Rural Wellness Stroud Hospital

“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: 39648 Based on record review and interview, the hospital failed to ensure central log documentation for one (Pt #21) of 21 ED patients reviewed. This failed practice resulted in a lack of documentation from the patient encounter and subsequent inability to track the patient across the care continuum. (see 2405) Based on record review and interview, the hospital failed to ensure provision of an appropriate MSE for one (Patient #21) of 21 ED patients reviewed. This failed practice had the likelihood to result in unrecognized emergency medical condition, delay in treatment and adverse patient outcomes. (see 2406)”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure central log documentation for one (Pt #21) of 21 ED patients reviewed. This failed practice resulted in a lack of documentation from the patient encounter and subsequent inability to track the patient across the care continuum. Findings: Pt #21 Review of the ED central log showed no documentation of an ED visit on 07/15/25 by Pt #21. On 07/15/25 at 2:52 pm Staff D stated, “A gentleman came to the window and said she is pregnant, and she is having contractions about one minute apart. I said we don’t have an OB department more than likely we would have to send you out. They asked where? I said probably Shawnee they can accommodate a delivery. The man said Oklahoma City that was where her doctor was, and it was 45 minutes away as well. The woman shook her head yes and they turned and left. I was confused because we don’t have an OB department and was unsure of what treatment.” Staff D then stated basically anyone who comes to the ER should be registered.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 39648 Based on record review and interview, the hospital failed to ensure provision of an appropriate MSE for one (Patient #21) of 21 ED patients reviewed. This failed practice had the likelihood to result in unrecognized emergency medical condition, delay in treatment and adverse patient outcomes. Findings: Review of hospital records showed no documentation Pt #21 received an MSE. A review of a policy titled “5007 - EMTALA Guidelines” read in part, “All patients should receive a medical screening exam (MSE) that includes providing all necessary testing and on-call services within the capability of the hospital to reach a diagnosis.” Review of an internal hospital document dated 07/10/25 and signed by Staff D read in part: “On July 7th 2025 a young man and young lady came into the ER. The young man approached the window and started saying she’s pregnant, pointing to the young lady coming in behind him... continued saying they were headed to Oklahoma City because that’s where their doctor is and that her contractions are about a minute apart. I said we do not have an OB department and that she would probably have to be sent out to another hospital. I do not recall this type of scenario being covered in training. I said that Shawnee has an OB department and they are about 45 minutes away....” A review of a security video at the ED entrance dated 07/07/25 showed: 1) 11:43 am a man and a woman wearing a long blue t-shirt and shorts who had a rounded abdomen entered the ED; 2) 11:44 am they were at the ED registration desk; they appeared to speak with someone then turned and exited the ED walking outside. On 07/15/25 at 2:38 pm Staff B stated, Pt #21 did not receive an MSE.”

“NURSING SERVICES CFR(s): A nursing care plan must be developed and kept current for each inpatient. This Standard is not met as evidenced by: 39648 Based on record review and interview, the hospital failed to ensure the care plan reflected the primary diagnosis for one (Pt. 1) of five patients reviewed. Findings: Pt #1 A review of the medical records showed the patient was seen at the ED due to an abscess to R lateral leg. The patient was admitted to the hospital 05/19/25 with a diagnosis of sepsis related to an abscess to the R lateral leg. The abscess to R lateral leg measured 8.5 x 9.5 x unknown (L x W x D) area 80.75 cm2. The care plan did not reflect a wound or issues with skin integrity or wound care. . On 05/22/25 Staff C at 10:42 am stated the care plan should reflect the wound.”

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 39648 Based on record review and interview, the facility failed to ensure a grievance with investigation was completed for one (Pt 2) of five patients reviewed. Findings: Pt 2 A review of the record showed the patient alleged that they had been abused. The allegation did not result in a grievance with an investigation conducted or completed. On 05/22/25 at 2:14 pm Staff F stated: 1) They would have started an investigation of the allegation regardless of the patient’s mental status; 2) The Quality Risk Manager should have completed the investigation; 3) They would have investigated the allegation by conducting a chart review, visiting with providers and witnesses; 4) There was no investigation documented.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 50779 Based on record review and interview, the facility failed to ensure that the governing body provided oversight of the hospital policy and procedures for 17 0f the 17 policies reviewed, potentially effecting the safety of all current and future patients. Findings: A review of the 7 policies below showed a name for another hospital (names omitted) and no policy for the hospital being surveyed: 1. Quality of Care dated 01/15/2016; 2. Credentialing and Privileging Process dated 01/15/2016; 3. Telemedicine Services (no date); 4. Assessment dated 08/24/2016; 5. Access and Visitation Rights (no date). 6. Nutritional Plans of Care dated 04/13/2016. 7. Enteral and Total Parenteral Nutrition dated 04/13/2016. A review of the following 11 of 17 policies showed no effective date of the policy: 1. Telemedicine Services; 2. Access and Visitation Rights; 3. Swingbed Services; 4. Patient Assessment; 5. Rehabilitation Services for Patients Admitted to Swing Bed; 6. Pain Scale; 7. Nutritional Consults; 8. Nutritional Screening-Monitoring; 9. Complaint and Grievance; 10. Cleaning a Patient Room-Occupied Quality of Care Concerns; 11. Allegations of Abuse and Neglect. A review15 of the 17 policies below were not updated every 2 years. 1. Quality of Care dated 01/15/2016 unable to determine when the policy was last updated. 2. Credentialing and Privileging Process dated 01/15/2016 unable to determine when the policy was last updated. 3. Telemedicine Services (no date) unable to determine when the policy was last updated. 4. Assessment dated 08/24/2016 unable to determine when the policy was last updated. 5. Access and Visitation Rights (no date) unable to determine when the policy was last updated. 6. Nutritional Plans of Care dated 04/13/2016 unable to determine when the policy was last updated. 7. Enteral and Total Parenteral Nutrition dated 04/13/2016 unable to determine when the policy was last updated. 8. Swingbed Services has (no date) unable to determine when the policy was last updated. 9. Patient Assessment has (no date) unable to determine when the policy was last updated.. 10. Rehabilitation Services for Patients Admitted to Swing Bed has (no date) unable to determine when the policy was last updated. 11. Pain Scale had (no date) unable to determine when the policy was last updated. 12. Nutritional Consults hda (no date) unable to determine when the policy was last updated. 13. Nutritional Screening-Monitoring has (no date) unable to determine when the policy was last updated. 14.0Cleaning a Patient Room-Occupied (no date) unable to determine when the policy was last updated 15. Allegations of Abuse and Neglect (no date) unable to determine when the policy was last updated On 11/08/24 at 1:00 p.m. employee L stated they had not updated some policies to reflect the current facility’s name and they could not tell when the policies were updated. On 11/08/24 at 1:20 p.m. employee L stated some of the policies were updated but the updates were not documented on the policy. They are effective now, but it is not on the policy. On 11/08/24 at 1:40 p.m., employee L stated that they would have to look up the last time the policies were updated.”