Tristar Hendersonville Medical Center

“MEDICAL RECORD SERVICES CFR(s): 482.24(c)(1) All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures. This Standard is not met as evidenced by: 32777 Based on review of facility policy, medical record, surveillance video footage and interview, the hospital failed to maintain a complete and accurate medical record for 1 (Patient #1) of 2 patients reviewed. The findings included: 1. Review of the Hospital policy “Medication Use Policy” last approved 04/2023, revealed, “ ...MEDICATION ADMINISTRATION ...Medication should be administered following the procedures below ...Document medications given on the electronic MAR [Medication Administration Record] ...” Review of the Hospital policy “Medication Distribution - Automated Dispensing Machines” last approved 10/2023, revealed, “ ...WASTING MEDICATIONS - Wasting of controlled substances is documented...by two nurses. One nurse wastes the medication and the other nurse serves as a witness to the discard ...” Review of the Hospital “Medical Staff Rules and Regulations” last approved 04/2025, revealed, “ ...MEDICAL RECORDS ...General Requirements ...Medical records should be accurate ...” Review of the Hospital policy “Controlled Substance Monitoring” Effective date: November 1, 2023, revealed, “...Purpose: Establish controls related to ordering, receiving, prescribing, dispensing, administering, documenting and handling controlled substances ...Controlled substance administration and documentation are completed immediately ...” 2. Review of Patient #1’s medical record revealed Patient #1 was seen in the Emergency Department (ED) on 10/06/2025 with an initial complaint of lower back pain radiating down leg. Review of the physician’s orders dated 10/06/2025 at 5:53 PM, revealed an order for Fentanyl (a powerful synthetic opioid painkiller) Injection 100 mcg (micrograms) IV (intravenous), one time dose, and an order for Ketorolac (a potent nonsteroidal anti-inflammatory drug used for moderately severe, acute pain) Injection 30 mg (milligrams) IV, one time dose. Review of the Medication Administration Record (MAR) revealed, Nurse A administered 100 mcg of Fentanyl IV at 6:18 PM for pain management and 30 mg of Ketorolac IV at 6:18 PM for pain management. 3. Review of surveillance footage dated 10/6/2025 in the Medication Room revealed Paramedic (a provider who has received extensive training in emergency medical care) B wasting a syringe of medication into the hospital waste disposal system. Nurse A was also in the Medication Room standing at the ADC (Automatic Drug Dispensing Cabinet) typing. Her back was to Paramedic B who was wasting the medication and was unable to visualize Paramedic B wasting the drug. Once Paramedic B wasted the medication, he stepped up to the ADC and typed in an entry. 4. During an interview on 1/7/2026, Paramedic B watched the video footage and confirmed he had taken the medications to Patient #1’s room and did administer the medications given to him by Nurse A but stated he did not administer the Fentanyl dose to the patient. Paramedic B stated Nurse A had told him not to administer the Fentanyl (Paramedic B could not remember what that reason was). Paramedic B confirmed he did waste the Fentanyl as observed in the video. Paramedic B was shown the printed MAR that documented Nurse A had administered the medications. There was no entry that identified Patient A did not receive the Fentanyl. Paramedic B stated Nurse A must have forgotten to go back into the computer and document the Fentanyl was not given. Paramedic B was asked how the Fentanyl was entered as given when it was not given. Paramedic B stated as soon as a medication is removed from the ADC, it is automatically charted in the MAR as administered by the nurse who removed it from the Pyxis. Paramedic B stated if for any reason the medication is not given, the nurse must go back into the computer system and document the medication was not given. Patient #1’s medical record was inaccurate because the MAR showed Nurse A administered Fentanyl when it was not administered to Patient #1. there was no documentation the dose of Fentanyl was not given. The MAR showed Nurse A administered Ketorolac to Patient #1 when Paramedic B actually administered Ketorolac to Patient #1.”

“REPORTING ABUSES/LOSSES OF DRUGS CFR(s): 482.25(b)(7) Abuses and losses of controlled substances must be reported, in accordance with applicable Federal and State laws, to the individual responsible for the pharmaceutical service, and to the chief executive officer, as appropriate. This Standard is not met as evidenced by: 32777 Based on review of facility policy, facility documents, medical records, and interviews, the hospital failed to ensure ongoing sufficient supervision and monitoring to detect possible drug diversion when Nurse A entered a verbal order for 0.5 mg (milligrams) of Dilaudid using another nurse’s credentials. When the facility became aware, the Director of Pharmacy was notified and began an in-depth investigation which yielded several questionable events over the previous 12 months. The findings included: Review of the Hospital policy “Controlled Substance Monitoring” Effective date: November 1, 2023, revealed, “...Purpose: Establish controls related to ordering, receiving, prescribing, dispensing, administering, documenting and handling controlled substances ...POLICY ...The facility CEO [Chief Executive Officer] or DEA [Drug Enforcement Agency] Registrant designates a facility multidisciplinary Medication Diversion Team (MDT) that is responsible for policy compliance. Each facility’s MDT is charged with developing a coordinated and systematic approach to prevent, detect, and report medication diversion. The MDT is responsible for maintaining a medication diversion monitoring and reporting program that discourages diversion and strengthens accountability, rapidly identifies suspected diversion, responds to known or suspected diversion incidents, and continually seeks to improve controls ...Administration ...Controlled substances are removed by authorized colleague at the time of administration. Controlled substance administration and documentation are completed immediately ...Wasting of a controlled substance remaining from administration ...occurs at the end of the medication’s use. This is recorded in the ADC [Automatic Dispensing Cabinet]...or manual documentation form per facility policy ...” Review of the hospital’s “Medication Adherence and Compliance Index” (MACI) review notes revealed, “...Medication Diversion Team Notes...08/22/2025...Diversion not suspected at this time...At this time [Named Nurse A] is not due to return to work until mid-Sept...11/03/2025 [Named Nurse A] currently suspended pending further information gathering after circumstances surrounding October 6th incident...along with insubordination by not following ER Nurse Leadership directives on caring for patients and not accessing medications after return from leave in August. HR to follow up with corporate legal to discuss probably diversion based on previous MACI findings...” Review of the Director of Pharmacy’s undated “Potential DEA [Drug Enforcement Administration]” 106 findings for [Named Nurse A] diversion” revealed: 2 full dose wastes in November, 2024 11/20/2024 - Hydromorphone 1 mg dispensed by Nurse A at 1:06 PM, and full dose wasted at 1:13 PM. A second dose was dispensed by another nurse at 1:19 PM and administered to the patient at 1:24 PM. 11/21/2024 - Morphine 4 mg dispensed by Nurse A at 1:37 PM and full dose wasted at 1:39 PM. Another order was entered at 1:57 PM on the same patient and dispensed by Nurse A at 2:22 PM. The order was cancelled by the physician at 2:25 PM and Nurse A full dose wasted at 2:27 PM. 2 full dose wastes in December, 2024 12/8/2024 - Fentanyl 100 mcg (micrograms) dispensed by Nurse A at 12:59 PM, full dose wasted at 1:11 PM. Another dose dispensed by Nurse A at 1:57 PM and documented as administered by Nurse A at 1:58 PM. 12/12/2024 - Hydromorphone 1 mg dispensed by another nurse at 9:17 AM and also dispensed by Nurse A at another Pyxis at 9:18 AM, full dose wasted at 1:11 PM. Another dose dispensed by Nurse A at 1:57 PM and documented as administered by Nurse A at 1:58 PM. No full dose wastes documented in January, 2025 1 full dose waste in February, 2025 2/26/2025 - Fentanyl 100 mcg Nurse A dispensed (no time documented) Dose documented at “No” with comment pt. (Patient) changed mind and did not want meds”. No full dose wastes documented in March, 2025 2 full dose wastes documented in April, 2025 04/14/2025 - Fentanyl 100 mg at 3:48 PM documented as administered by Nurse A. Same patient: Hydromorphone 1 mg verbal order entered by Nurse A but administered by another nurse. Same patient: Fentanyl 100 mcg dispensed by another nurse at 6:56 PM documented as administered at 6:59 PM, but changed to “no” at 7:03 PM with comment, “PT [Patient] REFUSED DUE TO NOT WANTING TO BE MORE CONSTIPATED” wasted by the other nurse and witnessed by Nurse A. 04/30/2025 - Fentanyl 100 mcg at 11:02 AM documented as administered by Nurse A then edited to “no” at 11:18 AM with comment, “pt decided she did not want a narcotic pain med at this time, will re-eval pain level.” Full dose waste not documented on the report. 2 full dose wastes in May, 2025: 05/01/2025- Fentanyl 50 mcg documented as administered by Nurse A at 11:31 AM, then edited to “no” at 11:38 AM with comment, “PT REFUSED”. 05/30/2025 - Hydromorphone 0.5 mg No documented administration or edits. Full dose wasted by Nurse A. No times noted. 4 total full dose wastes in June, 2025 06/03/2025 - Fentanyl 50 mcg dispensed by Nurse A at 10:33 AM. Nurse A documented administration at 10:51 AM, then edited to “No” for given at 11:02 AM with comment “pt [patient] decided she did not want medication”. 06/13/2025 - Fentanyl (No dose specified) dispensed by another nurse at 11:46 AM and dispensed by Nurse A at 11:50. Both doses were full dose wasted. Nurse A documented administered at 12:03 PM and edited to “No” at 12:11 PM. Another dose was pulled at 12:28 PM by the other nurse and edited the administration time to 12:33 PM. 06/19/2025 - Hydromorphone 1 mg dispensed by Nurse A and within 9 seconds another identical dose for same patient pulled by another nurse from another Pyxis machine and documented as administered. Nurse A wasted the full dose she dispensed. No times are documented on the report. 06/27/2025 - Hydromorphone 1 mg ordered at 5:27 PM. dispensed by Nurse A at 5:35 PM and again at 5:43 PM. One dose is administered and the other dose is full dose wasted. 6 total full dose wastes in July, 2025 07/3/2025 - Hydromorphone 1 mg dispensed by Nurse A at 5:44 PM and full dose wasted at 5:47 PM. 07/4/2025 - Hydromorphone 1 mg dispensed by Nurse A at 1:13 PM and full dose wasted at 1:17 PM. 07/11/2025 - Fentanyl 100 mcg dispensed by Nurse A at 6:25 PM and full dose wasted at 6:41 PM. 07/15/2025 - Hydromorphone 0.5 mg dispensed by Nurse A at 10:27 AM and full dose wasted at 10:31 PM. 07/18/2025 - Hydromorphone 1 mg dispensed by Nurse A at 6:36 PM and full dose wasted at 6:41 PM. 07/24/2025 - Fentanyl 100 mcg dispensed by Nurse A at 12:31 PM and full dose wasted at 12:38 PM. No activity in August, 2025 as Nurse A was on leave. 2 variances noted for September, 2025: 09/04/2025 - patient had 2 different prescriptions for a drip (unknown drug or dosage). Nurse A dispensed the drip under 1 prescription and documented administration under the the other prescription. 09/29/2025 - Fentanyl 100 mcg dispensed by Nurse A at 2:14 PM and documented as administered at 2:22 PM. The Electronic Medical Record showed this patient’s discharge time at 2:00 PM. 1 full dose waste for October, 2025 10/06/2025 - Fentanyl 100 mcg dispensed by Nurse A at 6:13 PM and documented administered at 6:22 PM. Full dose waste documented at 6:33 PM by Nurse A. Nurse A dispensed a total of 4 medications, and handed them off to Paramedic B who administered 3 of the 4 medications. The Medication Administration Record (MAR) showed Nurse A administered all 4 medications. The MAR was not revised to reflect the patient did not receive the Fentanyl. The report further showed Nurse A had more total Opioid injections on the MACI report of 81 total injections over 17 shifts with activity on 85 different patient accounts. Review of the Director of ER’s undated “2025 Coaching Log” revealed, on July 18th 2025 the Director of ER met with Nurse A and told her to stop giving other nurse’s medications. The ED Nurse Manager explained to Nurse A that her name appeared on the MACI (a software tool that collects data and flags data from previous diversion). On July 25th, 2025 the Director of ER again met with Nurse A and told her not to take a patient assignment. The Director of ER stated to Nurse A not to give any narcotic medications at all. The Coaching Log showed, “ ...[Named Nurse A] clearly got upset and said, “This isn’t right, all I am doing is trying to help with patient flow” ...She [Nurse A] checked in as a patient within the hour ...” On July 31st, 2025, Nurse A notified the Director of ER she would be out for 30 days. On September 2nd, 2025 Nurse A returned to work. Nurse A was again advised not to give any medications at all and not to take a patient assignment. The Director of ER typed in the Coaching Log, “ ...I reiterated that she is not to give any medications under no circumstances. She verbalized understanding and stated, ‘I will not give any medications at all.’” On September 30th, 2025, the Director of ER texted Nurse A and asked why she wasn’t at work and why she didn’t attend a scheduled meeting that morning. Nurse A texted she missed it and “that was on her. She went on to explain she has spoken to [Nurse C] about what days that she would work this week ...I told her that was not the correct way of doing things ...and she should have cleared things through me ...” On October 6th, 2025, The Director of ER received a call while on vacation from Nurse C who was upset that Nurse A had placed a narcotic order under her name. Nurse A stated she had told Nurse C that she did it. The Coaching Log showed the Director of ER documented, “..I asked [Named Nurse A] why she would place a narcotic order for a patient with C-diff, that clearly was not emergent and especially since I specifically told her not to give any narcotics. I told her, ‘I specifically told you not to place any narcotic orders, or any medication orders, and not to give any medications.’ She [Nurse A] stated, ‘I know but she was hurting. I am not doing anything ...but trying to help patients.’ ...when I got back on Thursday October 9th, that I would address this situation. I told her do not under any circumstances tough any medication period. She [Nurse A] verbalized understanding and said I swear that I won’t” On October 9th, 2025, the Director of ER called the Director of Human Resources and asked for guidance on this situation. 3. During an interview on 12/19/2025 at 9:58 AM, the Director of Pharmacy confirmed Nurse A had a leadership role and was a nurse manager in the ED. He stated the Narcotic Diversion Committee (NDC) meets monthly and reviews reports generated from MACI (a software tool that collects data and flags data from previous diversion). He stated Nurse A had flagged for “ ...full dose waste ...that can be a potential diversion” He stated a full dose waste can occur if a patient refuses the medication after it is pulled from the Pyxis (Automatic Drug Dispensing Machine). He stated there was an incident on October 6th, 2025 when Nurse A took a verbal order from a new provider (1st day in the ED). The order was for 0.5 mg. (milligrams) of Dilaudid (narcotic pain medication). Nurse A then asked Named Physician Assistant C to enter the order in the computer. Physician Assistant C refused because she did not feel comfortable. The Director of Pharmacy stated later, Physician Assistant C saw in the computer where another nurse (Nurse D) had entered the order. Physician Assistant C asked that nurse if she had entered the order for the Dilaudid. The other nurse denied entering the order. Nurse A had entered the order in a computer when Nurse D had walked away from the computer she was using. The Director of Pharmacy stated he was made aware of this incident a week later. The Director of Pharmacy stated Nurse A had several flags in July but stated, “ ...The team [NDC] felt we did not have clear cut diversion, so they were continuing to monitor her. She went on leave in August and was back in September ...The Director [ED] had a talk with her about administering narcotics and told her not to give narcotics ...She did this independent of the committee. [Named Director of ED] went on vacation in September ...In July, there were 6 instances of “full dose waste” [Named Nurse A] was pulling the drug at the same time as another nurse ...After the situation in October and the new information from [Named ED Director] the committee [NDC] felt this was diversion ...probably a high probability she diverted ...” The Director of Pharmacy stated Dilaudid comes in a prefilled syringe and Fentanyl is in a vial. The Director of Pharmacy stated that [Named Nurse A] was terminated for insubordination and diversion, and falsified records. There was 1 or 2 incidents that she [Nurse A] gave a full dose of Fentanyl and also wasted it per the documentation. The Director of Pharmacy stated, “The committee deemed her poor practice not diversion ...in July activity, she [Nurse A] had the highest pulls of opiates and IV [intravenous] Dilaudid and was the top nurse for Fentanyl ...” The Director of Pharmacy stated the committee met in August to review July. He stated Nurse A was in staffing a lot in July [due to short staffing], and working 5 days per week. She accessed more [medications] because she was taking care of more patients, they didn’t look at diversion. The Director of Pharmacy confirmed the last day Nurse A worked was October 6, 2025 and she was suspended pending the outcome of the investigation. The Director of Pharmacy stated, “We [Narcotic Diversion Committee] felt she was diverting the waste ...we could only go back to October, 2024 ...we needed to go back to see if the behavior was back further ...I was looking for a pattern ...it is in my report, my notes ...” During an interview on 12/19/2025 at 11:08 AM, the Vice President of Human Resources (VP of HR) stated he first became a little suspicious when the first incident happened in June (2025) when one of the house supervisors came and stated he and Nurse A were wasting a drug (did not recall what drug), but the nurse stated he took his eyes off of her when she was wasting. The nurse stated to the VP of HR that Nurse A wasted the drug into a container that was not the usual container. The usual container is locked. The nurse reported it he could not say confidently what she actually squirted in the container. The VP of HR stated he brought her in for questioning. He stated Nurse A described the exact process. The VP of HR stated Nurse A gave us nothing to think she was doing anything weird, but if there was anything else it will be added. The VP of HR then said fast forward to the incident on 10/06/2025 and stated the Director of ER had told Nurse A that she should not be taking patient assignments. She told Nurse A not to administer drugs for the nurses. During an interview on 12/19/2025 at 12:13 PM the Director of ER confirmed Nurse A worked for her for approximately 12 years. The Director of ER stated staff members began noticing Nurse A not “acting right” before she went out on medical leave (2024). She was the night shift manager at that time and when she came back after 4 or 5 months, she was moved to the day shift as a manager in the ER. The Director of ER confirmed she had several conversations and texts with Nurse A from June, 2025 to October 6th, 2025. She confirmed she told Nurse A multiple times to not take patient assignments, or give any medication to patients. Nurse A continued to pull Narcotics from the Pyxis with multiple wasted drugs. The Director of ER stated she asked Nurse A if she was diverting drugs. Nurse A denied diverting any drugs. Nurse A told the Director of ER she still had narcotic prescriptions from when she was out on medical leave. The Director of ER asked Nurse A to send a picture of the bottles. Nurse A never provided the pictures of the medication bottles to the Director of ER. The Director of ER stated this happened in June or July, 2025. The Director of ER stated Nurse A was listed on a MACI report again for large numbers of full wastes. The Director of ER stated she was in contact with the Director of Pharmacy regarding the discrepancies but there was never anything solid to prove diversion. The Director of ER stated on July 8th, she met with Nurse A and told her stop giving everyone else’s medications because she is listed on the MACI report again. On July 25th, 2025 the Director of ER stated she once again told Nurse A not to give any narcotics at all and Nurse A became upset and walked outside to her car. The Director of ER stated Nurse A came back into the ER within the hour and checked in as a patient. She remained in the hospital and on July 31st, 2015, Nurse A checked in to a rehab treatment program for alcoholism. The Director of ER stated Nurse A returned to work on September 2nd, 2025 in her same role as day shift nurse manager in the ER. The Director of ER stated she again advised Nurse A “ ...not to give any medications whatsoever. Don’t touch the fixes, don’t give any medications, don’t go in the room and give medications that another nurse had drawn [put into a syringe], don’t give medications. Don’t touch them ...” The Director of ER stated that Nurse A stated she understood. On September 30th, the Director of ER stated she told Nurse A that she was going out of town on vacation and again told her she was not to touch medications. The Director of ER stated Nurse A again voiced understanding. The Director of ER stated on October the 6th she was on vacation in Florida and she received a text message from Nurse C asking me to call her. The Director of ER called Nurse C and Nurse C was very upset and told her that Nurse A had entered an order for a narcotic under Nurse C’s profile. The Director of ER stated she came back to work the next day on October 7th, 2025. During an interview on 12/19/2025 at 1:41 PM, Nurse C stated she was at the computer at the nurse’s desk and got up from the computer without logging out. Nurse C stated about 45 minutes later, the PA asked her if she had put in an order for a narcotic because she had seen Nurse A sitting at the computer right after Nurse C had gotten up. Nurse C further stated she looked up the order and saw the order was there. Nurse C confirmed she spoke to the Director of ER on the phone that day about the incident. Nurse C further stated she had noticed over those past few weeks Nurse A’s behavior was “bizarre”. During an interview on 12/19/2025 at 1:59 PM, the Physician Assistant (PA) stated she was aware she had gone into rehab because she had an alcohol problem. The PA stated the patient needed Dilaudid, and she saw Nurse A at the computer and said “I’m putting a Dilaudid order in for you” but Nurse C did not hear her. I told Nurse C about it, and “that’s all I know”.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 19001 Based on policy review, medical record review and interview, the hospital failed to ensure patient rights were met to include informing patient/family of transfer to another facility for 1 of 3 (Patient #1) sampled patients. The findings included: 1. Review of the hospital policy “Patient Rights” effective July 1, 2020, revealed, “PURPOSE: The commitment to treat all patients with respect and dignity is an obligation in every [named corporation]...Ensure that there is no harassment, discrimination or distinction in ...the admission, transfer or discharge of patients, in the care provided, Ensure that all patients receiving care and or patient representatives are informed of their rights...Definitions Family- A person or persons who play a significant role in an individuals life. A family is a group of two or more persons united by blood...marital...” Review of the Patient Rights policy dated 12/2024 revealed, “Please refer to the Model Statement of Patient Rights and Responsibilities” Review of the Model Statement of Patient Rights and Responsibilities attached to the policy revealed, “[named hospital] respects the dignity and pride of each individual we serve...We adopt and affirm as policy the following rights of patients/clients who receive services form our facilities:...Information regarding Health Status and Care: To be informed of his/her health status in terms that patient can reasonably be expected to understand, and to participate in the development and the implementation of his/her plan of care and treatment...The right to be informed about any continuing heath care requirements after his/ her discharge from the hospital ...Additional Patient Rights: Except in emergencies, the patient may be transferred to another facility only with full explanation of the reasons for the transfer, provisions for continuing care and the acceptance of the receiving institution...” 2. Medical record review revealed Patient #1 presented to the Emergency Department (ED) on 12/29/2023 at 1:30 PM for agitation and aggressive behavior including hitting a nurse in the stomach at an assisted living facility, his primary residence. Patient #1 had diagnoses including Dementia and Parkinson’s Disease. Patient #1 was reported as confused and unable to sign his admission paperwork. Patient #1 had no family to accompany him to the ED. Patient #1’s wife made telephone calls to the ED to communicate with the hospital staff about his care and treatment. Review of the medical screening exam revealed Patient #1’s mental status was confused and disoriented to person, place and time, with no physical concerns. The ED Physician recommended a psychiatric evaluation. The psychiatric evaluation was conducted via telemedicine on 12/29/2023 at 1:00 PM and revealed, “ ...when seen pt [patient] was quite confused and unable to participate in the psychiatric evaluation. He did not respond appropriately to any questions and the evaluation was terminated...” The Assessment and Plan revealed a recommendation to admit Patient #1 involuntarily for further evaluation and treatment at an inpatient psychiatric facility. The hospital began making referrals for Patient #1 to inpatient psychiatric facilities for elderly patients on 12/29/2023, per the psychiatrist recommendation. Review of the nursing notes revealed the following communication with Patient #1’s wife: 12/29/2023 2:23 PM- Wife wants to be called with any updates or changes. 12/29/2023 5:35 PM- Wife would like a call from the Psychiatrist after consult. 12/31/2023 11:14 AM- Spoke with wife, wants a follow up call regarding patient condition. 12/31/2023 12:44 PM- Spoke with wife, calling to request an update, transferred to charge nurse. 12/31/2023 12:48 PM- Wife updated on plan of care. Wife very upset, she was not notified he was going to a psychiatric facility. Wife updated on plan of care and assured he is being watched closely by a sitter. 12/31/2023 7:26 PM- Wife called and wants us to call her back before placement occurs. Patient #1 was transferred to an inpatient psychiatric hospital on 1/1/2024 at 7:10 PM. There was no documentation Patient #1’s wife was informed prior to, or at the time of the transfer, as requested and documented on 12/31/2023 3. In a telephone interview on 7/23/2025 at 7:20 AM, Nurse #1, who conducted the transfer and documented the discharge in the medical record, stated she could not recall whether she informed Patient #1’s wife that he was being transferred to the psychiatric hospital on 1/1/2024. Nurse #1 verified there was no documentation that she communicated with Patient #1’s wife that Patient #1 was being discharged.”

“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 hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE) for one (1) of 20 (Patient #18) sampled patients. The findings included: Medical record review revealed Patient #18 presented to Hospital #1’s ED on 6/23/2025 at 4:00 PM via “walk-in” with a chief complaint of a fall, with pain in the lower back, right hip, right knee and right elbow. Triage assessment revealed Patient #18 was alert and oriented with limited mobility. Patient #18 rated the pain as 5- 6 out of 10 on pain scale of 0-10 (0 is no pain and 10 is the worse pain ever). Patient #18’s chief pain complaint was in the”hip/pelvis” and described the pain as being constant. A MSE was initiated on 6/23/2025 at 5:02 PM by Provider #1. Provider #1 performed an examination and ordered tests to determine any untoward effects from the patient’s fall. An x-ray of the hip and pelvis, signed by the radiologist on 6/25/2025 at 6:03 PM, documented “...strongly suspected impaction fracture of the right femoral neck... Please correlate with clinical findings, recommend follow-up CT [Computed Tomography; helps healthcare providers detect diseases and injuries] or MRI [magnetic resonance imaging - uses magnetic fields and radio waves to create detailed images of the inside of the body] if the clinical picture is unclear...” At the end of the shift on 6/23/2025, Physician #1 assumed care of Patient #18 from Provider #1. Physician #1 documented she had interpreted the patient’s x-rays and Patient #18 was without evidence of fracture. Physician #1 further documented CT imaging had been obtained and reviewed by the radiologist; the Patient is without evidence of significant acute injury. Review of and addition text note revealed Physician #1 “... called today [6/27/2025] to notify family of radiologist x-ray read as the R [right] femoral head fracture was missed on wet read. The patient is now at [named Hospital #2] awaiting surgical fixation...” Cross Refer to A-2406.”

“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 hospital policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s Emergency Department (ED) seeking care for an emergency medical condition (EMC) received an appropriate and ongoing medical screening examination (MSE) for one (1) of 20 (Patient #18) sampled patients reviewed. The findings included: 1. Review of the hospital’s “Medical Staff Rules and Regulations” policy (revised 4/2025) revealed, “...Medical Screening Exam...A. Federal and state laws and regulations provide that any individual who comes to the Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition exists...C. The MSE 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...” Review of the hospital’s “[Named State] EMTALA [Emergency Medical Treatment and Labor Act], Medical Screening Examination and Stabilization” policy (revised 9/2024) revealed, “...An EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and...the individual or a representative acting on the individual’s behalf requests an examination or treatment for a medical condition...A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists...An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms...The individual shall be continuously monitored according to the individual’s needs until it is determined whether or not the individual has an EMC...The medical record shall reflect the amount and extent of monitoring that was provided prior to the completion of the MSE and until discharge or transfer...” 2. Medical record review revealed Patient #18 presented to Hospital #1’s ED on 6/23/2025 at 4:00 PM via “walk-in” with a chief complaint of a fall, with lower back and right hip pain as well as right knee and right elbow pain. Patient #18 arrived in the ED with family who reported the Patient slipped and fell and had a skin tear to the right arm. The family member denied the Patient hit her head. Family reported the Patient had a history of Dementia (condition characterized by impairment of memory loss and/or judgment). The Triage assessment, initiated at 4:02 PM, revealed Patient #18 was alert and oriented x 3 (to person, place and time), mobility was limited, and pain was rated as 5- 6 out of 10 on pain scale of 0-10 (with 0 indicating no pain and 10 indicating the worse pain one can experience). The chief complaint of Patient #18 was the “hip/pelvis” with pain characterized as constant. The Patient was triaged as a level “3” on the Emergency Severity Index (ESI - used in emergency rooms to quickly assess patient acuity and prioritize care) was urgent. A MSE was initiated on 6/23/2025 at 5:02 PM by Provider #1. Provider #1 documented Patient #18 presented to the ED with family after an accidental slip and fall. Patient #18 had complaints of a skin tear to the right upper extremity, discomfort to the lower back, right hip and knee. The Patient had been ambulatory since the fall. The Family denied Patient #18 hit her head or had any loss of consciousness (LOC). Provider #1 documented on the physical examination that Patient #18 had “...Lower Ext [extremities]/Pelvis Atraumatic, Inspection w/o [without] erythema [redness of the skin], eccymosis [ecchymosis; medical term for a bruise], break in skin, or gross deformity, Full range of motion, Neurologic intact, Vascular intact ...” The following x-rays were ordered on 6/23/2025 at 5:15 PM by Provider #1: x-ray of right elbow, x-ray of hip with pelvis (bilateral), x-ray of right knee. X-ray of hip with pelvis (signed by radiologist on 6/24/2025 at 6:03 PM) revealed “strongly suspected impaction fracture of the right femoral neck ...Please correlate with clinical findings, recommend follow-up CT or MRI [magnetic resonance imaging - uses magnetic fields and radio waves to create detailed images of the inside of the body] if the clinical picture is unclear” Provider #1 documented Progress Note #2 as “Patient laboratory investigations as well as imaging pending at end of my shift. Case discussed with [named Physician #1], care transferred, disp [disposition] pending imaging results and reassessment. Re-Eval [re-evaluation] Status Improved...” Provider Handoff note by Physician #1 revealed, “This patient’s care was assumed from initial mid-level provider who saw and evaluated the patient on arrival. Patient care was assumed awaiting completion of ED evaluation. Patient plain film radiographs have been interpreted by me without evidence of fracture. CT imaging has been obtained and reviewed by radiologist. Patient is without evidence of significant acute injury...” Patient #18 was discharged from the ED to home on 6/23/2025 at 10:15 PM. An “Additional Text” note by Physician #1 revealed, “...[named Physician #1] called today (6/27/2025) to notify family of radiologist x-ray read as the R [right] femoral head fracture was missed on wet read [preliminary interpretation of a medical image]. The patient is now at [named Hospital #2] awaiting surgical fixation...” Medical record review of Patient #18’s history and physical from Hospital #2 revealed Patient #18 presented to the ED at Hospital #2 on 6/26/2025 for evaluation of right hip pain. The pain had been ongoing for three days. A CT scan of the right hip/thigh noted a severely displaced subcapital femoral neck fracture (fracture at the base of the femoral head). Patient #18 was admitted to the hospital and scheduled for surgical repair of the hip on 6/27/2025. In an email correspondence on 7/15/2025 at 11:03 PM, Physician #1 stated she was very familiar with the patient (Patient #18). Physician #1 stated she made an attempt to reach out to the family and apologize for her error, the night she found out she had missed the fracture. The Patient was already at another facility to have her hip repaired at that time. Patient #18 presented to Hospital #1 on 6/23/2025 at 4:00 PM after an accidental fall. Patient #18 complained of pain to the right hip/thigh area. The Initial physical examination by Provider #1 revealed no deformity to the lower extremities. An x-ray of bilateral hips/pelvis was ordered and initially read in the ED by Physician #1. Physician #1 did not interpret any evidence of an acute fracture. Patient #18 was discharged home on 6/23/2025 at 10:15 PM. A radiologist report of the hip/pelvis x-ray was signed the following day on 6/24/2025 with the impression of strongly suspected impaction fracture of the right femoral neck with a recommendation to follow-up with a CT or Magnetic Resonance Imaging (MRI) if the clinical picture was unclear. There was no documentation Provider #1 assessed Patient #18’s ability to ambulate or bear weight to the right lower extremity during the initial physical examination on 6/23/2025. There was no documentation Physician #1 reassessed Patient #18’s lower extremity musculoskeletal status, the ability to ambulate or the ability to bear weight, prior to discharging Patient #18 home on 6/23/2025. Hospital #1 failed to provide a complete Medical Screening Examination to determine if Patient #1 had an Emergency Medical Condition.”

“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: 19001 Based on document review, policy review, medical record review, and interview the hospital failed to ensure an appropriate and complete medical screening exam (MSE) was performed for 1 of 21 (Patient #1) patients seeking medical treatment for an emergency medical condition. The findings included: Patient #1 was a 14-year-old female who presented to Hospital #2’s Emergency Department (ED) after being treated on 9/30/2024 at an out-of-state hospital ED. On 9/30/2024, Patient #1 was transferred from Hospital #1 (out-of-state hospital) to Hospital #4 (in-state hospital located in Town #3), via ground ambulance for critically low hemoglobin (a protein in red blood cells that carries oxygen from the lungs to the body’s tissues and organs), critically low hematocrit (the percentage by volume of red cells in the blood), hypotension (low blood pressure; a condition in which the force of the blood pushing against the artery walls is too low) and tachycardia (a heart rate of more than 100 beats per minute at rest). En route to Hospital #4 Emergency Medical Services (EMS) became concerned with increased hypotension, nausea and vomiting, and syncope (fainting or a sudden temporary loss of consciousness). Based on the decomposition of vital signs, EMS contacted the receiving hospital’s (Hospital #4) physician who instructed EMS to seek care for Patient #1 at the nearest emergency room for a blood transfusion and to avoid hemorrhagic shock (a form of shock caused by insufficient blood volume in the body; can be caused by dehydration or blood loss). EMS transported Patient #1 to Hospital #2’s (Hospital #2 was located in Town #2) Freestanding Emergency Department (located in Town #1), the closest ED. Upon arrival to Hospital #2’s Freestanding ED, ED Physician #1 questioned EMS as to who authorized them to bring Patient #1 to a Freestanding ED. ED Physician #1 told EMS there was no blood available at Hospital #2’s Freestanding ED and instructed EMS not to remove Patient #1 from the stretcher and continue to Hospital #4. There was no triage assessment or MSE conducted on 9/30/2024 for Patient #1 at Hospital #2’s Freestanding ED. Refer to 2406.”

“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: 19001 Based on document review, policy review, medical record review, and interview the hospital failed to ensure an appropriate and complete medical screening exam (MSE) was performed for 1 of 21 (Patient #1) patients seeking medical treatment for an emergency medical condition. The findings included: 1. Review of the Hospital’s “Medical Staff Rules and Regulations” last revised 09/2024, revealed, “Preamble- The Medical Staff shall initiate and adopt such Rules and Regulations as it may deem necessary for the proper conduct of its work and shall periodically review and revise its Rules and Regulations with current Medical Staff practice...VI. EMERGENCY SERVICES/MEDICAL SCREENING...1. Emergency Services A. Members of the Medical Staff shall accept responsibility for Emergency Service care in accordance with the Medical Staff Bylaws, Emergency Department policies and procedures and applicable state at federal law...2. Medical Screening Exam [MSE]...Federal and State laws and regulations provide that any individual who comes to Hospital property or premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by individuals qualified to perform such examination to determine whether or not an emergency medical condition [EMC] exists. An appropriate MSE includes routinely available ancillary services An MSE shall be provided to determine whether an emergency medical condition exists...” 2. Review of the hospital policy “TN [TENNESSEE] EMTALA [Emergency Medical Treatment and Active Labor Act] Medical Screening Examinations and Stabilization” last revised 09/2024 revealed, “...PURPOSE: To establish guidelines for providing appropriate medical screening examinations (MSE) and any necessary stabilizing treatment for an appropriate transfer...Policy: An EMTALA obligation is triggered when the individual comes to a dedicated emergency department (DED) and 1. the individual or representative acting on the individual’s behalf requests and examination or treatment of a medical condition... Procedure: When an MSE is required- A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: to any individual...who requests such an examination...An MSE shall be provided to determine whether or not the individual is experiencing an EMC [emergency medical condition]...An MSE is required when...The individual comes to a DED of a hospital and a request is made by the individual or on the individual’s behalf for examination and treatment for a medical condition...Extent of the MSE: a. Determine if an EMC exists. The hospital must perform and MSE to determine if an EMC exists...b. Definition of an MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital. C. An on-going process. The individual shall be continuously monitored...until it is determined whether or not the individual has an EMC...1. Depending on the individual’s presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also includes performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT [computed tomography] scans, and other diagnostic tests and procedures...No Delay in Medical Screening or Examination...EMS. A hospital has an obligation to see the individual once the individual presents to the DED whether by EMS or otherwise. A hospital that delays the MSE or stabilizing treatment of any individual who arrives via transfer from another facility, by not allowing EMS to leave the individual, could be in violation of EMTALA...the hospital must assess the individual’s condition upon arrival of the EMS service to ensure the individual is appropriately prioritized based on his or her presenting symptoms to be seen for completion of the MSE...” 3. Medical record review revealed a 14-year-old female who presented via private vehicle to Hospital #1’s Emergency Department (ED) (out-of state hospital) on 9/30/2024 at 3:09 PM with complaints of heavy vaginal bleeding. The triage nursing assessment was initiated at 3:13 PM and revealed the chief complaint “Started period on Friday and having heavy bleeding and lots of clots started yesterday and fainted was washing hands and everything started going dark and passed out today, was here yesterday.” The MSE was initiated at 3:24 PM and revealed Patient #1 presented with vaginal bleeding, reported heavy menstrual bleeding with clots for the past 3 days, with 2 near syncope (light headedness/near fainting) over the past 2 days. The ED Physician documented Patient #1 had been seen in Hospital #1’s ED on 9/29/2024 and had a hemoglobin of 10.2 (the normal average hemoglobin level for a 14-year-old female is 13.5 grams/deciliter) with mild orthostasis (orthostasis/orthostatic hypotension is a condition where blood pressure drops when moving from a seated position to a standing position). Patient #1 was treated with Iron on 9/29/2024 and discharged home. Patient #1 reported another syncopal episode prior to arrival in ED on 9/30/2024. The MSE physical exam revealed Patient #1 had an elevated heart rate of 103 and low blood pressure of 100/68. Laboratory results revealed low red blood cell count- 2.46, (normal red blood count for a 14-year-old female is 3.8-5.0 million cells per microliter of blood) critically low hemoglobin (Hgb)- 6.7 (hemoglobin is a protein inside red blood cells that carries oxygen from the lungs to tissues and organs in the body and carries carbon dioxide back to the lungs) and critically low hematocrit- 20.0 (A hematocrit test measures the ratio of red blood cells to the total volume of blood in your body. Normal range for adolescent female is 30-44. Anemia is a condition where your body doesn’t have enough healthy red blood cells or hemoglobin to carry oxygen to your body’s tissues). The ED Physician documented “Medical decision making: Worsening Orthostasis noted today, unable to stand from sitting, Hb [Hgb] significantly lower than yesterday. 4:00 PM- spoke with [named physician] about patient [#1] and will admit for transfusion and further work up, Labs type and cross ordered [A type and crossmatch is a blood test that determines a patient’s blood type and Rh factor, and matches the patient’s blood with a donor’s blood to prepare for a transfusion] 4:30 PM Repeat CBC shows Hb 6.7...message sent to [named physician] and feels better served at higher level of care with GYN [gynecological services]. Patient’s mom prefers [named Hospital #4] due to family in [Town #3]. Patient #1 was administered 1000 milliliters hydration bolus [a single dose with a large amount of fluid given as quickly as possible] Intravenous at 3:40 PM. A physician at Hospital #4 [located in Town #3] accepted Patient #1. Patient #1 was transferred from Hospital #1 to Hospital #4 for specialized pediatric care via ground ambulance on 9/30/2024 at 5:55 PM...” 4. Review of the Emergency Medical Services (EMS) trip report dated 9/30/2024 revealed Patient #1’s primary diagnosis was vaginal hemorrhage. The EMS unit arrived at Hospital #1 on 9/30/2024 at 5:46 PM to transport Patient #1 to a higher level of care at Hospital #4. The EMS narrative revealed, “...PT [patient] is a 14 year old female who came to the [named Hospital #1] on Friday [9/27/2024- 3 days prior to this visit]...for heavy bleeding and clots during their menstruation. PT Hgb was noted to be 10.2 on Friday. PT came to [Hospital #1] today due to continuous bleeding...[Hospital #1] reported...Hgb is now 6.7. Pt is borderline hypotensive [low blood pressure] and tachycardic [abnormally elevated heart rate above 100 beats per minute]...EMS inquires as to blood administration and Hospital #1 reports they do not have the availability of blood products...” EMS documented Patient #1 reported no pain, was non-hypoxic (low oxygenation level of a patient’s body) and tachycardic EMS departed Hospital #1 with Patient #1, en route to Hospital #4 on 9/30/2024 at 6:02 PM. The following vital signs were documented by EMS: 6:09 PM: BP - 131/56, Pulse-120; 6:20 PM: BP - 106/50, Pulse-117; 6:34 PM: BP - 72/40, Pulse-117; 6:37 PM:BP - 62/34, Pulse-106; 6:48 PM: BP - 96/47, Pulse 107; 6:58 PM: BP - 72/32, Pulse 108; 7:08 PM: BP - 82/62, Pulse 116; 7:20 PM: BP - 78/52, Pulse 115; and 7:29 PM: BP - 78/52, Pulse 114. The EMS narrative further revealed, “...During transport EMS monitors for any trending negatives or acute status changes...PT noted approximately 30 minutes into transport to have inadequate MAP [mean arterial pressure-arterial pressure is the force of blood against the walls of the arteries and a vital measurement that ensures enough blood reaches the body’s organs and tissues] PT reports feeling dizzy and nauseated. EMS obtains PIV [peripheral intravenous line is a tiny, short, flexible tube, called a catheter] access to the right cephalic vein [a superficial vein in the arm]...for cannulation [the placement of the catheter into the vein] due to the expectation of transfusion [blood transfusion a common treatment for anemia]...EMS notes line to flush freely [a small amount of saline in a syringe is pushed through the catheter flows with difficulty] with brisk blood return ...line is saline locked [a leur-lock device in which saline is put through into the vein to keep the vein open in case the patient requires intravenous fluids] and secured...Pt vomits before EMS is able to confirm allergen status and rights to administer Zofran [anti-nausea medication]. EMS administers Zofran with good effect noted...EMS confirms hypotension with manual auscultation [manual check of BP] and upgrades to emergency traffic [lights and sirens]. EMS initiates a small BOLUS of LR [Lactated Ringer’s injection is used to replace water and electrolyte loss in patients with low blood volume or low blood pressure] in attempt to allot for permissive hypotension without further dilution of Hgb. Pt reports their vision to be blurred and ‘black around the edges’ as well as feeling extremely dizzy as if they may pass out. EMS contacts medical control [dispatch system] at Hospital #4 and speaks to [named accepting physician with Hospital #4] and informs doctor of current situation, EMS informs doctor approximately 49 min [minutes] ETA [estimated time of arrival]. EMS further informs they currently only have the option to potentially give TXA [tranexamic acid, a drug used to control bleeding] which PT does not meet protocol, or initiate Norepinephrine infusion to increase NIBP [noninvasive blood pressure] for adequate MAP. [named accepting physician with Hospital #4] informs EMS to do neither option and divert to nearest emergency room so PT can receive blood transfusion until they are stable enough for transport to Hospital #4, so as to avoid PT arresting [heart stop beating] due to hemorrhagic shock [a life-threatening condition that occurs when the body loses too much blood and can’t meet the body’s need for oxygen and nutrients]...EMS diverts to the nearest emergency room [ER] which at the time was [named Hospital #2’s freestanding ED in Town #1]. EMS calls via cellphone and gives report to RN [Registered Nurse] along with an estimated ETA. Upon arrival EMS is directed into room #3 and PT is taken by stretcher into room. EMS begins giving report to RN when [named ED Physician #1] enters the room and demands EMS not unbuckle the PT or transfer the PT to the ER bed. [named ED Physician #1] states ‘Who authorized you to come here? This is not an appropriate facility, this is a standalone clinic, not an emergency room.’ [named ED Physician #1] informs EMS they do not have blood products, do not have a laboratory that can perform [perform] a type and screen and cannot get the PT the help they need. EMS is informed by RN in the room that [named Hospital #3 located in Town #2] would be able to best care for this PT. [named ED Physician #1] again asked EMS ‘Who told you to come here?...You should not have come here.’ EMS informs MD that they are not from this state and were not aware their Emergency Room was not an actual Emergency Room and incapable of emergency care. EMS transports PT back to ambulance and then continues emergency traffic to Hospital #3. EMS contacts charge nurse @ [at] facility and gives full report as well as estimated ETA...EMS continually monitors PT during transport for any trending negatives or acute changes of which EMS notes hypotension and tachycardia. EMS does attempt to mitigate hemorrhagic shock with ambient temperature increase with good effect...” Patient #1’s care was transitioned to the ED staff at Hospital #3 on 9/30/2024 at 7:40 PM. 5. Review of the late entry nursing triage from Hospital #2’s Freestanding ED, dated 10/4/2024 (4 days after Patient #1 presented seeking care for vaginal bleeding and decompensated vitals) revealed Patient #1 presented to Hospital #2’s Freestanding ED on 9/30/2024 at 7:19 PM. RN #1 documented, “Per EMS Crew Pt presents with C/C [chief complaint] of vaginal bleeding. BP enroute was 66/44 and heart rate 120. Enroute to [named Hospital #4]. Was advised to go to nearest hospital by medical control ...Pt in sitting position on stretcher. Awake. Alert. Color WNL [within normal limits]. No obvious sweating noted. No grimacing/guarded or restlessness.” RN #1 documented Patient #1 was discharged at 7:21 PM, 2 minutes after she arrived seeking care. RN #1 documented a Patient note on 10/4/2024 at 1:38 PM, “[named ED Physician #1 communicated to EMS Pt [#1] stable for continuing transport to [named Hospital #4].” Review of a late entry for the MSE from Hospital #2’s Freestanding ED, dated 10/4/2024 (4 days after Patient #1 presented seeking care for vaginal bleeding and decompensated vitals) revealed ED Physician #1 documented vaginal bleeding as the chief complaint. The free text history and Present illness notes of the MSE revealed, “I partially overheard the radio call with EMS on the line stating they were en route to the ED...with a pt who was hypotensive and bleeding out. The nurse did mention to me that the paramedics indicated that the pt was having profuse vaginal bleeding and still noted with low blood pressure. At this point my main focus was on how to resuscitate this pt when she presents to the ED. I was unaware there was whole blood in the ED to initiate an immediate blood transfusion since we have to contact the blood bank at [named Hospital #2] for blood including type and crossmatch. I finally decided we will at least continue with fluid resuscitation when pt arrives. When EMS arrived, they went into room #3 with the pt. I went into the room to see the pt. The Paramedic came forward to me and stated they had just bolused the pt with about 900 mls [milliliters] of saline en route and did not have sufficient time to check the BP before their arrival...He then stated the BP is now 119/82. [There was no documented evidence from EMS medical record to support Patient #1’s BP was ever recorded at 119/82] At this time, I did glance at the pt who was calmly laying on the stretcher without visible acute distress. Pt was alert and halfway sitting up at the stretcher without any exhibition of distress or discomfort. I then mentioned to the nurses that the transfer of this pt to [named Hospital #4] should continue. The Paramedic then mentioned if they had rechecked the BP after the 900 mls fluid bolus before their arrival at the ED [Hospital #2 Freestanding ED] that they would have continued to transport the pt to Hospital #4 without having to stop at [named Hospital #2 Freestanding ED]. The medical screening was not completed at this point before they left the ED...” ED Physician #1’s late entry documented Patient #1 was discharged home in stable condition with a Primary Diagnosis of Vaginal Bleeding. Patient #1 was not discharged home, nor transported to Hospital #4, but was instead transported to the next closest Hospital ED [Hospital #3] for medical care and treatment due to her continued unstable vital signs and potentially life threatening medical condition. 6. Review of the ED record from Hospital #3 revealed Patient #1 was triaged at 7:48 PM with chief complaint patient was being transported via EMS to Hospital #4 for decreased hemoglobin and blood pressures, related to heavy menses with clots. The triage vital signs were BP-133/87 and Pulse-112. The triage nurse documented the heart rate was abnormal but the patient was alert and oriented and moving all extremities. The MSE was initiated at 7:51 PM and revealed a 14-year-old female with complaints of vaginal bleeding with symptoms beginning a week ago, with associated symptoms of syncope. The ED Physician documentation revealed, “At their worst the symptoms were severe, in the emergency department they have improved. Patient was seen at outside facilities in [out-of-state] and noted to have falling hemoglobin. She developed tachycardia and hypotension en route to [named Hospital #4]. The paramedics were instructed to divert to a facility which could provide blood for her...She is awake and alert with clear sensorium, she has not diaphoretic...Hemoglobin is 6.9. We had trauma blood ready on arrival, but I believe that the patient’s condition did not necessitate emergent transfusion of crossmatch blood. Therefore, we will give her a unit of blood and I have contacted [Hospital #4] and she will be transported expeditiously ...” Patient #1 had a urinalysis, Complete Blood Count and cardiac monitoring at Hospital #3. Patient #1 was educated and consented to receive blood products. Patient #1 was administered one (1) unit of packed red blood cells at 9:20 PM which was infusing upon transfer to Hospital #4 at 9:45 PM. Patient #1’s BP was 112/64 and Pulse 108 at 9:42 PM, just prior to transfer. 7. Review of the ED record from Hospital #4 revealed Patient #1 arrived via EMS on 9/30/2024 at 10:21 PM. The Nursing triage note at 10:28 PM revealed, “Arrives as a transfer via EMS. Per report, pt began with vaginal bleeding beginning 2 days ago. Pt found to have Hgb of 6.9. Blood transfusion initiated and ongoing...Breaths even, unlabored. Skin appropriate and warm. Blood infusing upon pt arrival...[named accepting Physician for Hospital #4] at bedside. The MSE was initiated at 10:45 PM and revealed Patient #1 was a transfer from another hospital for heavy menstrual bleeding and symptomatic anemia. The physical examination by the ED Physician revealed Patient #1 appeared pale had a pulse of 103. Laboratory results revealed Patient #1’s Hemoglobin was 7.3. The ED Course and Medical Decision making narrative revealed, “ ...presents with heavy menstrual bleeding. On exam patient has active ongoing vaginal bleeding and she is tachycardic to the 100s. Suspect ongoing symptomatic anemia due to ongoing bleed. Unclear etiology of bleed at this time given no family history of bleeding disorders and patient has not had heavy menstrual bleeding in the past and denies sexual activity. Had negative pregnancy test at outside hospital today. Discussed patient’s case with gynecology who recommended obtaining pelvic ultrasound and starting on progesterone and estrogen pills every 4 hours for cessation of bleeding. They will continue to reassess the patient throughout her hospital stay. CBC [complete blood count- measures the number and types of cells in the blood], CMP [comprehensive metabolic panel - measures 14 substances in your blood to provide an overall picture of your body’s chemical balance and metabolism], coags [to measure blood clotting] ordered. Hemoglobin 7.3 on CBC. Patient consented for blood and 1 more unit packed red blood cells was ordered. Pelvic ultrasound currently pending. Discussed patient’s case with hematology who had no further recommendations, will admit for further care. Plan of care discussed with mother, aunt, patient at bedside. Patient at time of admission appears floor appropriate despite ongoing bleeding with blood pressure 110/71, heart rate 103...” Review of a Gynecological consult note dated 10/1/2024 at 12:45 AM revealed, “...presented as ER [emergency room] to ER transfer for heavy vaginal bleeding Gynecology consulted for further management recommendations...She reports her most recent period started on 9/27, it was normal until yesterday when the bleeding increased and she started saturating a pad/hour. She presented to her local ED [Hospital #1] where she was found to have Hgb 10. She was discharged home on PO [by mouth] iron, however continued to have heavy bleeding...She had two episodes of syncope today and re-presented to her local ED. Her Hgb was found to be 6.9 and the decision was made to transfer [named Hospital #4]. En route she became hypotensive to 50’s/30’s...the ambulance stopped at another OSH [outside hospital] where they started, her on 1 U [unit] pRBC [packed red blood cells] for the remainder of her transport to [named Hospital #4]. On arrival...tachycardia-110, normotensive...Labs notable for WBC [white blood cells] 7.6, H/H [Hgb and Hematocrit] 7.3/23...She has never experienced bleeding like this before. She endorses dizziness and lightheadedness...Physical Exam...Heart: Mildly tachycardic...Abdomen: Soft, non-tender, non-distended, no masses or organomegaly [abnormal enlargement of organ] Pelvis: Tanner Stage 4 development [The Tanner staging scale, also known as the sexual maturity rating, is a tool used by healthcare providers to track physical changes during puberty] pad 100% saturated, normal external genitalia without lesions, introitus [external opening of the vaginal canal] normal and well estrogenized with slow trickle of dark vaginal bleeding, no other abnormal discharge... Assessment and Plan...Recommend transfusion with 1U pRBC [packed red blood cells] and repeat CBC...” Patient #1 was admitted inpatient to Hospital #4 on 10/1/2024 at 2:11 AM for further evaluation and treatment. 8. In an interview on 10/21/2024 at 1:23 PM, the Vice President of Operations for Hospital #2 verified there was no MSE or nursing assessment documented for Patient #1 on 9/30/2024. The VP of Operations stated the late entries, dated 10/4/2024 (4 days after Patient #1 presented via EMS for care) were a part of the corrective action plan implemented after the incident was identified. In an interview on 10/22/2024 at 10:48 AM, the Laboratory (Lab) Supervisor at Hospital #2’s Freestanding ED stated the Freestanding ED had 2 units of O negative blood stored in the lab. The Lab Supervisor stated if the units were used, staff would call the main campus and ask for 2 more units to be delivered within the same day. On 10/22/2024 at 10:50 AM, the surveyor observed 2 units of blood in a refrigerator in the lab. In an interview on 10/22/2024 at 12:20 PM, Licensed Practical Nurse (LPN) #1 from Hospital #2’s Freestanding ED verified she took a call from an EMS unit on 9/30/2024. LPN #1 confirmed the call was related to Patient #1, a 14-year-old with vaginal bleeding who had a decompensation of vital signs during transport from an out-of-state hospital to Hospital #4. The LPN stated EMS reported they called Hospital #4 who directed them to take Patient #1 to the nearest hospital. LPN #1 stated when she took the call she provided the information to RN #1 and ED Physician #1. LPN #1 stated when EMS rolled Patient #1 into the ED, Physician #1 instructed EMS not to take the patient off the stretcher. LPN #1 stated she then went on break and had no other knowledge of the incident. In an interview on 10/22/2024 at 12:34 PM, the ED Nursing Manager from Hospital #2’s Freestanding ED verified on 9/30/2024, there were 2 units of blood in the lab. The ED Nursing Manager stated the nurse and physician should have created a medical record for Patient #1 when she presented via EMS. The ED Nursing Manager stated RN #1 was attempting to get information on Patient #1 and she barely got a name before the ED Physician instructed EMS to continue on to Hospital #4 for the higher level of care. In a telephone interview on 10/22/2024 at 3:29 PM, RN #1 from Hospital #2’s Freestanding ED verified she was working on 9/30/2024 when Patient #1 arrived via EMS for vaginal bleeding and hypotension. RN #1 stated EMS called ahead and stated the patient had become unstable and Hospital #4 (receiving hospital) instructed them to seek care at the closest Emergency room. RN #1 stated when Patient #1 arrived via EMS she went to retrieve a scale and brought it to room 3, where EMS was directed to take Patient #1. RN #1 stated when she returned with the scale she heard ED Physician #1 say “Don’t take the patient off the stretcher, why did you come here?” RN #1 stated ED Physician #1 told EMS this was a Freestanding ED and they were delaying Patient #1’s care. RN #1 stated Patient #1 was alert and awake in a sitting position on the stretcher. The surveyor asked if she had ever witnessed anything similar while working in the ED. RN #1 stated, “No I haven’t.” RN #1 verified the ED had blood stored in the lab. RN #1 stated she had to look at the Patient’s arm band as EMS was wheeling her out of the ED to get her name. In a telephone interview on 10/23/2024 at 9:47 AM, the ED Medical Director from Hospital #2’s Freestanding ED stated he was familiar with the case for Patient #1 who presented to Hospital #2’s Freestanding ED on 9/30/2024, via EMS. When asked what the expectation was for Patient #1’s care, he stated the patient would be taken into the ED for an assessment and either they [staff] could allow EMS to leave, or they could ask EMS to stay and possible transport the patient on to a higher level of care after the assessment/ medical screening exam. The surveyor asked the ED Medical Director if an MSE was provided to Patient #1. He stated there was no medical screening exam documented, he further stated ED Physician #1 took Patient #1’s BP but did not document. The ED Medical Director verified there were 2 units of blood at Hospital #2’s Freestanding ED. The Medical Director stated that prior to last year, the ED did not have any blood products, but when Patient #1 presented on 9/30/2024, there was blood available. The ED Medical Director stated ED Physician #1 reported to him when Patient #1 presented she was awake alert and in no distress and he did not want to delay her care. In a telephone interview on 10/28/2024 at 8:19 AM, ED Physician #1 from Hospital #2’s Freestanding ED verified he was working in the ED when Patient #1 presented via EMS on 9/30/2024. ED Physician #1 stated he heard the EMS call come in on 9/30/2024 that Patient #1 was bleeding out and had a low blood pressure. ED Physician #1 stated he was not aware the ED had 2 units of blood in the lab and when he heard the call he panicked. ED Physician #1 stated, “I feel really badly for some of my mistakes... I tried to get EMS to go somewhere with blood...” ED Physician stated Patient #1 was lying on the stretcher in upright position and she was not in distress. ED Physician #1 stated EMS reported the last blood pressure taken, as 119/82 and EMS reported if they had checked the blood pressure before pulling into Hospital #2, they would have continued on to Hospital #4. ED Physician #1 stated, “I should have done a full blown MSE at that time, but I did not...” When asked if on-call physicians were available for Obstetrics and Gynecology, he stated, “Yes, available at [named Hospital #2’s main campus located in Town #4] and to us at [Town #1]...””

“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: 33763 Based on a review of medical records, hospital policies, Medical Staff Rules and Regulations, OB/GYN Physician on-call schedules, and interviews, it was determined that Hospital #1 failed to ensure that Patient #1 (one of 17 sampled patients with pregnancy related conditions who presented at the hospital’s emergency department) received an appropriate medical screening examination (MSE) that made use of the hospital’s capabilities (including but not limited to the ancillary services of the on-call OB/GYN physician routinely available to the emergency department) to determine whether an emergency medical condition (EMC) existed. The hospital’s failure to provide an appropriate medical screening examination, within the capability of the hospital’s emergency department, placed the patient at risk for deterioration of her health and wellbeing as a result of an untreated emergency medical condition(s). The findings included: On December 4, 2022, Patient #1 presented to the hospital emergency department 19-weeks pregnant with a complaint of “watery” vaginal discharge and lower abdominal pain. Ultrasound showed a live intrauterine pregnancy. Despite hospital policy requiring that for pregnant patients seeking emergency care, “the medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e. ruptured, leaking and intact), to document whether or not the woman is in labor,” only fetal heart tones were assessed and documented. There was no documentation to support that Patient #1 was evaluated for contractions, fetal position and station (location within the pelvis), cervical dilation, status of membranes, or preterm labor. Hospital policy further required that “the evaluation of rupture of membranes should be made using Amnisure test when patients report signs, symptoms, or complaints suggestive of rupture of membranes,” but no such testing was performed or offered, despite Patient #1’s reported symptoms and complaints of “watery” discharge and lower abdominal pain. The hospital’s Medical Staff Rules and Regulations require that on-call physicians “help stabilize and/or evaluate” emergency department patients upon request, and the hospital’s on-call schedule revealed that there was an on-call OB/GYN physician available when Patient #1 presented. However, the on-call OB/GYN physician did not participate in the evaluation or management of Patient #1 as part of her medical screening examination. The hospital’s failure to provide an appropriate medical screening examination, within the capability of the hospital’s emergency department and in accordance with hospital policies, placed the patient at risk for deterioration of her health and wellbeing as a result of an untreated emergency medical condition(s). Cross Refer to 2406.”

“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: 33763 Based on a review of medical records, hospital policies, Medical Staff Rules and Regulations, OB/GYN Physician on-call schedules, and interviews, it was determined that Hospital #1 failed to ensure that Patient #1 (one of 17 sampled patients with pregnancy related conditions who presented at the hospital’s emergency department) received an appropriate medical screening examination (MSE) that made use of the hospital’s capabilities (including but not limited to the ancillary services of the on-call OB/GYN physician routinely available to the emergency department) to determine whether an emergency medical condition (EMC) existed. Specifically, the hospital failed to follow its own policies that described required elements of an appropriate MSE for pregnant patients and failed to make use of its on-call OB/GYN physician, who was available when Patient #1 presented. Consequently, Patient #1 was not provided an MSE appropriate to assess for preterm premature rupture of membranes (also known as PPROM) and/or preterm labor by making use of available diagnostic testing (such as, but not limited to, pH testing, microscopic examination, Amnisure testing [biochemical testing of the leaking fluid], and/or consultative ultrasonography to assess for oligohydramnios). PPROM is a pregnancy complication in which the amniotic membrane surrounding the fetus ruptures before week thirty-seven of pregnancy. PPROM carries the risk of infection, sepsis, severe bleeding, premature labor, and risk of future infertility, among other complications. Oligohydramnios is an amniotic fluid disorder resulting in decreased amniotic fluid volume for gestational age. Low amniotic fluid volumes can be the result of numerous maternal, fetal, or placental complications and can lead to poor fetal outcomes, including death. The findings included: 1. Review of Hospital #1’s Medical Staff Rules and Regulations, approved July 2019, revealed, “... Emergency Services [:] a. Emergency Screening, Stabilization, and Transfer: Medical screening as defined by EMTALA will be provided to all patients presenting for emergency care in accordance with present federal, state, and local law and facility policy and procedure. A physician or designated qualified medical personnel with the appropriate approval by the Board of Trustees will provide this medical screen ...o. Emergency Department On-Call Requirements: It is the responsibility of the medical staff to support the patient care mission of the Hospital by providing treatment for patients presenting to the facility seeking emergency medical care, regardless of the patient’s ability to pay for such services ...Every member of the medical staff in the ‘Active’ category ...shall be expected to participate in the Hospital’s on-call system and respond promptly ...when called to render clinical services within their specialization. This includes coming to the Hospital upon the request of the Emergency Department physician to help stabilize and/or evaluate the patient for needed care and/or for transfer to another facility where appropriate care may be given.” 2. Review of Hospital #1’s “TN [Tennessee] EMTALA, Medical Screening Examination and Stabilization” policy, last revised June 2020, revealed, “1. When an MSE is Required[:] A hospital must provide an appropriate MSE within the capability of the hospital’s emergency department, including ancillary services routinely available to the DED, to determine whether or not an EMC exists: (i) to any individual, including a pregnant woman having contractions, who requests such an examination; (ii) an individual who has such a request made on his or her behalf; or (iii) an individual whom a prudent layperson observer would conclude from the individual’s appearance or behavior needs an MSE. An MSE shall be provided to determine whether or not the individual is experiencing an EMC or a pregnant woman is in labor . . . 3. Extent of the MSE [:] a. Determine if an EMC exists. The hospital must perform an MSE to determine if an EMC exists ... b. Definition of MSE. An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an EMC or not. It is not an isolated event. The MSE must be appropriate to the individual’s presenting signs and symptoms and the capability and capacity of the hospital... e. Extent of MSE varies by presenting symptoms [:] i. Depending on the individual’s presenting symptoms, an appropriate MSE can involve a wide spectrum of actions, ranging from a simple process involving only a brief history and physical examination to a complex process that also involves performing ancillary studies and procedures. ii. Pregnant Women: The medical records should show evidence that the screening examination includes, at a minimum, on-going evaluation of fetal heart tones, regularity and duration of uterine contractions, fetal position and station, cervical dilation, and status of membranes (i.e. ruptured, leaking and intact), to document whether or not the woman is in labor.” 3. Review of Hospital #1’s “Amnisure” policy, last approved September 2021, revealed, “A. Purpose [:] To obtain a timely and accurate diagnosis of ruptured fetal membranes. B. Policy 1. The evaluation of rupture of membranes should be made using Amnisure test when patients report signs, symptoms, or complaints suggestive of rupture of membranes. 2. Amnisure test must be ordered by a physician...” The Amnisure policy does not limit testing to patients of any specific gestational age. 4. Medical record review revealed that on December 4, 2022, at 1944 hours, Patient #1 presented to Hospital #1 with a 19-week pregnancy seeking examination and treatment for vaginal discharge and lower abdominal pain. Although some details of the hospital’s records are internally inconsistent, the majority of records clearly indicate that Patient #1’s chief complaint was yellow, watery vaginal discharge over a period of one week. A hospital record labeled “Rapid Initial Assessment” and created by Triage Registered Nurse documented that Patient #1 presented to the emergency department (ED) with a stated complaint of “ ...pregnant with watery continuous vaginal d/c [discharge] x [times] 1 wk [week] with thick yellow d/c [discharge] intermittently. Also now having lower ABD [abdominal] pain intermittently ...” Documentation by ED Physician #1 also corroborated Patient #1’s complaint was “vaginal discharge that is yellow, watery over the past week.” A subsequent “Assessment” by Registered Nurse #1 documented that Patient #1’s vaginal discharge was “pink-tinged” and “light” in amount and began “12-24 hours ago.” (This latter documentation appeared to contradict the description of Patient #1’s complaint in multiple other locations in the medical record.) The fetal heart rate was recorded as 143. 5. A hospital record labeled “Emergency Provider Report”, dated December 4, 2022, at 2002 hours completed by ED Physician #1, documented “20 Year old female ...presenting with vaginal discharge that is yellow, watery over the past week ...Denies any current vaginal bleeding.” Patient #1’s physical examination included: “Genitourinary: Vaginal discharge ...Abdomen/GI: Atraumatic, Soft, Non-tender ...Genitourinary: Vaginal Bleeding/Discharge: Discharge thick, Discharge yellow.” The medical record did not contain evidence that the screening examination included evaluation for contractions, fetal position and station (location within the pelvis), cervical dilation, status of membranes, or preterm labor. There also was no documentation that ED Physician #1 assessed for preterm premature rupture of membranes (also known as PPROM) by making use of available diagnostic testing (such as, but not limited to, pH testing, microscopic examination, and/or consultative ultrasonography to assess for oligohydramnios), all of which were routinely available to the emergency department. There was no documentation that ED Physician #1 ordered or performed Amnisure testing (biochemical testing of the leaking fluid), as recommended by hospital policy “to obtain a timely and accurate diagnosis of ruptured fetal membranes,” despite Patient #1’s reported symptoms and complaints of “watery” discharge and lower abdominal pain, which are commonly associated with PPROM. 6. The hospital’s “Gynecology” on-call schedule for December 2022 revealed that on December 4, 2022, there was an on-call OB/GYN physician available when Patient #1 presented to the hospital’s ED. According to hospital records, the on-call OB/GYN physician did not participate in the evaluation or management of Patient #1 as part of her medical screening examination. 7. ED Physician #1’s “MDM” (medical decision-making) documented in Patient #1’s medical record reads, in its entirety, “This is a 20-year-old female presenting with vaginal discharge in wanting a pregnancy check. She is approximately 19 weeks pregnant. Reports yellowish creamy discharge. Denies any STD [sexually transmitted disease] exposure and low suspicion for such. I did a pelvic exam, which shows no cervical motion tenderness or adnexal tenderness, however there is creamy yellow discharge. Wet prep is negative. UA [urinalysis] is positive. I do have concerns for chlamydia and expressed that [to] her privately. We will treat her for gonorrhea, chlamydia, discharge her on oral antibiotics and advised her to check the portal to see if this is positive. Otherwise, may require antibiotic change if this is only UTI [urinary tract infection]. I also performed a bedside transabdominal ultrasound, which shows a live intrauterine pregnancy with a heart rate of 166 and movement of all the extremities.” 8. Hospital records documented that Patient #1’s sole diagnosis at discharge on December 4, 2022, was “UTI [urinary tract infection].” Hospital instructions provided to Patient #1 were documented as the following: “Your urine appears to be infected.” Patient #1 was given a prescription for antibiotics and referred to make an appointment with her OB/GYN. 9. In a telephone interview on December 12, 2023, at 1300 hours, ED Physician #1 reported that if an ED patient presented with OB complaints, they would typically consult with OB/GYN. When asked what was typically done for patients that are less than 20 weeks gestation, ED Physician #1 stated those patients are seen in the ED, and their screening might include a vaginal exam, vaginal swab, urinalysis, STD testing, and sometimes ultrasounds depending on the patient’s complaint. ED Physician #1 stated, “Most orders, I send them for a formal ultrasound. If in the early stage, I usually send them for a transvaginal; I don’t do those.” ED Physician #1 was asked if he performed ultrasounds in the ED, and he stated, “I just do abdominal ultrasound to look for heartbeat and movement. We’re not able to document the images...In general, my ultrasounds are limited, an alive fetus is all I can determine...I do them to show them [patient] the baby is moving and has a heart rate; it decreases their stress level when they see an obvious heartbeat.” He did not describe evaluation for oligohydramnios as part of his limited bedside ultrasound examination. ED Physician #1 was asked when he would consult the OB/GYN physician on-call. He stated, “It depends on how far along they are and if there were any concerns.” 10. In a telephone interview on December 12, 2023, at 1500 hours, Registered Nurse (RN) #1 verified she was the primary nurse for Patient #1 on the December 4, 2022 visit but was unable to recall the patient. The RN was asked what type of services were provided to pregnant patients in the ED. The RN stated vaginal exams are completed on some pregnant patients that present with complaints of vaginal spotting or bleeding with the RN standing by while the physician performs the exam. When asked which patients usually had ultrasounds ordered, RN #1 stated, “We do them on pregnant patients if they say they are hurting.” The RN verified the ultrasounds are usually done by ultrasound technicians. RN #1 was asked if she had seen any of the ED Providers perform the ultrasounds in the ED. The RN stated, “I’ve never seen a physician do an ultrasound in the ED.” The RN was asked when OB/GYN physicians were usually consulted. RN #1 stated, “The physicians contact OB/GYN; we tell them what we see, then the provider notifies OB. Nurses don’t make the decisions to notify OB.” 11. In a telephone interview on December 14, 2023, at 1022 hours, the ED Medical Director (EDMD) verified he had access to Patient #1’s medical record. The EDMD was asked if the ED providers ever perform ultrasounds at the bedside. The EDMD stated, “If we [ED providers] pick up an ultrasound probe, we have enough concern and we are already calling the techs [ultrasound technicians]. We don’t have the means of keeping our results.” The EDMD was asked if ED providers had credentials and training to perform and interpret ultrasounds. The EDMD verified ED Physician #1 was credentialed to perform bedside ultrasounds and also verified the facility had ultrasound technicians available 24 hours a day, 7 days a week. 12. Medical records from Hospital #2 were reviewed for context about Patient #1’s subsequent clinical course and revealed Patient #1 was hospitalized on December 15-17, 2022. The Discharge Summary revealed an admitting and discharge diagnosis of Previable Preterm Premature Rupture of Membranes (pPPROM). The summary further specified a “Hospital Course” as follows: “Pt [Patient] presented for routine OB visit and US [ultrasound], reported leaking fluid for a week. She was found to have pooling positive and an AFI [amniotic fluid index] of 3. She was sent to [Hospital #2] for monitoring for possible septic abortion or hemorrhage due to placenta previa.” 13. Medical record review from Hospital #3 revealed Patient #1 was subsequently hospitalized from December 20, 2022 through January 17, 2023. According to medical records dated December 20, 2022, Patient #1 presented with the following stated complaint: “[M]y water broke about 2 or 3 [weeks] ago and I need a second [opinion].” Hospital #3 record labeled “History and Physical” dated December 20, 2022, documented, “Two weeks ago, she experienced leaking of clear fluid ...reports she was diagnosed with UTI and told it looked like she had chlamydia ...When she went for her anatomy scan last week, she was found to have very low fluid and admitted to [Hospital #2] for IV fluids for 2 days ...She followed up with an MFM [maternal fetal medicine specialist physician] at that practice today and was told she had no [amniotic] fluid on US [ultrasound] ....This is a desired pregnancy and she wants every effort made to prolong pregnancy.” In an addendum to this record, a physician noted, “[Patient #1] here for suspected previable ROM [rupture of membranes] 2-3 weeks ago... It was discussed with patient high likelihood of poor fetal outcomes and pt seems to understand this... Exam notable for vaginal discharge with an odor and a mild leukocytosis. Will monitor closely for infection, and she is certainly at risk.” Patient #1 was admitted to Hospital #3 for PPROM. On January 15, 2023, at 0108 hours, Patient #1 underwent surgical cesarean section (C-Section) to deliver a premature male infant at 24 4/7 weeks estimated gestational age. The male infant died approximately one hour after delivery. Discharge records indicate Patient #1 experienced “Pregnancy complicated by prolonged PPROM since 18 weeks, fetal demise 2/2 hypoplastic [underdeveloped] lungs, gHTN [gestational hypertension].””