Unity Medical Center

“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: 30553 Based on review of facility policy, review of facility documentation, and medical record review, the facility failed to provide an appropriate Medical Screening Examination (MSE) for two patients (#6, #15) 2 of 20 sampled patients. The findings include: Review of Facility A’s policy, “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines,” reviewed 6/24/2024, revealed “...Medical Screening Exams should include Emergency Department Log...entry including disposition of patient...all patients presenting to [Facility A] and seeking care, or presenting somewhere elsewhere on hospital’s main campus and requesting emergency care, must be accepted and evaluated regardless to the patient’s ability to pay, condition, race, and religious preference...all patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis...” Patient #6 was admitted to Facility A’s ED on 1/19/2026 at 11:02 PM, with Altered Mental Status (AMS). A MSE was completed with diagnostic testing and a physical examination. The patient’s mentation improved and the patient was discharged home. The patient presented to Facility A’s ED on 1/20/2026 at 4:10 AM (1 hour and 33 minutes after discharge) when she had reportedly assaulted a family member, Emergency Medical Services (EMS) staff, and had allegedly attempted to take an overdose of Gabapentin (medication to treat nerve pain). There was no documentation in the medical record the patient had attempted to take Gabapentin. No diagnostic testing or psychiatric evaluation was completed for Patient #6. The patient was medically cleared for release into police custody on 1/20/2026 at 4:24 AM (14 minutes after arrival at the ED) into police custody. The patient was taken to Facility B’s ED by local police on 1/20/2026 at 5:03 AM for a mental health evaluation. Patient #6 was evaluated and ultimately transferred to an inpatient psychiatric facility. Patient #15 was admitted to facility A’s ED on 4/20/2026 and evaluated for a Seizure Disorder, Schizophrenia, Combative Disorder and Hypertension. The patient had chronic Behavioral/Cognitive disorder and was chronically confused. The patient had previously been a resident in a mental health institution and had been moved to a group home where his behaviors escalated and he was taken to jail. While at the jail, the patient exhibited aggressive behaviors with the staff and other patients. Patient #15 was taken to Facility A for a psychiatric evaluation. The patient was placed under a 6404 (Certificate of Need for Involuntary Admission) and evaluated by Mobile Crisis for inpatient transfer to a psychiatric facility. The patient remained in the ED for several days and then was admitted to the Medical Surgical Unit for continued care. During this time, the patient continued with aggressive behaviors and was moved to the Intensive Care Unit for further monitoring. The patient was treated for Pneumonia, Congestive Heart Failure, a left lower extremity wound, and an Acute Kidney Injury. Patient #15 was accepted at an inpatient psychiatric facility on 5/5/2026. Upon discharge, the patient continued with an indwelling urinary catheter. On arrival at the psychiatric facility, Patient #15 was not accepted related to the urinary catheter and was sent back to Facility A via EMS. Upon return to Facility A, the patient was not registered in the ED, he was not placed on the ED Central Logs and a MSE was not completed. Patient #15 was taken to Facility B where a MSE was completed and the patient was transferred to an inpatient psychiatric facility. Cross Refer to A-2405 and A-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: 30553 Based on review of facility policy, review of the Emergency Department (ED) Central Logs, medical record review and interview, the facility failed to ensure 1 patient (Patient #15) was placed on the ED Central Logs after presenting to the ED for evaluation on 5/5/2026 for 1 of 20 patients reviewed. The findings include: Review of Facility A’s policy, “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines,” reviewed 6/24/2024, revealed “...Medical Screening Exams should include Emergency Department Log...entry including disposition of patient...” Patient #15 arrived by Emergency Medical Services (EMS) at facility A’s ED for evaluation on 5/5/2026, after being transferred to an inpatient psychiatric facility the same day. Review of the ED Central Logs revealed the patient was not listed on the ED log for 5/5/2026. During an interview on 6/11/2026 at 11:53 AM, the Director of Inpatient Services confirmed she informed EMS the only way the urinary catheter could be removed was to sign the patient into the ED and have the provider evaluate the patient for removal of the urinary catheter. EMS stated they could take the patient to another hospital and she informed them she could not make that decision. The patient was not registered in Facility A’s ED.”

“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: 30553 Based on review of facility policy, facility documents, Emergency Medical Services (EMS) Trip Record, medical record review and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 2 patients (#6 and #15) who presented to the Emergency Department (ED) for evaluation of 20 records reviewed. The findings include: Review of Facility A’s policy, “EMTALA [Emergency Medical Treatment and Labor Act] Guidelines,” reviewed on 6/24/2024, revealed “...all patients presenting to [Facility A] and seeking care, or presenting somewhere elsewhere on the hospital’s main campus and requesting emergency care, must be accepted and evaluated regardless to the patient’s ability to pay, condition, race, and religious preference...all patients shall receive a medical screening exam that includes providing all necessary testing and on call services within the capability of the hospital to reach a diagnosis...” Medical record review revealed Patient #6 presented to Facility A’s ED on 1/19/2026 at 11:02 PM, with Altered Mental Status (AMS) and for mental health examination. The patient’s AMS improved and the patient was discharged home on 1/20/2026 at 2:37 AM. Medical record review of a Nursing Triage record from Facility A, dated 1/20/2026 at 4:10 AM (1 hour and 33 minutes after discharge) revealed Patient #6 presented once again to Facility A’s ED after she had attempted to assault her boyfriend, she had damaged EMS equipment and physically assaulted an EMS worker. Her family reported she had attempted to ingest Gabapentin (medication used to treat nerve pain). Medical record review of an ED Provider Record from Facility A, dated 1/20/2026 at 4:11 AM, revealed the patient was brought in by local police. The patient had attempted to assault her boyfriend and EMS staff prior to arrival. The patient had been evaluated in the ED two (2) hours prior related to AMS related to taking additional pain medications. There were no diagnostic testing or a psychiatric mental health evaluation completed for the patient to determine an increased risk for self-harm or harm to others. The patient was medically cleared for discharge with local police. The patient was discharged on 1/20/2026 at 4:24 AM (24 minutes after her second presentation to the ED) into police custody. Medical record review revealed Patient #6 was admitted to Facility B on 1/20/2026 at 5:03 AM (38 minutes after discharge from Facility A) by local police with AMS and possible ingestion of Gabapentin. The patient had been previously evaluated at Facility A and discharged into police custody. Medical record review of an ED Provider Record from Facility B dated 1/20/2026 at 8:07 AM, revealed Patient #6 presented with AMS, possible ingestion of Gabapentin and neck excoriations. The local police brought the patient to the ED under a 6401 (emergency hold). The patient’s family stated the patient remained altered and with uncharacteristic behavior. The patient had slurred speech and was somnolent. The patient was evaluated by Mobile Crisis at 10:44 AM and at 6:22 PM the patient was accepted at an inpatient psychiatric facility. Patient #6 was transferred to an inpatient psychiatric facility for stabilization. During a telephone interview on 6/11/2026 at 3:45 PM, Registered Nurse (RN) #1 stated the patient was evaluated in the ED and during her first visit, the patient was obtunded but she became more alert prior to discharge. RN #1 stated on her second visit, the patient came with handcuffs related to physically assaulting her boyfriend, EMS staff and police. During a telephone interview on 6/12/2026 at 9:30 AM, Physician #1 stated he evaluated Patient #6 on 1/19/2026 and 1/20/2026. Diagnostic testing was completed on the first visit which did not reveal any acute findings and the patient’s mental status improved while in the ED. Physician #1 stated on the second admission, the patient presented in handcuffs due to physically assaulting a family member, EMS, and the police. He did not order labs for the second admission related to the patient who had just been discharged and there were no acute findings. Review of a facility investigation dated 5/5/2026 revealed Patient #15 had been admitted to Facility A since 4/20/2026. A transfer to an inpatient psychiatric facility was initiated and the patient was transferred on 5/5/2026. The patient had an indwelling urinary catheter and upon arrival to the psychiatric facility, the patient was refused related to the presence of a urinary catheter. The patient was transported back to Facility A via EMS. Review of an EMS Trip Record dated 5/5/2026, revealed “...upon arrival at [Facility A] hospital staff met EMS crew in ambulance bay. Patient was not taken out of ambulance. [Facility A] staff denied patient. Hospital staff stated they did not have an admitting physician currently at the hospital. Hospital staff also stated they do not have any beds at this time...” The patient was transported to Facility B. Review of the ED Central Logs revealed Patient #15 was not listed on the ED Central Log. There was no medical record for Patient #15 for the date of 5/5/2026, when EMS presented on hospital property seeking an evaluation for the patient. Medical record review revealed Patient #15 arrived by EMS to Facility B’s ED on 5/5/2026 at 7:41 PM. The patient had been admitted to Facility A and a transfer to an inpatient psychiatric facility had been arranged but the facility denied the patient related to the presence of a urinary catheter. EMS transported the patient back to Facility A but he was not evaluated at Facility A. Review of EMS records revealed Patient #15 was then transported to Facility B, the urinary catheter was removed and the patient was medically cleared. [Named inpatient Psychiatric facility] agreed to accept the patient once the urinary catheter was removed and the patient was transferred back to (named inpatient psychiatric facility) on 5/6/2026 at 3:02 PM. During an interview on 6/11/2026 at 11:53 AM, the Director of Inpatient Services, stated on 5/5/2026, she received a call from the ED and was informed EMS was transporting the patient back to Facility A related to the urinary catheter was not removed. She, the ED and ICU charge nurse spoke with the EMS transport team in the ambulance bay. She informed EMS the patient was an inpatient upon discharge and there was not an accepting physician since the patient had been transferred. She confirmed the patient remained in the ambulance, the patient was not taken into the ED for evaluation and EMS left with the patient. The patient was not registered and was not evaluated in the ED on 5/5/2026. The next day she was informed by Facility B the patient had been transported by EMS to their facility. During a telephone interview on 6/12/2026 at 8:40 AM, Facility A’s Chief Executive Officer confirmed Patient #15 was not registered or evaluated in Facility A’s ED on 5/5/2026.”