Williamson 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: 35244 Based on policy review, medical record review and interview, the facility failed to ensure patients presenting to the Emergency Department (ED) for medical treatment, then leaving before receiving a medical screening examination (MSE), were advised of the risks prior to leaving the ED for 1 of 2 (Patient #6) sampled patients that left the ED before being medically screened. The findings included: 1. Medical record review revealed Patient #6 presented to the ED on 4/7/2025 at 10:57 PM with chief complaint of mouth, lungs and head pain. Review of an Account Representative (registration clerk) note dated 4/7/2025 at 11:25 PM revealed, “Patient did not want to sign consent [to treat] form at the time of registration... the questions that the patient was asking are out of my realm”. Review of an Account Representative note dated 4/8/2025 at 1:23 AM revealed, “Patient refused to sign the consent [to treat] form due to it saying something about paying...Patient then spoke with the nursing supervisor and essentially decided that she did not want to be seen... Patient refused to sign and left with out speaking to anyone”. Review of “Discharge Plan” dated 4/8/2025 at 1:41 AM revealed Patient #6’s disposition was documented as Left Without Being Seen (LWBS). There was no documentation a Left Without Being Seen form was completed; and no documentation Patient #6 refused to sign a LWBS form as per facility policy. There was no documentation ED staff attempted to locate Patient #6 to discuss the risks of leaving the ED without being seen by a provider for medical screening examination. Cross Refer to A2406.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to ensure patients presenting to the Emergency Department (ED) for medical treatment, then leaving before a medical screening examination (MSE) was completed, were advised of the risks prior to leaving the ED for 1 of 2 (Patient #6) sampled patients that left the ED before being medically screened. The findings included: 1. Review of the facility’s “Medical Screening Examination” policy (reviewed 2/7/2024) revealed, “...Refusal of Screening Exam...If a patient withdraws his or her request for examination or treatment or refused further examination or treatment, an appropriately trained individual from the Emergency Department staff will discuss the medical issues related to a voluntary withdrawal. In the discussion, the Emergency Department staff member will... inform the patient of the benefits of the examination and treatment, and of the risks of withdrawal prior to receiving the examination and treatment... take all reasonable steps to secure the individual’s written informed refusal of such examination and treatment... If the patient refuses to sign the form, the written document should indicate that the person has been informed of the risks and benefits of the examination and/or treatment but refused to sign the form...” Review of the facility’s “LEAVING THE EMERGENCY ROOM LEFT WITHOUT BEING SEEN (LWBS) or AGAINST MEDICAL ADVICE (AMA)” policy (reviewed April 2025) revealed, “... If patient leaves without notice (no opportunity to discuss risks/benefits), document attempt to locate patient and document when in process patient was determined to have departed... If a patient notifies a staff member of their desire to leave before being seen by a provider, a nurse or provider should discuss risks and benefits of leaving prior to treatment. Ask patient to remain in the department to discuss situation with the provider...If the patient refuses to wait for treatment or if, after the discussion of risks and benefits, they still desire to leave the patient is requested to sign a Left Without Being Seen form...If patient refused to sign LWBS form, notate patient’s refusal of signature on the form...If patient refuses to discuss risks and benefits document: Attempted to explain risks and benefits of leaving prior to treatment. Patient refuses to discuss or listen to risks and benefits and departed, and declined to sign LWBS form...” 2. Medical record review revealed Patient #6 presented to the ED on 4/7/2025 at 10:57 PM with chief complaint of mouth, lungs and and head pain. Patient #6 reported head and chest pain where she had basal cell carcinoma (a type of skin cancer) lesions, gum pain from gum disease, Histoplasmosis (lung infection caused by inhaling spores from the fungus Histoplasma capsulatum) lung pain, chronic cough from Covid (Coronavirus-disease caused by the SARS-CoV2 virus) and a headache from coughing. Review of an Account Representative (registration clerk) note dated 4/7/2025 at 11:25 PM revealed, “Patient did not want to sign consent form at the time of registration. Patient requested to speak with billing and I told her it was a M-F [Monday through Friday] 8-5 [8:00 AM through 5:00 PM] and to call back up. She then proceeded to get upset that we could not help her and wanted the email to [Risk Manager] and I gave her [ED patient access manager] email just in case because the questions that the patient was asking are out of my realm”. Review of an Account Representative note dated 4/8/2025 at 1:23 AM revealed, “Patient refused to sign the consent form due to it saying something about paying. Patient also refused to sign the consent form in the booth with me and wanted to take it with her. I offered a copy, that was not good enough. The patient then spoke with the nursing supervisor and essentially decided that she did not want to be seen. I asked the supervisor to get the consent form from the patient and the supervisor said well she is not being seen so it does not matter that she is not signing. Patient refused to sign and left with out speaking to anyone”. Review of “Discharge Plan” dated 4/8/2025 at 1:41 AM revealed Patient #6’s disposition was documented as Left Without Being Seen. There was no documentation a LWBS form was completed; and no documentation Patient #6 refused to sign the LWBS form as per facility policy. There was no documentation the ED staff attempted to locate Patient #6 to discuss the risks of leaving the ED without being seen by a provider for medical screening examination. In an interview on 5/13/2025 at 9:01 AM, Registered Nurse (RN) #1 was asked how patients leaving the ED without being seen for medical screening examinations were handled. RN #1 stated there was a form the patient had to sign and explain why they (patients) were leaving. RN #1 stated the form acknowledged the patient had been told the reasons they (patient) needed to stay for examination. RN #1 stated before you designated a patient LWBS, you gave them a couple chances to show up when you call their (patient) name. RN #1 stated the ED staff asked the registration staff if they had seen the patient and if they (registration staff) also checked the bathrooms (for Patient #6). RN #1 verified she would document on the LWBS form if a patient refused to sign the form. In an interview on 5/13/2025 at 12:45 PM, Nurse Supervisor #1 verified Patient #6 refused to be seen and refused to sign the LWBS form. Nurse Supervisor #1 stated she did not document the Patient’s refusal to sign the form. Nurse Supervisor #1 stated, “...down front [registration] does that...””