters per minute per nasal cannula. Supplies ordered included a portable and stationary oxygen system with nasal cannula, tubing, and humidification. The resident was educated on his medications and follow-up appointments. Review of the AVS form revealed it was not signed by Patient #4. During an interview on 04/24/25 at 2:35 P.M. with RN/Director of Acute Care Services (Staff #K) revealed Patient #4’s medical record did not contain documentation of his refusal of a wheelchair, of the removal of his IV, or of the set-up of his portable oxygen. Staff #K stated the medical record should have contained all of this information. Staff #K confirmed Patient #4 did not sign his discharge/After Visit Summary. Review of the facility’s policy titled, “Discharge Planning and After Visit Summary Requirements,” dated 05/01/24, revealed all after visit summary or discharge instructions provided to patients and/or families will require a signature prior to the patient leaving the facility.”

“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: 49793 Based on record review, interview and policy review, the hospital failed to ensure a medical screening exam was completed in a timely manner to determine if a medical emergency existed. This affected one (Patient #3) of 20 records reviewed. Findings include: Medical record review revealed Patient #3 arrived at the Emergency Department (ED) on 02/25/25 at 11:56 P.M. via personal vehicle. Patient #3 complained of lower severe abdominal pain, nausea and vomiting, with the pain radiating into the chest. Patient #3 stated he had gallbladder surgery two days ago. He reported feeling the need to have a bowel movement but was unable to do so and had some liquid stool. Patient #3 arrived via personal vehicle. Triage was completed on 02/26/25 at 12:09 AM. Patient #3 was classed as a II on the emergency screen index (ESI) indicating life/organ threat. Initial vital signs were blood pressure 143/83, heart rate 71, respirations 18, temperature 98.5 degrees Fahrenheit (F) orally and oxygen saturation of 99 percent on room air. Patient #3 rated the pate an eight on a one to ten scale. An electrocardiogram (EKG) was obtained. Patient #3 was then put in the “results pending” room in a chair. At 12:27 AM., nursing protocol orders were placed. Registration was completed at 1:46 AM. At 4:04 AM, an intravenous saline lock was placed. At 4:11 AM, a computed tomography (CT) scan was ordered for the abdomen and pelvis with IV contrast. No further vital signs were obtained until 4:25 AM and at that time blood pressure was 109/54. heart rate 83, respirations 22, temperature 97.6 degrees F orally and oxygen saturation was 100 percent on room air. Patient #3 rated his pain a ten on a one to ten scale. Laboratory orders were not placed until 4:26 AM and the specimens were collected at 4:27 AM. A physician assistant was assigned to Patient #3 at 4:27 AM. At 4:42 AM, Patient #3 was medicated for pain with Dilaudid one milligram IV push. The CT scan was done at 4:54 AM. At 5:46 AM, Patient #3 was finally moved from the “results pending” room to an ED room for examination and treatment. A physical examination was completed by the physician assistant at 5:52 AM. At 6:09 AM, Patient #3 was seen by a physician. Patient #3 was given a rectal enema of mineral oil at 11:58 AM. At 4:31 PM, Patient #3 was discharged home in stable condition. During an interview on 04/17/25 at 9:15 AM, Emergency Department (ED) Chief Medical Director AA stated the ED was very busy this day with 50 patients present in the ED and 24 in the waiting area. At 12:09 AM, the nurse screened Patient #3 and put him in the “results pending” room and the on duty ED physician was notified. During an interview on 04/17/25 at 9:15 AM, ED Physician BB stated she signed on for her shift on 02/26/25 at 6:00 AM and signed onto Patient #3’s case at 6:08 AM. She treated him and admitted him and the Hospitalist became his physician of record. He was discharged later that day. Review of the policy titled “Triage and Triage Acuity Classification”, dated 06/09/22, stated an ESI II patient was a patient presenting with high risk situations, or confused or lethargic, or sever pain or distress. ESI Level II may include but is not limited to: Threatened with possible life/organ threat. Needs physician within approximately ten minutes and requires high resource intensity. Multiple diagnostic studies or procedures needed. Record review of the policy titled “Assessment and Reassessment of the ED Patient”, dated 09/12/24, stated the primary assessment will be performed by a RN and all patients are continually reassessed at continual intervals, or more frequently as condition dictates. Assessments and reassessments will be documented in the Electronic Charting Record (ECR) and will be completed with the following guidelines: ESI II reassessments every 5-15 minutes with vital signs every 30 minutes for one hour or until stable every one hour. ESI levels are assigned on admission to the ED. The levels may be adjusted upwards as acuity warrants but are not adjusted downward due to potential deterioration of the patient’s condition. Vital sign intervals may be changed up to every four hours as the condition may improve. Nursing documentation needs to support the patient’s reassessments and status changes.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 28999 Based on record review, interview and policy review, the facility failed to ensure staff staff followed the current facility policy related to clinical escalations in one Labor and Delivery patient. This affected Patient #4. Findings include: Review of the medical record revealed Patient #4, a Gravida 1 Para 0 at 36.3 weeks gestation, presented to Obstetric Triage on 08/07/24 at 6:22 PM with complaints of vaginal bleeding and pain from contractions. At 6:27 PM the patient was placed on external fetal monitor and tocodynamometer to assess the fetal heart rate and uterine activity. A Category I, or normal fetal heart tracing was documented, but contractions were occurring every one to two minutes. At 6:30 PM, the patient’s vital signs included a blood pressure of 140/83 and pulse of 97 beats per minute. The Attending Obstetric Physician’s (Staff P) history and physical revealed the patient had a current obstetrical history remarkable for pre-eclampsia without severe features and a low lying placenta (placenta that partially covers the cervix). The history and physical stated the patient reported intermittent cramping and unprovoked vaginal bleeding that was more than just with wiping. The plan, outlined in the history and physical, was to administer an intravenous (IV) bolus of lactated ringers, continue home Labetalol (medication used to treat high blood pressure in pregnant women) at 300 mg three times a day, and administer two doses of Betamethasone (steroid administered to preterm pregnant women to accelerate fetal lung maturity). The physician further stated the patient and her husband were advised it would be preferred to wait 12-24 hours to give Betamethasone time to aid in fetal maturity but if the fetal heart tracing began to show decelerations, increased bleeding, or pain increased significantly, the physician would move to delivery. According to the history and physical, the plan was always to perform a cesarean section due to the low lying placenta, however, since the patient was less than 37 weeks, the protocol was to administer Betamethasone. At 6:35 PM, the labor flowsheet revealed the patient rated her pain a 4 on a 0-10 scale. At 7:00 PM, contractions with a moderate quality were occurring every 1-2 minutes. The baseline fetal heart rate was 140 beats per minute with moderate variability at this time. A nurse’s note at 6:40 PM stated the Attending Obstetric Physician was notified of the patient’s arrival due to vaginal bleeding and the nurse being uncomfortable performing a sterile speculum exam due to the patient’s low lying placenta. The nurse also informed the physician that the patient was contracting every 1-2 minutes, however the abdomen was soft between contractions. The physician stated she would come to the hospital. Review of the Medication Administration Record (MAR) revealed the patient was medicated with a 1000 mL bolus of lactated ringers, from 7:01 PM to 7:46 PM, to eliminate the contractions, and at 7:02 PM, Betamethasone 12 mg was administered intramuscularly. At 7:40 PM, the Attending Obstetric Physician was at the bedside of the patient. The patient’s cervix was visually closed and a digital exam was deferred. At 8:30 PM, the labor flowsheet noted a baseline fetal heart rate of 130 beats per minute with late decelerations, a Category II fetal heart tracing. The patient was positioned left lateral and an IV fluid bolus of lactated ringers was initiated at 8:40 PM as intrauterine resuscitative measures. The MAR noted the patient was medicated with 4 mg of IV Zofran (medication used to treat nausea and/or vomiting). According to the labor flowsheet, at 9:00 PM, the Category II fetal heart tracing continued with a baseline fetal heart rate of 120 beats per minute with late decelerations. The patient was positioned side to side as an intrauterine resuscitative measure. Contractions continued to occur every 1-2 minutes. The patients pulse was 112 beats per minute at this time. A nurse’s note, at 9:15 PM stated a call was placed to the Attending Obstetric Physician to notify her that the patient was reporting the contractions were more intense but vaginal bleeding was still scant. The note further stated the physician was notified that the fetal heart rate was in the 100’s-110’s with the staff nurse and the charge nurse agreeing there appeared to be late decelerations with moderate variability. The physician ordered the nurse to administer acetaminophen and advised the nurse that she would review the fetal heart tracing from home. At 9:23 PM, the labor flowsheet revealed that the patient rated her pain from contractions a 6 on a 0-10 scale. The MAR noted the patient was medicated with 1,000 mg of acetaminophen at this time. An indeterminate deceleration was audible at 9:30 PM. A nurse’s note at 9:33 PM stated the physician called back to the unit after reviewing the fetal heart tracing and stated she did not see late decelerations but advised the nurse to keep watching the patient’s bleeding and pain, and if either increased, to call back. A nurse’s note at 10:15 PM stated the patient called out reporting she was bleeding more. The nurse further documented a small amount of bleeding was noted on the pad and peri area. A deceleration in the fetal heart rate was also noted. A nurse’s note, at 10:30 PM, stated the patient advised the nurse that she needed to urinate. The nurse went to the room to assess the patient’s bleeding and discovered increased bleeding with clots when the patient got up to the bathroom. A nursing note, at 10:46 PM, stated a call was placed to the Attending Obstetric Physician to notify her that the contractions were “back to back” and the patient was not getting any relief between contractions. The physician advised the nurse that she would be coming to the hospital to perform a cesarean section. The Attending Physician’s Progress Note at 11:09 PM stated she was notified that the patient was becoming increasingly uncomfortable with contractions. The physician further stated there was a Category II fetal tracing with a wandering baseline and nonrecurrent late decelerations, and tocodynamometer with consistent contractions every 1-2 minutes. The physician discussed with the patient, she would “proceed toward delivery via primary cesarean section now.” The physician stated two units of packed red blood cells were placed on hold and the hemorrhage kit was immediately available in the OR. The patient was removed from the external fetal monitor and tocodynamometer at 11:15 PM and taken to the Operating Room (OR). The Intraoperative Report noted the patient was in the OR at 11:19 PM. The Attending Obstetric Physician was also in the OR at this time. Anesthesia began placement of spinal anesthesia at 11:25 PM and ended the procedure at 11:28 PM. According to the anesthesia record, the patient’s blood pressure and pulse were 171/98 and 124 beats per minute at 11:25 PM, her pulse was 117 beats per minute at 11:26 PM, 110 beats per minute at 11:27 PM, and 108 beats per minute at 11:28 PM. At 11:29 PM, using a doppler, a staff nurse obtained a fetal heart rate of 120 beats per minute. At 11:32 PM, the patient’s blood pressure was 109/57. The incision was made at 11:43 AM. The Delivery Summary revealed the infant girl was delivered at 11:51 PM. The infant was limp, cyanotic, and apneic with Apgars of 0 and 0. The infant was brought directly to the warmer where a pediatrician, present during delivery, performed aggressive resuscitative measures including positive pressure ventilation with FiO2 at 100%, chest compressions, and intubation. Despite these aggressive resuscitative measures for more than an hour, the infant never had a heart rate and was pronounced deceased. A cause of death of acute blood loss due to placental abruption was identified by the pediatrician. The Operative Report noted an estimated blood loss of 1200 mL. A placental abruption was suspected. Although the parents requested an autopsy, no results were available in the medical record. Staff Q was interviewed via phone on 10/09/24 at 5:30 PM. Staff Q identified herself as the primary nurse caring for Patient #4 during labor and delivery. She stated she was concerned about the patient. Staff P, the Attending Obstetric Physician, was interviewed via phone on 10/16/24 at 4:31 PM. She reported that the patient informed her she had a gush of blood at home and immediately came to the hospital. She stated the patient’s contractions looked “impressive” on admission but she didn’t believe she was feeling them. The physician stated she was unaware that on admission, the patient rated her pain from contractions a 4 on a 0-10 scale but stated that the patient was calmly conversing and didn’t appear overly uncomfortable. Staff P stated she was aware there was tachysystole in the contraction pattern. She was unaware that the patient was medicated with Zofran for complaints of nausea. Staff P stated that the patient did not present like placental abruptions that she has seen in the past so she was shocked and horrified at the outcome. She stated it wasn’t at all what she expected and was a tragic outcome. Staff C, Director of Women & Children, was interviewed via phone on 10/18/24 at 2:24 PM. It was confirmed that the patient presented to Obstetric Triage with complaints of pain from contractions, the pain worsened and she rated the pain a 6 on the same 0=10 scale. It was further confirmed that the physician was notified of the patient’s report of contractions getting more intense at 9:15 PM but did not present to the hospital until more than two hours later, at 11:19 PM. It was confirmed that despite the physician advising both the patient and the nurse that she would move to a cesarean section in the event of increased pain, despite intrauterine resuscitative measures being administered due to the Category II fetal heart tracing, and despite the nurse’s admitted concern for the patient, the medical record lacked documentation a charge nurse clinical coordinator, or manager contacted the physician regarding the concern as outlined in the facility policy. The facility policy titled “Fetal Monitoring:, effective 07/12/24, defined tachysystole as excessive uterine activity, more than five contractions in a 10 minute segment averaged over a 30 minute period. Tachysystole can be the result of both spontaneous and stimulated labor. Addendum C of the policy advised staff nurses of intrauterine resuscitative measures to reduce uterine activity in the event of tachysystole. Staff nurses are advised to administer an intravenous fluid bolus of lactated ringers solution, position the patient either to the left or right lateral position, and if no response, consider administration of Terbutaline 0.25 mg subcutaneously. The facility policy titled “Clinical Escalations in Labor and Delivery and Postpartum”, effective 05/10/24, stated if a nurse is caring for an obstetrical patient and believes they have received an unsatisfactory telephonic response from the practitioner, the following steps are to be followed: 1.1. The nurse will notify the charge nurse, clinical coordinator, or manager who will contact the practitioner regarding the concern. 1.2. If there is an unsatisfactory response, the charge nurse, clinical coordinator or manager may contact the director or may contact the appropriate Women’s Services line chair or vice chair regarding the concern. This deficiency represents non-compliance investigated under Substantial Allegation OH00157253.”

“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: 21893 Based on policy review, medical record review, and staff interview, the facility failed to follow their policies and procedures for care provided in the emergency department for one of 20 emergency department medical records reviewed (Patient #33). A total of 27,468 patients were seen in the emergency department in the last six months. Findings include: Review of the “Patient Safety Monitoring for Suicidal and Non-Suicidal” policy, effective 07/01/21, revealed assessment of a suicidal patient includes completion of the Columbia-Suicide Severity Rating Scale (C-SSRS) upon admission to the emergency department. The patient will be placed on suicide precautions and monitored accordingly based on the C-SSRS. The C-SSRS will determine if a one to one patient monitor, a continual visual sitter, or no monitor but just hourly rounding is needed. Review of the medical record for Patient #33 revealed an arrival date of 01/19/24 at 9:28 AM to the emergency department. The triage note at 9:36 AM documented the patient was having suicidal thoughts but denied having a plan. The medical record lacked documentation of a C-SSRS or orders for patient monitoring. The medical record noted registration was completed at 10:06 AM and blood was drawn for ordered labs at 10:57 AM. At 12:05 PM, the patient was assigned a room in the emergency department. At 12:21 PM, the medical record noted the patient was not in the lobby. The medical record contained documentation the facility and facility grounds were searched without location of the patient. Since the patient reported suicidal thoughts, the local police were contacted to locate the patient and return him to the emergency department. The emergency department was notified on 01/19/24 at 9:14 PM, that the police were unable to locate the patient. The medical record contained documentation that the patient has been admitted to this facility for medical reasons twice since 01/19/24. On 02/08/24 at 12:10 PM, Staff FF stated that on 01/19/24 they were busy and had eight to ten patients waiting in the lobby at this time for a room. They usually had security keep an eye on any psychiatric patients temporarily until a sitter could be obtained. Staff FF verified that no sitter was ordered, no suicide screening (C-SSRS) was completed, and there was no documentation of any need for monitoring in the medical record.”

“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: 21893 Based on record review and staff interview; the facility failed to ensure qualified medical personnel were determined in the bylaws or rules and regulations as qualified to administer a medical screening examination (A2406). The facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409).”

“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: 21893 Based on facility policy review, review of facility medical staff bylaws and medical staff rules and regulations, and staff interview, the facility failed to ensure qualified medical personnel were determined in the bylaws or rules and regulations as qualified to administer a medical screening examination. The facility’s emergency department saw 27,468 patients in the last six months. Findings include: Review of the facility’s policy titled, “Responsibilities of Genesis Emergency Department in Emergency Cases (EMTALA)”, effective 02/09/23, revealed a Medical Screening Examination (MSE) must be conducted by qualified medical personnel to determine whether or not an Emergency Medical Condition exists. The MSE must be conducted by an individual determined to be qualified by hospital by-laws, rules and regulations, or approved by the Board of Directors. Review of the facility’s Medical Staff Bylaws and Medical Staff Rules and Regulations lacked documentation to designate or define who were qualified medical personnel and who was designated to perform the MSE to determine the presence or absence of a medical emergency condition as referenced in the facility’s EMTALA policy. Interview with Staff D on 02/08/24 at 4:50 PM confirmed the Medical Staff Bylaws and Medical Staff Rules and Regulations failed to define or designate who the qualified medical personnel was and who could perform the MSE to determine the presence or absence of an emergency medical condition.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 21893 Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer for three of three medical records of transferred patients reviewed (Patient #27, #28, and #29). A total of 20 emergency department medical records were reviewed. A total of 27,468 patients were seen and 544 patients were transferred to other facilities in the last six months. Findings include: Review of the policy titled, “Psychiatric Patients Awaiting Evaluation in the Emergency Department,” effective 05/13/21, revealed a Writ is a legal document that may be signed by a physician, law enforcement officer, or mental health professional that permits a person to be held without their permission when it has been determined that the person is a threat to self or others. 1. Review of the medical record for Patient #27 revealed an arrival date of 11/05/23 at 8:43 PM to the emergency department. The medical record contained documentation the patient was suicidal and homicidal. The medical record progress notes documented that the patient had been placed on a Writ. The medical record contained documentation the patient was transferred to a psychiatric facility on 11/06/23 at 11:22 AM. The medical record lacked documentation of a Writ or a transfer document that listed the risks and benefits of the transfer signed by the physician. 2. Review of the medical record for Patient #28 revealed an arrival date of 09/03/23 at 3:30 AM to the emergency department. The medical record contained documentation the patient was transferred to a Level 1 Trauma facility by a Mobile Intensive Care Unit on 09/03/23 at 6:50 AM. The “Consent to Transfer to Another Facility” form was signed by the physician; however, the risks and benefits of transfer section was blank. 3. Review of the medical record for Patient #29 revealed an arrival date of 01/10/24 at 12:59 PM to the emergency department. The medical record contained documentation the patient had third degree burns to his right lower extremity. The medical record contained documentation the patient was transferred to a burn center on 01/10/24 at 3:12 PM. The medical record lacked documentation of a transfer document that listed the risks and benefits of the transfer signed by the physician. On 02/08/24 at 10:45 AM, Staff FF verified the above findings in an interview.”