Starr Regional Medical Center Athens

“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: 51701 Based on review of facility policy, medical record review and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) for 1 patient (#4) who was admitted with a possible overdose and acute behaviors of 26 Emergency Department (ED) records reviewed; and failed to provide an appropriate transfer for 1 patient (#5) who was admitted with acute behaviors and required transfer to another acute care facility of 13 ED transfers reviewed. The findings include: Patient #4 was admitted to the ED on 12/8/2024 with a possible overdose of an unknown amount of non-steroidal anti-inflammatory medication. The patient became agitated and hostile and attempted to hit one of the Registered Nurses (RNs) with his fist. The patient exited the room prior triage vital signs being obtained related to the patient’s acute behaviors. The local police department returned the patient to the ED where the ED physician spoke to the mother in the presence of the police officer. An appropriate MSE was not performed related to the patient’s potential psychosis. The patient was at risk for potential self-harm and possible overdose. The patient left the ED with his mother. Patient #5 presented to the ED with Psychosis, Auditory Hallucinations, Delusions, Suicide Ideation and Schizoaffective Disorder. The patient was transferred to an accepting facility, but an EMTALA form was not found in the medical record. In addition, risks and benefits of the transfer were not documented in the medical record. Cross refer to A-2406 and A-2409.”

“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: 51701 Based on review of facility policy, medical record review, review of facility documentation, review of police report and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination (MSE) for 1 patient (#4) who was admitted with a possible overdose and acute behaviors of 26 Emergency Department (ED) records reviewed. The findings include: Review of facility policy, “Emergency Screening/Stabilization/Transfer/250 Yard Rule and EMTALA,” revised 3/2022, showed “...a Medical Screening Examination is the process required to reach a reasonable clinical confidence, the point as which it can be determined whether or not an Emergency Medical Condition exists...is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred...” Medical record review of the ED nursing triage dated 12/8/2024 at 2:12 PM showed Patient #4 was brought to the ED by his mother and his 16-year-old-brother for treatment of a potential overdose of ibuprofen (non-steroidal anti-inflammatory medication). Medical Record review of the ED nursing notes dated 12/8/2024 at 2:19 PM, showed two registered nurses (RNs) came to the lobby, after being called by registration regarding a possible overdose, to take the patient to treatment room #6. The mother and brother denied knowing the reason (s) for the overdose. The brother reported the patient had been passing out and couldn’t speak. After the mother left the ED to move her car, the patient told the RNs he had taken 45 pills 45 minutes ago. When the brother raised his voice toward RN #2, Patient #4 stated “...don’t [explicative] talk to him like that...” The 14-year-old patient began to yell and scream. He jumped up, tore the blood pressure cuff off and ripped his gown off and threw it across the room...” Patient #4 spit in the nurse’s face, pinned her against the wall and raised his fist, but the mother grabbed his arm. The patient pushed his mother into the wall. As the ED physician was entering the room, the patient pushed the ED physician out of his way and proceeded to run down the hallway towards the ED lobby. Hospital security was paged, and the local police department was called. Medical record review of the ED physician’s record dated 12/8/2024 at 2:20 PM, showed “...14-year-old- male presented to ED with complaints of overdose and is questionable whether accidental or intentional overdose of ibuprofen. Patient was placed in room. Shortly after placed in room he became aggressive and violent towards the nursing staff. I did hear patient screaming loudly. I immediately went to the room and the door came open patient pushed by me running out of the building and security was alerted. Law enforcement was also alerted. I did speak with the patient’s mother who stated that he is never attempted this before they recently moved to the area from [named city and state]. Patient is noted to have cuts on arms of what I could see on short visualization. Patient was cursing and violent. Patient left the ER [emergency room]...” Medical record review showed triage vital signs and a MSE were not performed. The patient left the ED with his mother and the AMA form was not signed. Review of the facility documentation (Incident Report) showed Security was called at 2:20 PM on 12/8/2024, for an assault in progress. The report showed patient #4 was running towards the security officer and pushed the security officer to the side. The patient was in a rage yelling he was going to hurt everyone and at this point it became a physical altercation between the patient and the security officer. For the safety of the people in the lobby the security officer let the patient exit outside. At 2:25 PM, the officer found the patient lying in the grass and not responding to his name when called. The officer called the admission department and asked them to update the police department of the security officer’s location. The patient jumped up and screamed he “was going to kill us.” The patient struck the security officer with a rock hitting her thigh. [local police department] arrived at 2:31 PM. Review of the (local named police department) incident report showed officers responded to the ED on 12/8/2024 related to a “disturbance.” They were informed the patient (#4) was being treated at the hospital for a drug overdose. They were advised Patient #4 had fled from the hospital on foot after his family caused a disturbance with the nurses. The police officers searched the area and found the patient walking westbound on a sidewalk where he was apprehended, placed in handcuffs and returned to the ED. During an interview on 01/13/2025 at 1:32 PM, the ED Physician stated the patient’s family reported the patient had taken ibuprofen. The Physician stated after one hour the patient should have had nausea and vomiting. He heard screaming and yelling. When he went to the Patient #4’s room the patient was attempting to run out the door, and the door hit the ED physician. The patient left the ED, ran into the parking lot and laid on the ground. The patient picked up a large rock and threw it at the security guard. The physician informed the patient’s mother he would check and examine the patient but only in the presence of the police. During an interview on 1/13/2025 at 1:55 PM with Registered Nurse (RN) #1, she stated she was notified by registration the patient was “passing out.” She and another registered nurse went to the ED lobby where she observed the patient’s eyes were shut and spit running down his chin. During a telephone interview on 1/14/2025 at 4:55 PM RN #2 stated her first assessment of the patient showed the patient leaning his head, holding spit in his mouth, and drooling. The patient appeared alert. The patient stated he had taken 45 pills about 45 minutes ago. The patient’s brother stated Patient #4 was trying to kill himself. While removing his shirt and putting on a gown, she noticed scars up and down his arms. The mother stated “...he [the patient] has psych issues...” The mother became more aggressive, the patient hopped off the exam table, drew back his fist while he was spitting in her face and said he was going to kill her. The mother pulled back his arm and the two of them scuffled. The patient began to cry and scream as he ran out the door into the ED lobby and continue to scream, he was going to kill somebody. During a telephone interview on 1/14/2025, at 6:06 PM with Security Officer #1, she stated while making rounds she was notified of an assault in progress and her help was needed. When she arrived in the lobby, the patient was standing in the lobby screaming “he was going to kill somebody.” He pushed her aside and went out the double doors of the ED. She drove around the campus until she found him lying on his side in a grassy area. Security Officer #1 stated she thought the patient had passed out but when she leaned over him, he threw a large rock hitting her in the side of the leg. The patient started running again saying he was going to kill everyone in the ED. The [local police department] found the patient and brought him back to the ED EMS entrance. Review of the medical record showed no further attempts were initiated to return the patient to the ED to continue his assessment, after the mother refused to have the police restrain her son. Interviews confirmed the mother left the hospital with her son.”

“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: 51701 Based on review of facility policy, medical record review and interviews, the facility failed to ensure risk and benefits related to a transfer were explained and failed to provide the Emergency Medical Treatment and Labor Act (EMTALA) transfer certification for 1 patient (#5) of 13 Emergency Department (ED) patients reviewed for a transfer. The findings include: Review of the facility policy, “ Emergency Screening Stabilization/Transfer/250 Yard Rule and EMTALA,” revised 3/2022, showed “...For transfer with physician certification. For a patient who has not been stabilized, a physician must have signed a certification that, based on 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... from being transferred. This certification must contain a summary of the risks and benefits upon which it is based...” Medical record review of Patient #5’s ED nursing triage dated 12/20/2024 at 2:50 PM, showed the patient was admitted with Psychosis, Auditory Hallucinations, Delusions, and Suicidal Ideations without a plan. The patient stated she has been paranoid for 2 to 3 weeks and started a new medication for her psychiatric disorders. The patient’s Emergency Severity Index (ESI) score was a 3 indicating urgent needs. Medical record review of Patient #5’s ED physician’s documentation dated 12/20/2024 at 2:50 PM, showed the patient had previous history of Anxiety, Hallucinations, and Paranoia. The patient had experienced similar chronic episodes in the past where she had been seen two weeks prior for similar complaints. The patient’s diagnosis included Schizoaffective Disorder, Bipolar Disorder with Psychotic Features, and Suicidal Ideations. Medical record review of Patient #5’s Disposition record dated 12/20/2024 showed a behavior health referral was sent to Facility B (inpatient behavioral health facility) and the referral was accepted. Medical record review of Patient #5 ED visit on 12/20/2024 revealed there was no documentation regarding risks and benefits of the transfer to Facility B and there was no EMTALA transfer form in Patient #5’s record. During an interview on 1/14/2025 at 10:00 AM, in the Administrative Conference Room, the Quality Manager #1 and the ED Director confirmed there was no documentation of the risks and benefits of transfer in Patient #5’s medical record on 12/20/2024. Further interview confirmed there was no EMTALA transfer form in patient #5’s medical record for the ED visit on 12/20/2024.”

“STANDARD TAG FOR NUCLEAR MEDICINE SERVICES CFR(s): 482.53 Standard-level Tag §482.53 Condition of Participation: Nuclear Medicine Services If the hospital provides nuclear medicine services, those services must meet the needs of the patients in accordance with acceptable standards of practice. This Standard is not met as evidenced by: 41291 Based on review of the facility’s policy, medical record review and interviews, the facility failed to safely administer a radiopharmaceutical isotope (safe radioactive drug healthcare providers use for special imaging tests) for 1 patient (Patient B) of 4 patients reviewed for outpatient nuclear medicine testing. The findings include: Review of the facility’s policy titled, “Handling of Radioactive Materials,” dated 1/2023, revealed “...All radiopharmaceuticals are delivered as unit doses with appropriate labels...Receive isotopes in the Imaging Department by a Nuclear Medicine Technologist...Patient identified by armband or date of birth and name...Orders checked with chart or against doctor’s prescription with patient...Patient is questioned on history pertinent to the examination and recorded on the requisition...Isotope Comparison with Patient...Isotope is checked...for accuracy prior to injection...” Review of the medical record for Patient B, dated 3/1/2024, revealed the patient was scheduled for an outpatient bone scan for Primary Malignant Neoplasm of Prostate. The scan was not performed and the medical record did not indicate why the scan was discontinued. Review of the medical record for Patient J, dated 3/1/2024, revealed the patient was scheduled for an outpatient Hepatobiliary Iminodiacetic Acid (HIDA) scan (an imaging procedure used to diagnose problems of the liver, gallbladder, and bile ducts). The scan was not performed and the medical record did not indicate why the scan was discontinued. Review of the Unit Dose Prescription Records, dated 3/1/2024, did not show Patient B had received a radioactive isotope. There is a label for Patient J, dated 3/1/2024, which read “...Product...Mebrofenin [radioactive isotope agent, which may be used to find and treat certain diseases or to study the function of the body’s organs]...4.97 mCi [millicurie-unit of measure]...Indication: Hepatobiliary Imag. [imaging]...” During an interview on 7/16/2024, at 2:29 PM, the Director of Radiology recalled an incident when a patient (Patient B) received another patient’s isotope for a nuclear scan. The Nuclear Technician (NT) reported the incident to the Director of Radiology. The Director of Radiology was unable to recall if an internal facility incident report had been completed and the Director of Radiology stated the NT was counseled after the incident and there were no negative outcomes. The interview revealed the NT reported Patient B received another patient’s isotope; it was explained to the patient the scheduled test could not be performed and would need to be rescheduled. When asked if the NT had identified the Patient B by name, date of birth, and verified the physician’s order for the test, could the administration of the incorrect isotope have been avoided, the Director of Radiology replied, “possibly...yes...” During an interview on 7/17/2024 at 10:34 AM, the NT recalled the incident involving Patient B which occurred on 3/1/2024. He stated Patient J had been scheduled for a HIDA scan and once in the procedure room, decided to cancel the scan (unsure exact reasons for cancellation). The NT stated Patient J was escorted back to the registration desk. The NT then called for Patient B in the waiting area and stated he asked for Patient B’s name and date of birth while they were walking to the nuclear medicine procedure room. Patient J’s radiopharmacologic isotope was still set up and had not been removed from the procedure room. The NT stated, “...I did not look...administered the wrong isotope...realized immediately once the syringe came back down what I had done...” Patient B received 5 mCi of Mebrofenin and should have gotten 20 mCi’s for the scheduled bone scan. The NT confirmed he did not follow the “5 rights of medication administration” and Patient B received the wrong dose of medication. During a telephone interview on 7/17/2024 at 1:39 PM, Patient B had the bone scan at another facility and had no negative outcomes from receiving the incorrect isotope.”

“Means of Egress - General CFR(s): NFPA 101 Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1 This Standard is not met as evidenced by: 46789 Based on observation and interview, the facility failed to ensure corridors in the means of egress were continuously maintained clear of all obstructions per the requirements of: NFPA 101 2012 Edition 19.2.3.4 The findings include: Observation and interview with the Plant Operations Director, during the facility tour on 2/29/2024 between 2:22 PM and 3:10 PM confirmed the corridor in The E.D. had 2 Portable air conditioner units ducted into the ceiling located in the egress corridor. The Plant Operations Director was present when the deficiency was identified and acknowledged by the Chief Executive Officer during the exit conference on 2/29/24.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 46789 Based on observation, the facility failed to prohibit the use of portable space heaters in patient care vicinity per the requirements of. NFPA 101 2012 Edition 19.7.8 The findings include: Observation with the Plant Operations Director, on 2/29/24 at 2:43 PM revealed the Admissions office had a portable space heater under staff desk in the patient care vicinity. The Plant Operations Director was present when the deficiency was identified and acknowledged by the Chief Executive Officer during the exit conference on 2/29/24.”