Big South Fork Medical Center

“QAPI CFR(s): Condition of Participation: Quality Assessment and Performance Improvement Program The CAH must develop, implement, and maintain an effective, ongoing, CAH-wide, data-driven quality assessment and performance improvement (QAPI) program. The CAH must maintain and demonstrate evidence of the effectiveness of its QAPI program. (a) Definitions. For the purposes of this section- Adverse event means an untoward, undesirable, and usually unanticipated event that causes death or serious injury or the risk thereof. Error means the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems; and Medical error means an error that occurs in the delivery of healthcare services. This Condition is not met as evidenced by: 36003 Based on facility job description reviews, facility policy reviews, medical record review, facility documentation review, observations and interviews, the facility failed to ensure preventative measures and mechanisms were in place and failed to fully implement and monitor processes to prevent elopement of Emergency Room (ER) patients with Suicidal Ideation for 2 patients (Patients #1 and #2) of 2 patients reviewed for elopement which placed all patients presenting to the ER with Suicidal Ideation at risk. The findings include: Review of the Chief Nursing Officer (CNO) job description, dated 1/9/2017, revealed “...The Director of Nursing is responsible for planning, directing, controlling and evaluating the activities, functions, and personnel of all nursing units to ensure delivery of high quality patient care...Directs the department activities, functions and management of personnel of the department to ensure that quality nursing care is provided according to...all internal/external regulations, policies and procedures...Ensure appropriate staffing levels and mix to achieve and maintain effective nursing care...Implements and ensures the consistent effort toward quality improvement...Monitor and evaluate clinical, operational and administrative performance in areas of...effectiveness, competence, responsiveness...” Review of the Chief Executive Officer (CEO) job description, dated 1/10/2017, revealed “...The Chief Executive Officer responsibility is to provide leadership, assume responsibility and accountability for the overall strategic planning of rural hospital, including... emergency medical services...Essential Duties and Responsibilities...Assures consistent compliance with quality, risk...Works collaboratively with leaders and staff to ensure that quality patient care is delivered...” Review of the facility’s policy titled, “Quality Assessment and Performance Improvement (QAPI) Plan,” dated 12/19/2024, revealed “...The purpose of the...(QAPI) Plan...is to provide guidance for our overall quality improvement program. QAPI principles will drive the decision making...Decisions will be made to promote and ensure that all patients receive excellent, high-quality care...Vision...To provide comprehensive emergency and acute care with a patient-centered approach...Reviewing and making recommendations for improvements in areas such as...adverse events reporting, and monitoring of staff quality control practices in each service provided...The QAPI program will incorporate quality indicator data including patient care data from all departments... Monitor effectiveness and safety of services provided and the quality of care that our patients receive...Develop and monitor indicators that will identify areas of risk and will track our ongoing performance...The services provided...are reviewed monthly in each Quality Leadership meeting to ensure patient safety metrics...are being maintained...” Review of the facility’s policy titled, “CARE OF THE AT RISK PATIENTS IN THE EMERGENCY DEPARTMENT,” dated 12/26/2025, revealed “...At-Risk Patient: A patient that has been identified by the Emergency Room Physician as either lacking capacity to make prudent judgments or identified as a danger to self or others. This could include...Patients presenting with a mental health crisis that present imminent danger to self or others...This would include voluntary patients as well as those involuntarily detained secondary to Crisis Consult...Once a patient has been identified as an at-risk patient, the Emergency Department staff will implement the following procedure to ensure patient and staff safety...The Emergency Department Provider will determine if the presenting patient meets the definition of an at-risk patient...At-risk patients presenting with a mental health crisis that present imminent danger to self or others will need to change out of their clothing and change into blue ‘paper scrubs’...The at-risk patient will be located in the appropriate observation (line of sight, constant observation, or one to one staffing) based upon their presenting condition, and collaboration between the attending Provider and Nursing staff...Patients identified as danger to self or others will remain with constant observation until they are assessed by a Mental Health professional. The level of observation will be determined by the scoring of their Columbia Suicidality Scale Revised [correct title/name of the scale printed on the form is Columbia-Suicidality Severity Rating scale/a short screening tool used to evaluate suicide risk by asking simple questions about thoughts and behaviors to measures suicidal ideation (thoughts), preparation, and actual suicide attempts to help decide what level of care a person needs]...” Patient #1 presented to the ER by police on 4/29/2026 at12:40 PM, with the complaint the patient had stated “he wanted to kill himself.” Medical record review revealed the patient reported he was tired of living “...I do not have anything to live for I will shoot myself’...” Patient #1 told the ER staff he wanted to go to a mental health facility in another city. Continued review revealed “...pt [patient] states that he is not going to stay her [here] for 6 or 7 hours waiting on a way to go to the hospital...” Review of the ER triage documentation for Patient #1 dated 4/29/2026 at 12:40 PM, revealed the Ask Suicide-Screening Questions (ASQ-screening tool with 4 brief yes/no questions to assess suicidal ideation and history) were asked with the patient’s response documented as “yes” for all questions. There was no documentation, a CSSR assessment was completed for Patient #1. Review of an ER Nursing Note for Patient #1 dated 4/29/2026, revealed the patient was observed leaving the triage room to the front lobby bathroom at 1:10 PM. ER Technician A took Patient #1 back to the triage room at 1:20 PM. ER Technician A assisted another patient to the bathroom at 2:27 PM. ER Technician A discovered Patient #1 was missing when she returned to the triage room at 2:37 PM. ER Technician A was unable to locate Patient #1. Review of an ER Nursing note for Patient #1 dated 4/29/2026 at 2:36 PM, revealed “...this is the 3rd attempt to maintain patient [Patient #1] to the ER. The first 2 we were able to get him back...This last attempt was unable to locate patient...” Review of an ER Nursing note for Patient #1 dated 4/29/2026 at 3:25 PM, revealed Registered Nurse (RN) B had spoken with Patient #1’s spouse who reported the patient was at home and was okay. Review of the medical record for Patient #1 revealed no evidence to indicate the patient was placed on 1:1 (one to one) observation (staff observing patient at all times). Review of the medical record for Patient #1 revealed the patient did not return to the ED. Review of facility documentation revealed facility leadership investigated Patient #1’s elopement from the facility on 4/29/2026, and revealed the following: 1. Constant observation was not maintained (no one was assigned to observation of Patient #1) 2. The policy for At Risk Patients was not followed. 3. The staff made no calls for assistance with monitoring the patient. 4. There was no designated room for at risk patients. 5. There was a delay in staff initiating internal code for a missing patient. The facility developed the following corrective action plan: 1. All ER staff will receive just in time education for all (3) levels of observation: Line of sight, Constant direct observation and 1:1 observation. There will be written acknowledgement of this training placed in all staff education folder. 2. All ER staff will receive just in time education on implementing the policy for at risk patients complete with written acknowledgement of the education by 5/8/2026. 3. Leadership will develop and implement an escalation pathway for whom to contact if additional assistance is needed in their department. This will be implemented and staff will be educated on it’s use by 5/8/2026. 4. A ligature resistant area has been identified. Modifications to the space will include a ligature resistant bed and surface, door alarms are to be installed, and exterior door lock to be added to hallway door, leaving the interior door unimpeded for egress (exit) 5. These modifications will be installed beginning immediately with complete implementation by 5/15/2026. 6. All facility staff will receive just in time education regarding the initiation of and the process of alerting the facility of a patient elopement. ER staff will receive and acknowledge this education by 5/8/2026. All other patient care areas will receive and acknowledge this education by 5/15/2026. Review of electronic mandatory nurse education participant attendance record provided on 5/8/2026 revealed 8 of 14 ER staff and 6 of 18 medical/surgical staff received education. There was no documentation to indicate additional in-services were provided. Review of Quality/Leadership (QAPI) meeting minutes dated 6/11/2026, revealed the meeting covered topics for the months of 4/2026 and 5/2026. There was no documentation to indicate Patient #1’s elopement from the ER on 4/29/2026 was discussed during the QAPI meeting. Patient #2 presented to the ER by ambulance on 6/15/2026 at 11:28 PM, with complaint of taking eight 800 milligram (mg) tablets of Ibuprofen. Medical record review revealed the patient stated she wanted to end her life and this was the first time she had attempted suicide. Patient #2 was 5 months postpartum (post-delivery). Review of ER triage documentation for Patient #2 dated 6/15/2026 at 11:28 PM, revealed the ASQ questions were asked with the patient’s response documented as “yes” for all questions. There was no documentation a CSSR assessment was completed for Patient #2. Review of the medical record revealed the ER Provider completed and initiated a Certificate of Need (CON - legal document showing a person requires inpatient mental health treatment; involuntary emergency commitment) for Patient #2 on 6/15/2026 at 11:38 PM. Review of an undated Suicidal Patient Observer Monitoring Checklist for Patient #2 revealed the patient was monitored by staff from 12:00 AM-6:00 AM. It was unclear if the patient was on 1:1 or every 15-minute observations. There was no documentation to indicate Patient #2 was being observed by staff after 6:00 AM. Review of a late entry ER Nursing note for Patient #2 dated 6/16/2026 at 11:50 AM, revealed the patient had asked nursing staff if there were any options besides inpatient treatment because she was currently breastfeeding. Review of an ER Nursing note for Patient #2 dated 6/16/2026 at 12:06 PM, revealed RN C was making rounds and discovered the patient had eloped from the ER. Review of facility documentation revealed facility leadership investigated Patient #2’s elopement from the facility on 6/16/2026, and revealed the following: 1. Patient #2 was identified as an at-risk patient and constant observation was not maintained. 2. The facility’s policy for at-risk patients was not followed. 3. No designated room for at risk patients. An area had been identified, however, the modifications were not completed. 4. There was a delay in staff initiating internal code for a missing patient. “...Staff seemed to be confused with the process of notification...” The facility developed the following corrective action plan: 1. All ER staff will receive just in time education for all (3) levels of observation: Line of sight, Constant direct observation and 1:1 observation. There will be written acknowledgement of this training placed in all staff education folders. To be completed by 6/25/2026. 2. All ER staff will receive just in time education on implementing the policy for at risk patients complete with written acknowledgement of the education by 6/25/2026. 3. A ligature resistant area has been identified. Modifications to the space will include a ligature resistant bed and surface, door alarms are to be installed, an exterior door lock to be added to hallway door, leaving the interior door unimpeded for egress. These modifications will be installed beginning immediately with complete implementation by 6/30/2026. 4. All facility staff will receive just in time education regarding the initiation of and the process of alerting the facility of a patient elopement. ER staff will receive and acknowledge this education by 6/25/2026. All other patient care areas will receive and acknowledge this education by 6/30/2026. Review of an in-service sign in sheet for 1:1 elopement education dated 6/23/2026, revealed 13 of 14 ER staff and 6 of 18 medical/surgical staff received the education. There was no documentation to indicate additional in-services were provided. During an interview on 7/7/2026 at 12:35 PM, Registered Nurse (RN) B stated Patient #1 had been placed in the triage area and had tried to start out the door “...several times...” and the staff were able to redirect the patient. RN B stated at one point the patient went outside and she went out and talked with the patient until he decided to go back inside the ER. RN B stated she was at another patient’s bedside when Patient #1 eloped. During an interview on 7/7/2026 at 12:38 PM, Licensed Practical Nurse (LPN) D stated Patient #2 was in Bed 1 (not identified as ligature resistant area) and was not wearing the blue paper scrubs as indicated by policy, when she assumed care of the patient the morning of 6/16/2026. LPN D stated the ER Provider had approved allowing Patient #2 to breastfeed her baby. Patient #2 was breastfeeding her baby when LPN D left the patient to triage a patient in Bed 5 for a stroke. LPN D was informed Patient #2 was asking about alternatives to inpatient mental health services since she was breastfeeding. LPN D stated Patient #2 had left when she went back to the bedside to talk to her. LPN D stated staff were unable to locate Patient #2. During an interview with the ER Nurse Manager/Quality Coordinator and observation of the triage area (area Patient #1 eloped from and identified as a ligature resistant area after the elopement) on 7/7/2026 at 4:02 PM, the ER Nurse Manager stated the area had been identified as an area to place patients with suicidal ideation. The ER Nurse Manager/Quality Coordinator stated all unsecured items would be removed and a mattress would be placed on the floor. Continued observation of the area revealed there was a functioning door alarm on the door entering the triage room from the ER area and a sliding glass door leading to the registration area. Observation included multiple areas for potential ligature risk including: a round doorknob; door closer (triangular shaped piece of metal protruding into the room) at top of the door; a desk secured to the wall, a storage cubby above the desk secured to the wall; and a television mounted to the wall near the ceiling. During an interview and observation of ER Bed B (primary room identified as a ligature resistant area) with the ER Nurse Manager/Quality Coordinator and the CNO on 7/7/2026 at 4:07 PM, the ER Nurse Manager/Quality Coordinator stated Bed B was the primary room where patients presenting with suicidal ideation would be placed. Observation revealed there was a functioning door alarm on the sliding glass door and a regular hospital bed was in the room. The ER Nurse Manager/Quality Coordinator stated the bed would be moved out and a mattress would be placed on the floor. Continued observation revealed the following ligature and/or harm risk: a monitor mounted on the wall; a covered/boxed light above the head of the bed; a blood pressure monitor mounted to the wall near the head of the bed; a sink mounted to the wall; a television mounted to the wall; a sharps container mounted to the wall, and a Personal Protective Equipment supply box mounted to the wall. During an interview on 7/7/2026 at 4:10 PM, the CNO and ER Nurse Manager/Quality Coordinator stated they were not aware an escalation pathway had been developed or implemented to guide ER staff who to contact for additional assistance with observing patients who required 1:1 observation. During an interview on 7/8/2026 at 9:45 AM, LPN E stated Patient #1 was placed in the triage area. LPN E stated Patient #1 started pacing the floor and staff were trying to contain him in the room. She stated the ER got busy. LPN E stated “...We should have had eyes on him...but we didn’t...we were trying to keep a good close watch on him...one of the other nurses had gotten him twice...” LPN E stated someone called the patient’s spouse who reported he was at home with her and she was going to take him to another facility. During an interview on 7/8/2026 at 10:00 AM, the ER Nurse Manager/Quality Coordinator confirmed the identified ligature resistant rooms (triage room and ER Bed B) were not ligature resistant as indicated in the corrective action plan for Patient #1 and #2’s elopement from the ER. During an interview on 7/8/2026 at 10:05 AM, the CNO confirmed the escalation pathway guidance had not been developed and confirmed the designated ligature resistant rooms (triage room and ER Bed B) were not ligature resistant as planned for in the corrective action, confirmed all staff had not received education according to the corrective action plans, and confirmed the corrective action plans for Patient #1 and #2’s elopements from the ED had not been fully implemented. During a telephone interview on 7/8/2026 at 10:58 AM, the Risk Management Consultant stated an area for a ligature resistant room had been identified, but the area had not yet been modified. He stated the modification was supposed to have been completed by 5/16/2026. The Risk Management Consultant stated the initial plan (following Patient #1’s elopement) may not have been fully implemented stating “...I know for sure the second elopement...the policy was not followed...” The Risk Management Consultant stated “...I am not responsible for monitoring the actions that were put into place...[monitoring] responsibility falls under the CNO...unit manager...and CEO...I serve as the compliance person...give them suggestions of what should and should not be done...” During an interview on 7/8/2026 at 4:03 PM, the CNO and ER Nurse Manager/Quality Coordinator stated audits had not been completed to ensure all ER staff and all medical/surgical staff had been educated after the elopements. When the survey team asked how they ensured all staff had received the education mentioned in the corrective action plan regarding elopement/at risk patients, the CNO and ER Nurse Manager/Quality Coordinator stated “...we just know our people...” During an interview on 7/8/2026 at 4:37 PM, the ER Nurse Manager/Quality Coordinator stated ER staff were completing the ASQ suicide screening but were not completing the CSSR assessments per facility policy “...We just treat all patients that come in as a suicide risk the same way...everybody is in constant observation...” The ER Nurse Manager/Quality Coordinator stated all patients presenting with Suicidal Ideation “...should have eyes on them at all times...” regardless of their CSSR assessment either by visual line of sight or by the camera. During an interview on 7/8/2026 at 4:42 PM, the CNO stated “...I don’t remember any one person being assigned to monitor...” to ensure the plan of correction was being implemented after Patient #1 eloped from the ED. “...I knew I was going to do education [after Patient #1’s elopement]...[Risk Management Consultant] told me we needed to do 1:1 education for all ER staff on 6/17/2026 and I started it on 6/23/2026...” The CNO stated all ER staff had been educated except RN C stating “...she rarely works...” The CNO confirmed RN C had worked in the ED on 7/4/2026 and confirmed RN C had not been educated prior to working the shift and confirmed audits were not completed to ensure all staff had been educated. During an interview on 7/8/2026 at 4:50 PM, the Interim CEO stated he, the Risk Management Consultant, CNO, and ER Nurse Manager met, discussed Patient #1’s elopement, developed an action plan, and everyone in the meeting agreed to the plan. The CEO stated “...It [ensuring corrective action plans implemented and monitored] ultimately falls back to me as CEO of the facility...” The Interim CEO confirmed the modifications to the area identified as a ligature resistant area had not been completed. The Interim CEO stated his expectation was for staff to “...monitor suicidal patients at all times...to keep all patients safe...” The Interim CEO stated he and the CNO were responsible for evaluating patient care services by observing the practices of the staff. He stated he expected events to be discussed and evaluated in QAPI and expected corrective action plan progress to be monitored for improvement. The Interim CEO confirmed the facility failed to ensure staff were following the facility’s patients at-risk policy when Patients #1 and #2 eloped and confirmed the facility failed to monitor and ensure the corrective action plans, prompted by Patient #1 and #2’s elopements, had been fully implemented. During a telephone interview on 7/9/2026 at 11:30 AM, RN C stated Patient #2 was in the first bed (ER Bed 1) which was “not usually where we put a patient on a hold [CON]...” and the patient was not wearing blue paper scrubs. RN C stated the patient was asleep when she arrived at work. “...Out of respect for her I was going to let her sleep before I made her change...” RN C stated she was triaging and completing orders for other patients who had arrived in the ER. RN C stated “...Every time I went by the room I could see her...At one point the doctor spoke to her [Patient #2], Mobile Crisis spoke with her over teleconference and determined she needed to be inpatient...” Interview continued and RN C stated Patient #2 asked if it was possible to do counseling as an outpatient since she was breastfeeding. RN C stated the facility’s CEO had come to her and wanted to speak with her privately about some in-house issues. RN C stated “...She [Patient #2] was in the bed when I went to speak with him. I came out and did a couple of tasks for other patients...she was still in the bed. Briefly after that, the housekeeper asked where this patient [Patient #2] was...I went looking for her...was unable to locate...” RN C stated she had started a new job and was PRN (worked as needed) at the facility. RN C went on to say “...I have not attended any of that training because I was working somewhere else Monday through Friday...was on orientation and couldn’t leave to do it...” During a telephone interview on 7/9/2026 at 4:14 PM, ER Physician A stated the patients who presented to the ER with Suicidal Ideation were expected to be monitored continuously by ER staff. ER Physician A stated “...Ideally, we would have a sitter on them...””

“EQUIPMENT, SUPPLIES, AND MEDICATION CFR(s): Equipment, supplies, and medication used in treating emergency cases are kept at the CAH and are readily available for treating emergency cases. The items available must include the following: This Standard is not met as evidenced by: 36003 Based on facility policy review, interviews and observations, the facility failed to ensure supplies to perform Computed Tomography Angiography (CTA/imaging procedure to allow visualization of arteries and veins of the body) were readily available for treating emergency cases. The findings include: Review of the facility’s policy titled, “...SCOPE OF SERVICES...,” dated 2/26/2026, revealed “...Provision of services provided at [named facility]...Radiology...Services include...Computed Tomography [CT] with contrast...” During an interview on 7/7/2026 at 11:15 AM, the Radiology Director stated the facility had been out of contrast injector syringes (device used to deliver dye during CTA) for “...about 2 months...” The Radiology Director stated she requested supplies through the facility’s purchasing system. Interview revealed the Materials Manager controlled what could and could not be ordered. The Radiology Director stated the contrast injector syringes were used to do CTA studies for detection of PE (Pulmonary Embolism/a blood clot in an artery of a lung) and the facility was unable to perform CTA studies without the syringes. During observation of the CT room and interview on 7/7/2026 at 11:27 AM, with the Radiology Director, he confirmed the CT Room was where the radiology supplies were stored and there were no contrast injector syringes in stock. During an interview on 7/7/2026 at 4:45 PM, the Interim Chief Executive Officer (CEO) stated he walked to every department daily to see what their needs were, but was not aware the facility was out of the contrast injector syringes until “...a couple of weeks ago...” The Interim CEO stated “...there is an order, but it’s on hold due to payment...trying to work with the vendor...” The Interim CEO confirmed the facility was unable to perform CTA studies, including testing for PE (a life threatening diagnosis). During an interview on 7/8/2026 at 9:27 AM, the Materials Manager stated she ordered contrast injector syringes when requested by the Radiology Department and had ordered 1 box of the contrast injector syringes on 5/19/2026 and on 5/26/2026. The Materials Manager stated the facility had not received the 2 boxes of syringes and was unaware why the orders had not been delivered, “...you’ll have to talk to Finance on that...” The Materials Manager stated she logged into the vendor website on an unknown date to check the status of the order and it showed the syringes were on order. The Materials Manager reached out to the Interim CEO “...shortly after...” the orders were placed to let him know there were 2 open orders for the syringes which had not been received. The Materials Manager stated the Interim CEO was aware the orders had not been received and “...he is aware of it and working on it...whatever the issue is...” During a telephone interview on 7/8/2026 at 10:33 AM, the vendor for contrast injector syringes stated the facility was on a “...credit hold due to credit issues...issue was resolved on 7/7/2026...syringes will be delivered by Friday 7/10/2026 or Monday 7/13/2026.”

“AGREEMENTS AND ARRANGEMENTS CFR(s): §485.635(c)(4) The person principally responsible for the operation of the CAH under §485.627(b)(2) of this chapter is also responsible for the following: (i) Services furnished in the CAH whether or not they are furnished under arrangements or agreements. (ii) Ensuring that a contractor of services (including one for shared services and joint ventures) furnishes services that enable the CAH to comply with all applicable conditions of participation and standards for the contracted services. This Standard is not met as evidenced by: 18784 Based on review of facility By-Laws, review of facility records, review of emails, and interviews, the facility failed to comply with agreements/arrangement for its operations when hospital staff and the contracted emergency department (ED) providers failed to receive funds for services furnished on more than one occasion. The findings include: Review of the facility By-Laws, under article 7.2, showed CEO [chief Executive Officer] job duties included, “SECTION 7.2 AUTHORITY AND DUTIES 7.2.1 The Board shall empower the CEO to be responsible for the Hospital’s management. The specific authority and duties of the CEO shall be the following: 7.2.1.1 to establish effective operations; 7.2.1.2 to establish information and support systems; 7.2.1.3 to recruit and maintain staff; 7.2.1.4 to conserve physical and financial assets...” Review of the CEO job description identified the CEO under the Administration department and showed it was the CEO responsibility to provide leadership, assume responsibility and accountability for the overall strategic planning of rural hospital...Assures consistent compliance with quality, risk, financial, and other expectations that are in accordance with expectations and directives...” Review of the current staffing schedule revealed three nurses on the current schedule had either resigned or been terminated related to the facility’s failure to meet payroll. A copy of an email was presented to the complaint survey showing the Vice President (VP) of Human Resources sent an email on 08/16/2024 to the hospital staff regarding [name of hospital] corporate payroll. The email was addressed to “Team” and stated “...regrettably, funding for the [name of hospital] payroll was not fully funded...without 100% funding the company was unable to release today’s payroll.” A copy of the social media post sent out by Registered Nurse (RN) #1 prior to their termination was presented to the survey on 08/20/2024. The social media post informed media that staff were “fed up and speaking out on [name of hospital] for not paying staff.” According to the social media post, “...this had become a habit yet again leaving people without the ability to pay bills or feed their kids.” The social media post reported checks that had been received prior also showed deductions for dental, vision, and life insurance even though dental, vision, and life insurance had been canceled months ago because of non- payment to the insurance company. During an interview with the CEO on 08/20/24 at 8:30 AM, the CEO stated payroll had been delayed on more than one occasion for staff due to a delay in funds. The CEO went on to say he attended a conference...last week and was not available “to calm things down.” When asked if the Governing Body/Advisory Board was aware of the payroll issue, the CEO provided an email sent out on 08/18/2024 at 8:56 AM, which stated the facility delayed payroll however there was no evidence found to show the Advisory Board had ever met to resolve the issue. During an interview on 08/20/24 at 9:30 AM, with the Director of Nursing (DON) she stated RN #1 was terminated after posting personal information on social media regarding facility failure to meet payroll and two additional nurses turned in immediate resignations. The DON stated agency staff are expected to be called in today to assist once the CEO gives approval. The DON stated managers were exhausted from working double shifts to provide coverage. According to the DON, the ED manager was not available for her assigned job duties today because the ED manager worked night shift to provide coverage for staff who gave immediate resignation, leaving the facility understaffed. A telephone interview was conducted on 08/20/2024 at 10:50 AM, with the Vice President (VP) of Human Resource (HR) located at the cooperate office in Florida. According to the VP of HR, RN #1 broke facility policy when the nurse posted a copy of the memo that was sent out to staff regarding delay in payroll. The VP of HR stated RN #1 was terminated because of the social media post and two additional nurses, Licensed Practical Nurse (LPN) #1 and RN #2, turned in their immediate resignation, stating the unfortunate mishap with payroll posed a burden. When asked if staff would be paid today, as stated in a memo, the VP of HR stated funds were not available today as of 11:08 AM. When asked how the facility would be paying Agency staff, the VP of HR stated the CEO had not made a request for Agency staff coverage as of 08/20/24 at 11:08 AM. A telephone interview on 8/20/2024 at 11:30 AM, with the contracted agency, who provided nursing staff to assist with staffing shortage, revealed the hospital had not made arrangement for 08/20/24 6:00 PM to 6:00 AM coverage as of 11:30 AM on 08/20/24. An interview on 08/20/24 at 11:40 AM, with the ED Provider, revealed the facility failed to pay contracted ED Providers. According to the ED Provider “...more staff are expected to walk out if Administration does not make payroll.” The ED Provider stated the facility averages seeing 30 patients a day in the ED however, the providers plan to give seven-day notice if Administration does not make payroll. During a telephone interview conducted on 08/20/2024 at 12:30 PM, the Chief of Staff/President of Medical Staff stated she was not aware of payroll concerns or the social media post stating the facility did not have funds to meet payroll for employees. The Chief of Staff had not spoken with the CEO regarding payroll and had not been informed of staff walking out or being terminated related to the facility’s failure to meet payroll. Random staff interviews were conducted on 08/20/2024 with staff, a certified nurse aide (CNA) at 12:50 PM, RN #3 at 1:00 PM, LPN #2 at 1:10 PM and the ED tech at 1:15 PM, and all confirmed there had been a delay in payroll on more than one occasion. The staff interviewed stated a memo was sent out on 08/16/2024 stating there would be a delay in payroll and staff should receive pay by 8/20/2024 or before, however no one had been paid as of 8/20/2024 at 1:15 PM. During an interview on 8/20/2024 at 1:25 PM, with the Medical-Surgical Supervisor, she stated she had been working double shifts to provide coverage for 3 nurses who resigned. The Supervisor stated the staffing schedule had been revised to provide coverage, but staff were exhausted. The Supervisor was aware of the concern regarding deductions coming out of paychecks for dental, vision and life insurance even though the insurance coverage had canceled benefits sometime in April of 2024 due to non-payment. According to the Supervisor, staff were told [name of insurance company] would reimburse the deductions made from each paycheck. The Supervisor was not aware of any staff who had received reimbursement.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 30553 Based on review of medical staff rules and regulations, review of facility policy, review of facility diversion logs, review of the Emergency Department (ED) Central Log, review of the Health Alert Network report (public health’s notification system for rapidly disseminating alerts, updates, and advisories to local, state, and federal partners), medical record review and interview, the facility failed to provide a Medical Screening Examination for 21 patients who presented to the Emergency Department (ED), and failed to provide an appropriate transfer for 1 patient (#39) who presented to the ED for care and was transferred by Emergency Medical Services (EMS) of 44 ED patients reviewed. The findings include: On 1/21/2024, the facility was placed on ED diversion related to ED Provider services were unavailable. During the time frame for 1/22/2024-1/25/2024 at 7:00 PM, 21 patients presented to the ED requesting medical treatment. The patients did not receive a nursing triage or a medical screening examination by a licensed medical provider. The facility had a ‘Diversion Log’ which did not have a patient name to identify those patients who presented to the ED. One of the 21 patients (#39) was transported by Emergency Medical Services (EMS) from Facility A to Facility B on 1/23/2024 for treatment. Refer to C-2406 and C-2409.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of facility diversion logs, review of Emergency Department (ED) Central Logs and interview, the facility failed to ensure all patients who presented to the ED were placed on the ED Central Log for 21 patients (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, and #44) who presented to the ED of 44 ED patients reviewed. The findings include: Review of the facility’s policy “Emergency Medical Treatment and Patient Transfers” dated 3/8/2017 showed, “...Emergency Department Log: the hospital shall maintain a central log on each individual who comes to the Emergency Department seeking assistance...and indicate whether the individual refused treatment...or was transferred, admitted and treated, stabilized and transferred, or discharged. In the event the patient’s name is not obtained, the patient shall be listed as a John/Jane Doe even if the patient leaves before entering the Emergency Department...” Review of a facility handwritten document titled “Diversion Log” showed 21 patients presented to the ED between the dates of 1/21/2024-1/25/2024. The patient names were not included on the “Diversion Log”. These patients were not listed on the ED Central Log. The patients were as follows: * Patient #24 arrived in the ED on 1/21/2024 at 11:30 PM with complaint of neck pain. * Patient #25 arrived in the ED on 1/22/2024 at 1:30 AM with complaint of a high fever. * Patient #26 arrived in the ED on 1/22/2024 at 3:00 AM with complaint of a possible kidney stone. * Patient #27 arrived in the ED on 1/22/2024 at 9:04 AM with complaint of a panic attack. * Patient #28 arrived in the ED on 1/22/2024 at 9:26 AM with complaint of a fall. * Patient #29 arrived in the ED on 1/22/2024 at 11:56 AM with complaint of a head laceration. * Patient #30 arrived in the ED on 1/22/2024 at 12:04 PM with complaint of wrist pain. * Patient #31 arrived in the ED on 1/22/2024 at 2:55 PM with complaints of a cough and not feeling well. * Patient #32 arrived in the ED on 1/22/2024 at 3:10 PM with complaint of psychiatric evaluation. * Patient #33 arrived in the ED on 1/22/2024 at 3:55 PM with complaint of a fall. * Patient #34 arrived in the ED on 1/22/2024 at 4:19 PM with complaint of chest pain. * Patient #35 arrived in the ED on 1/22/2024 at 9:23 PM with complaint of intoxication. * Patient #36 arrived in the ED on 1/23/2024 at 7:00 AM with complaint of wrist pain. * Patient #37 arrived in the ED on 1/23/2024 at 2:01 PM who stated they “needed a wheelchair.” * Patient #38 arrived in the ED on 1/23/2024 at 8:30 PM with complaints of nausea and vomiting. * Patient #39 arrived in the ED on 1/23/2024 at 9:45 PM with complaints of shortness of breath and chest pain. The facility called 911 for the patient and EMS transported the patient to another facility. * Patient #40 arrived in the ED on 1/24/2024 at 5:25 PM with complaint of a right thumb laceration. The patient had stated they were going to an urgent care. * Patient #41 arrived in the ED on 1/25/2024 at 6:36 AM with no complaint documented. * Patient #42 arrived in the ED on 1/25/2024 at 8:25 AM with complaint of shortness of breath. * Patient #43 arrived in the ED on 1/25/2024 at 1:52 PM with complaint of shortness of breath. The facility offered to call 911 for the patient but the patient declined. * Patient #44 arrived in the ED on 1/25/2024 at 6:20 PM with complaint of a psychiatric evaluation. Review of ED Central Logs for 1/21/2024-1/25/2024 showed the 21 patients were not listed on the ED Central Log. During an interview on 1/30/2024 at 1:35 PM, the Registration Supervisor stated when patients came to the ED during the diversion, the staff were told to ask the patient why they came to the ED and assist the patients as needed. They documented the patients on the ED diversion log. During an interview on 1/30/2024 at 1:15 PM the ED Nurse Manager confirmed the patients were listed on a ‘Diversion Log’ and not placed on the ED Central Log.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30553 Based on review of medical staff rules and regulations, review of facility policy, review of facility diversion logs, review of Emergency Department (ED) Central Log, review of the Health Alert Network report (public health’s notification system for rapidly disseminating alerts, updates, and advisories to local, state, and federal partners), medical record review and interview, the facility failed to provide a Medical Screening Examination for 21 patients (#24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43, and #44) who presented to the ED of 44 ED patients reviewed. The findings include: Review of the Medical Staff Rules and Regulations dated 3/2004 showed, “...any individual who presents to the Emergency Department of this hospital for care shall be provided with a medical screening examination to determine whether that individual is experiencing an emergency medical condition. Generally, an “emergency medical condition” is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child...” Review of the facility’s policy “Emergency Medical Treatment and Patient Transfers” dated 3/8/2017 showed, “...Coming to the Emergency Department...any individual on hospital property [including the parking lot or campus] requesting an examination or treatment...Medical Screening Examination: when an individual comes to the Emergency Department of the hospital, or any location on hospital property...and a request is made on the individuals behalf for a medical examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department...shall be provided to determine whether an emergency medical condition exists...An Emergency Department Provider shall perform medical screening examinations. An Emergency Department provider on duty shall be responsible for the general care of all patients presenting themselves to the Emergency Department...” Review of the facility’s policy “Scope of Services” revised 8/23/2021 showed, “...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated...All services provided by [named facility] will be evaluated on an ongoing basis to ensure the needs of the patients and community are being met to the highest capabilities of the facility...” On 1/21/2024, the facility posted a sign on the ED and EMS entrance which stated, “...attention, [Facility A] is currently on diversion status and can not accept patients for the next several hours. We apologize for the inconvenience...” Review of a facility handwritten document titled “Diversion Log” showed 21 patients presented to the ED between the dates of 1/21/2024-1/25/2024. The patient names were not included on the Diversion Log. These patients were not listed on the ED Central Log. The patients were as follows: * Patient #24 arrived in the ED on 1/21/2024 at 11:30 PM with complaint of neck pain. * Patient #25 arrived in the ED on 1/22/2024 at 1:30 AM with complaint of a high fever. * Patient #26 arrived in the ED on 1/22/2024 at 3:00 AM with complaint of a possible kidney stone. * Patient #27 arrived in the ED on 1/22/2024 at 9:04 AM with complaint of a panic attack. * Patient #28 arrived in the ED on 1/22/2024 at 9:26 AM with complaint of a fall. * Patient #29 arrived in the ED on 1/22/2024 at 11:56 AM with complaint of a head laceration. * Patient #30 arrived in the ED on 1/22/2024 at 12:04 PM with complaint of wrist pain. * Patient #31 arrived in the ED on 1/22/2024 at 2:55 PM with complaints of a cough and not feeling well. * Patient #32 arrived in the ED on 1/22/2024 at 3:10 PM with complaint of psychiatric evaluation. * Patient #33 arrived in the ED on 1/22/2024 at 3:55 PM with complaint of a fall. * Patient #34 arrived in the ED on 1/22/2024 at 4:19 PM with complaint of chest pain. * Patient #35 arrived in the ED on 1/22/2024 at 9:23 PM with complaint of intoxication. * Patient #36 arrived in the ED on 1/23/2024 at 7:00 AM with complaint of wrist pain. * Patient #37 arrived in the ED on 1/23/2024 at 2:01 PM who stated they “needed a wheelchair.” * Patient #38 arrived in the ED on 1/23/2024 at 8:30 PM with complaints of nausea and vomiting. * Patient #39 arrived in the ED on 1/23/2024 at 9:45 PM with complaints of shortness of breath and chest pain. The facility called 911 for the patient and EMS transported the patient to another facility. * Patient #40 arrived in the ED on 1/24/2024 at 5:25 PM with complaint of a right thumb laceration. The patient had stated they were going to an urgent care. * Patient #41 arrived in the ED on 1/25/2024 at 6:36 AM with no complaint documented. * Patient #42 arrived in the ED on 1/25/2024 at 8:25 AM with complaint of shortness of breath. * Patient #43 arrived in the ED on 1/25/2024 at 1:52 PM with complaint of shortness of breath. The facility offered to call 911 for the patient but the patient declined. * Patient #44 arrived in the ED on 1/25/2024 at 6:20 PM with complaint of a psychiatric evaluation. Review of the facility’s electronic medical records showed no medical records for the following patients: #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, #43 and #44. Review of an EMS Run Report for Patient #39 dated 1/23/2024 9:50 PM showed EMS was requested by 911 to respond to [Facility A] for a patient with complaints of shortness of breath and chest pain. The patient was outside the ED and ambulated to the ambulance. The patient stated his heart was racing and he was dizzy when standing up. The patient’s vital signs were obtained, an intravenous (IV) line was started and a 12 lead EKG was performed. The patient was given Aspirin (blood thinner) 324 milligrams (mg) orally and the patient refused sublingual Nitroglycerin (medications used to treat chest pain). The patient was transported nonemergent to (Facility B’s) ED. During an interview on 1/29/2024 at 10:40 AM the Chief Executive Officer (CEO) stated the facility was on ED diversion starting on 1/21/2024. The ED was on diversion until 1/25/2024 at 7:00 PM. A sign was placed on the ED entrance doors to notify patients they were unable to provide ED services. During an interview on 1/29/2024 at 1:10 PM the ED Medical Director confirmed all patients who present to the ED for treatment, should receive a medical screening examination by a licensed medical provider. During an interview on 1/30/2024 at 9:45 AM, the CEO confirmed the ED did not have ED provider coverage starting 1/21/2024 and ended 1/25/2024 at 7:00 PM. All patients who presented after 1/22/2024 at midnight were told the ED was on diversion and would be referred to another facility, their Primary Care Provider, or offered 911 services. Those patients who presented to the ED did not receive a medical screening examination related to the ED diversion. During an interview on 1/30/2024 at 1:40 PM Licensed Practical Nurse (LPN) #1 stated there was not an ED provider in the ED while the ED was on diversion. The staff were told tell the patients there was not a provider and the staff could call 911 for any patients who needed assistance. LPN #1 confirmed there were no patients evaluated in the ED during the ED diversion. During an interview on 1/30/2024 at 1:45 PM Registration Clerk #1 stated during the ED diversion they were instructed to tell the patients the ED did not have an ED provider, the patients could go to their primary care physicians office, or the staff could assist the patient with calling 911 to be transported to another facility. During an interview on 1/30/2024 at 1:15 PM the ED Nurse Manager, stated patients who presented to the ED were told the ED was on diversion. The staff offered to assist the patients by calling 911 if needed, but the patients were referred to their Primary Care Provider, an urgent care center, or the patients could go to another facility for care. The ED Nurse Manager confirmed there was no medical provider schedule during the time the ED was on diversion. During an interview on 1/30/2024 at 2:30 PM the Chief Nursing Officer stated there was no ED provider in the ED for 1/22/2024-1/25/2024 at 7:00 PM. Patients who presented to the ED were informed the ED was on diversion. The CNO confirmed there were 21 patients between 1/21/2024-1/25/2024 who presented to the ED and a nursing triage or medical screening examination was not performed.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of an Emergency Medical Service (EMS) Run Report, medical record review and interview, the facility failed to provide an appropriate transfer for one patient (#39) who presented to the Emergency Department (ED) with chest pain of 44 patients reviewed. The findings include: Review of the facility policy “Emergency Medical Treatment and Patient Transfers” dated 3/17/2017, showed “...after determining that an individual will be transferred from the Emergency Department...the individual will be transferred in accordance with the following procedures: [1] acceptance by receiving hospital and receiving provider...prior to transfer, the receiving hospital and provider must consent to the transfer of the individual and agree to provide appropriate medical treatment and hospital care [2] the hospital shall provide medical treatment within it’s capacity to minimize the risk of transfer to the individuals health...” Review of an EMS Run Report for Patient #39 dated 1/23/2024 9:50 PM, showed EMS was requested by 911 to respond to [Facility A] for a patient with complaints of shortness of breath and chest pain. The Run Report showed the patient was outside the ED and ambulated to the ambulance, stating his heart was racing and he was dizzy when standing up. The EMS staff obtained the patient’s vital signs, an intravenous (IV) line was started and a 12 lead EKG was performed. The patient was given Aspirin (blood thinner) 324 milligrams (mg) orally and the patient refused sublingual Nitroglycerin (medications used to treat chest pain). The patient was transported nonemergent to (Facility B’s) ED. The patient was on the facility property and did not receive a nursing triage or medical screening examination. During an interview on 1/29/2024 at 1:10 PM, the ED Medical Director confirmed all patients who present to the ED for treatment should receive a medical screening examination by a licensed medical provider. During an interview on 1/30/2024 at 9:45 AM, the Chief Executive Officer confirmed the ED did not have ED provider coverage starting 1/21/2024 and ended 1/25/2024 at 7:00 PM. All patients who presented after 1/21/2024 at 11:30 PM, were told the ED was on diversion and would be referred to another facility, their Primary Care Provider or offered 911 services. Those patients who presented to the ED did not receive a medical screening examination related to the ED diversion. During an interview on 1/30/2024 at 1:40 PM, Licensed Practical Nurse (LPN) #1 stated there was not an ED provider in the ED while the ED was on diversion. The staff were told to tell the patients there was not a provider and the staff could call 911 for any patients who needed assistance. LPN #1 confirmed there were no patients evaluated in the ED during the ED diversion. During an interview on 1/30/2024 at 1:15 PM, the ED Nurse Manager confirmed there was no medical provider schedule during the time the ED was on diversion. During an interview on 1/30/2024 at 2:30 PM, the Chief Nursing Officer confirmed there were 21 patients between 1/21/2024-1/25/2024 who presented to the ED and a nursing triage or medical screening examination was not performed and there was 1 patient (#39) where EMS was called and the patient was transported to another facility.”

“EMERGENCY SERVICES CFR(s): The CAH provides emergency care necessary to meet the needs of its inpatients and outpatients. This Condition is not met as evidenced by: 36003 Based on review of Medical Staff Rules and Regulations, review of facility policy, review of Emergency Department (ED) physician schedule, review of ED log (list of ED patients), review of a Health Alert Network (Public Health’s notification system for rapidly disseminating alerts, updates and advisories to local, state and federal partners) report, review of an ED Diversion (redirected patients) log, observations and interviews, the facility failed to provide emergency services 24 hours a day/7 days a week (24/7) and failed to provide physician coverage in the ED. The findings include: The facility failed to ensure 24/7 availability of a physician or midlevel provider (physician assistant or nurse practitioner) in the ED, to provide medical treatment for patients presenting to the ED, and failed to provide 24/7 emergency services. The ED went on diversion on 1/22/2024 at 12:00 AM-1/24/2024 due to no physician available to provide coverage for the ED. Sixteen patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) presented to the ED, then were turned away without receiving treatment because no ED physician was available. Refer to C-0882 and C-0894.”

“ORGANIZATIONAL STRUCTURE CFR(s): Organizational Structure This Condition is not met as evidenced by: 36003 Based on review of Medical Staff Rules and Regulations, review of the Chief Executive Officer (CEO) job description, review of Advisory Board Bylaws, review of facility policy, review of Emergency Department (ED) physician schedule, review of ED log (list of ED patients), review of an ED Diversion (list of redirected patients) log, observations and interviews, the facility failed to provide oversight related to medical care for patients presenting to the ED. The findings include: The facility failed to ensure 24/7 (24 hours a day/7 days a week) availability of a physician or midlevel provider (physician assistant or nurse practitioner) in the ED to provide medical treatment for patients presenting to the ED. The facility was behind with payments to the contracted company who provided ED physicians, which resulted in the physicians not covering scheduled shifts in the ED and the ED being on diversion from 1/22/2024 at 12:00 AM-1/24/2024. Patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, and #16) presented to the ED but were turned away without receiving treatment. Refer to C-0962.”

“AVAILABILITY CFR(s): Emergency services are available on a 24-hours a day basis. This Standard is not met as evidenced by: 36003 Based on review of facility policy, review of the Emergency Department (ED) log (list of ED patients), review of a Health Alert Network (Public Health’s notification system for rapidly disseminating alerts, updates and advisories to local, state, and federal partners) report, review of an ED Diversion log (list of redirected patients), observations and interviews, the facility failed to provide emergency services 24 hours a day/7 days a week (24/7) affecting 16 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 16 patients who presented to the ED from 1/22/2024-1/24/2024. The findings include: Review of the facility’s policy “Scope of Services” revised 8/23/2021 showed, “...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated...All services provided by [named facility] will be evaluated on an ongoing basis to ensure the needs of the patients and community are being met to the highest capabilities of the facility...” Review of the ED log for 1/1/2024-1/24/2024 showed the last patient listed on the ED log arrived on 1/21/2024 at 10:00 PM and was discharged on 1/21/2024 at 11:45 PM. Review showed patients listed on the ED Diversion Log were not on the ED Log. Review of a Health Alert Network report showed the facility went on diversion status on 1/21/2024 at 11:21 PM. The report showed the facility was on diversion due to no physician and Emergency Medical Services should transport patients to an alternate appropriate destination. Review of a facility handwritten document titled “Diversion Log” showed 16 patients listed by number (no patient names included)presented to the ED seeking treatment as follows: *Patient #1 arrived on 1/21/2024 at 11:30 PM with complaint of (c/o) neck pain. *Patient #2 arrived on 1/22/2024 at 1:30 AM with c/o high fever. *Patient #3 arrived on 1/22/2024 at 3:00 AM with c/o possible kidney stone. *Patient #4 arrived on 1/22/2024 at 9:04 AM with c/o panic attack. *Patient #5 arrived on 1/22/2024 at 9:26 AM with c/o fall. *Patient #6 arrived on 1/22/2024 at 11:56 AM with c/o head laceration (wound). *Patient #7 arrived on 1/22/2024 at 12:04 PM with c/o wrist pain. *Patient #8 arrived on 1/22/2024 at 2:55 PM with c/o cough/not feeling well. *Patient #9 arrived on 1/22/2024 at 3:10 PM with c/o psychiatric evaluation *Patient #10 arrived on 1/22/2024 at 3:55 PM with c/o fall. *Patient #11 arrived on 1/22/2024 at 4:19 PM with c/o chest pain. *Patient #12 arrived on 1/22/2024 at 9:23 PM with c/o intoxication. *Patient #13 arrived on 1/23/2024 at 7:00 AM with c/o wrist pain. *Patient #14 arrived on 1/23/2024 at 2:01 PM and asked for a wheelchair. *Patient #15 arrived on 1/23/2024 at 8:30 PM with c/o nausea and vomiting. *Patient #16 arrived on 1/23/2024 at 9:45 PM with c/o shortness of breath and chest pain. Staff called 911 for the patient. Observation of the facility’s main entrance on 1/24/2024 at 9:45 AM showed a sign was posted stating the ED was on diversion. During an interview on 1/24/2024 at 9:56 AM, the Chief Nursing Officer confirmed the ED was on diversion and confirmed the ED was not receiving patients. Observation of the ED on 1/24/2024 at 10:09 AM showed a sign stating the ED was on diversion posted at the ED entrance from within the facility and the ED main entrance. The ED was staffed with 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). No physician or midlevel provider (physician assistant or nurse practitioner) were in the ED. There were no patients observed in the ED. During an interview on 1/24/2024 at 10:18 AM, ED Registration Clerk #1 confirmed the ED had been on diversion since Sunday night (1/21/2024) and the ED was not receiving patients. ED Registration Clerk #1 stated patients who presented to the ED were told the ED was on diversion and were told to go to their primary care physician or to go to another hospital. Interview revealed the staff offered to call 911 for the patients. During an interview on 1/24/2024 at 10:54 AM, the Chief Executive Officer (CEO) confirmed the ED had been on diversion from 12:00 AM on 1/22/2024-1/24/2024 because there was no physician or midlevel provider to staff the ED and confirmed the ED was not receiving patients. During an interview on 1/24/2024 at 12:45 PM, the ED Nurse Manager stated the CEO notified her on Sunday (1/21/2024) the ED would be going on diversion at midnight (1/22/2024) because there was no physician to staff the ED. During a telephone interview on 1/24/2024 at 3:03 PM, the day shift RN #1 confirmed the ED was on diversion and was not accepting patients because there wasn’t a physician or midlevel provider to staff the ED on 1/22/2024 and 1/23/2024. RN #1 confirmed patients had presented to the ED on those dates and were instructed to go to their primary care provider or the nearest ED. During a telephone interview on 1/24/2024 at 3:21 PM, the night shift LPN #1 confirmed the ED was not staffed with a physician or midlevel provider after 12:00 AM on 1/22/2024 or on the night of 1/23/2024. LPN #1 confirmed patients who presented to the ED were told there was no physician for the ED and the staff could help them call 911 if needed. During a telephone interview on 1/25/2024 at 8:07 AM, the CEO confirmed the ED continued to be without a provider and remained on diversion. The CEO stated ensuring nursing staff was in the ED and diverting patients to another ED was all he could do.”

“PERSONNEL CFR(s): (1) Except as specified in paragraph (d)(3) of this section, there must be a doctor of medicine or osteopathy, a physician assistant, a nurse practitioner or a clinical nurse specialist with training or experience in emergency care on call and immediately available by telephone or radio contact, and available on site within the following timeframes: (i) Within 30 minutes, on a 24-hour a day basis, if the CAH is located in an area other than an area described in paragraph (d)(1)(ii) of this section; or (ii) Within 60 minutes, on a 24-hour a day basis, if all of the following requirements are met: (A) The CAH is located in an area designated as a frontier area (that is, an area with fewer than six residents per square mile based on the latest population data published by the Bureau of the Census) or in an area that meets criteria for a remote location adopted by the State in its rural health care plan, and approved by CMS, under section 1820(b) of the Act. (B) The State has determined under criteria in its rural health care plan, that allowing an emergency response time longer than 30 minutes is the only feasible method of providing emergency care to residents of the area served by the CAH. (C) The State maintains documentation showing that the response time of up to 60 minutes at a particular CAH it designates is justified because other available alternatives would increase the time needed to stabilize a patient in an emergency. (2) A registered nurse with training and experience in emergency care can be utilized to conduct specific medical screening examinations only if- (i) The registered nurse is on site and immediately available at the CAH when a patient requests medical care; and (ii) The nature of the patient’s request for medical care is within the scope of practice of a registered nurse and consistent with applicable State laws and the CAH’s bylaws or rules and regulations. (3) A registered nurse satisfies the personnel requirement specified in paragraph (d)(1) of this section for a temporary period if-- (i) The CAH has no greater than 10 beds; (ii) The CAH is located in an area designated as a frontier area or remote location as described in paragraph (d)(1)(ii)(A) of this section; (iii) The State in which the CAH is located submits a letter to CMS signed by the Governor, following consultation on the issue of using RNs on a temporary basis as part of their State rural health care plan with the State Boards of Medicine and Nursing, and in accordance with State law, requesting that a registered nurse with training and experience in emergency care be included in the list of personnel specified in paragraph (d)(1) of this section. The letter from the Governor must attest that he or she has consulted with State Boards of Medicine and Nursing about issues related to access to and the quality of emergency services in the States. The letter from the Governor must also describe the circumstances and duration of the temporary request to include the registered nurses on the list of personnel specified in paragraph (d)(1) of this section; (iv) Once a Governor submits a letter, as specified in paragraph (d)(3)(iii) of this section, a CAH must submit documentation to the State survey agency demonstrating that it has been unable, due to the shortage of such personnel in the area, to provide adequate coverage as specified in this paragraph (d). (4) The request, as specified in paragraph (d)(3)(iii) of this section, and the withdrawal of the request, may be submitted to us at any time, and are effective upon submission. This Standard is not met as evidenced by: 36003 Based on review of Medical Staff Rules and Regulations, review of facility policy, review of a Health Alert Network (Public Health’s notification system for rapidly disseminating alerts, updates and advisories to local, state, and federal partners) report, review of the Emergency Department (ED) physician schedule, review of the ED log (list of ED patients), review of an ED Diversion (redirected patients) log, observations and interviews, the facility failed to ensure availability of a physician or midlevel provider (physician assistant or nurse practitioner) in the ED 24 hours a day/7 days a week (24/7) affecting 16 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 16 patients who presented to the ED from 1/22/2024-1/24/2024. The findings include: Review of the Medical Staff Rules and Regulations dated 3/2004 showed, “...Any individual who presents to the Emergency Department of the hospital for care shall be provided with a medical screening examination...All patients shall be examined by qualified medical personnel which shall be defined as a physician trained in emergency medicine...” Review of the facility’s policy “Scope of Services” revised 8/23/2021 showed, “...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated...” Review of a Health Alert Network report showed the facility went on diversion status on 1/21/2024 at 11:21 PM. The report showed the facility was on diversion due to no physician in the ED. Review of the Emergency Department physician schedule for 1/2024 showed a physician nor midlevel provider was not scheduled from 12:00 AM on 1/22/2024-1/25/2024 at 7:00 PM. Review of the ED log for 1/1/2024-1/24/2024 showed the last patient listed on the ED log arrived on 1/21/2024 at 10:00 PM and was discharged on 1/21/2024 at 11:45 PM. Patients listed on the ED Diversion Log were not listed on the ED Log. Review of a facility handwritten document titled “Diversion Log” showed 16 patients listed by number (no patient names included) presented to the ED seeking treatment as follows: *Patient #1 arrived on 1/21/2024 at 11:30 PM with complaint of (c/o) neck pain. *Patient #2 arrived on 1/22/2024 at 1:30 AM with c/o high fever. *Patient #3 arrived on 1/22/2024 at 3:00 AM with c/o possible kidney stone. *Patient #4 arrived on 1/22/2024 at 9:04 AM with c/o panic attack. *Patient #5 arrived on 1/22/2024 at 9:26 AM with c/o fall. *Patient #6 arrived on 1/22/2024 at 11:56 AM with c/o head laceration (wound). *Patient #7 arrived on 1/22/2024 at 12:04 PM with c/o wrist pain. *Patient #8 arrived on 1/22/2024 at 2:55 PM with c/o cough/not feeling well. *Patient #9 arrived on 1/22/2024 at 3:10 PM with c/o psychiatric evaluation. *Patient #10 arrived on 1/22/2024 at 3:55 PM with c/o fall. *Patient #11 arrived on 1/22/2024 at 4:19 PM with c/o chest pain. *Patient #12 arrived on 1/22/2024 at 9:23 PM with c/o intoxication. *Patient #13 arrived on 1/23/2024 at 7:00 AM with c/o wrist pain. *Patient #14 arrived on 1/23/2024 at 2:01 PM and asked for a wheelchair. *Patient #15 arrived on 1/23/2024 at 8:30 PM with c/o nausea and vomiting. *Patient #16 arrived on 1/23/2024 at 9:45 PM with c/o shortness of breath and chest pain. Staff called 911 for the patient. There were no medical records for Patients #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16. Observation of the ED on 1/24/2024 at 10:09 AM showed a sign stating the ED was on diversion posted on the ED entrance from within the facility and the ED main entrance. The ED was staffed with 1 Registered Nurse (RN) and 1 Licensed Practical Nurse (LPN). No physician or midlevel provider was in the ED. During an interview on 1/24/2024 at 10:54 AM, the Chief Executive Officer (CEO) confirmed the ED had been on diversion from 12:00 AM on 1/22/2024-1/24/2024 because there was no physician or midlevel provider (physician assistant or nurse practitioner) to staff the ED. During an interview on 1/24/2024 at 12:45 PM, the ED Nurse Manager stated the CEO notified her on Sunday (1/21/2024) the ED would be going on diversion at midnight (1/22/2024) because there was no physician to staff the ED. During a telephone interview on 1/24/2024 at 3:03 PM, RN #1 (day shift) confirmed the ED was on diversion and not accepting patients related to no physician or midlevel provider to staff the ED during her shifts on 1/22/2024 and 1/23/2024. RN #1 confirmed patients presented to the ED during those shifts and were instructed to go to their primary care provider or the nearest ED. During a telephone interview on 1/24/2024 at 3:21 PM, LPN #1 confirmed the ED was not staffed with a physician or midlevel provider after 12:00 AM on 1/22/2024 or during the night of 1/23/2024. LPN #1 confirmed patients who presented to the ED were told there was no physician for the ED and the staff could help them call 911 if needed. During a telephone interview on 1/25/2024 at 8:07 AM, the CEO confirmed the ED continued to be without a physician or midlevel provider and remained on diversion.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 36003 Based on review of Medical Staff Rules and Regulations, review of the Chief Executive Officer (CEO) job description, review of Advisory Board Bylaws, review of facility policy, review of Emergency Department (ED) physician schedule, review of ED log (list of ED patients), review of an ED Diversion (list of redirected patients) log, observations and interviews, the facility failed to provide physician coverage in the ED from 1/22/2024-1/24/2024, affecting 16 patients (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15 and #16) of 16 patients who presented to the ED from 1/22/2024-1/24/2024. The findings include: Review of the facility’s Medical Staff Rules and Regulations dated 3/2004 showed, “...Any individual who presents to the Emergency Department of the hospital for care shall be provided with a medical screening examination...All patients shall be examined by qualified medical personnel which shall be defined as a physician trained in emergency medicine...” Review of the Chief Executive Officer (CEO) job description dated 1/10/2017 showed, “...The Chief Executive Officer responsibility is to provide leadership, assume responsibility and accountability for the overall strategies planning of rural hospital including outpatient and inpatient services, diagnostic, emergency medical services, surgical services, and physician practice. Essential Duties and Responsibilities...Leads hospital leadership team and participates in medical staff and governance strategic planning sessions for hospital...Meets regularly with hospital leadership to examine current financial performance, evaluates forecasts and ensures appropriate, timely interventions...Assures consistent compliance with quality, risk, financial, and other expectations that are in accordance with expectations and directives...Plans and directs the short- and long-range objectives/goals of Corporate to meet its financial and non-financial goals...” Review of the “Bylaws Governing the Advisory Board of [named facility]” dated 8/31/2018 showed, “...The role and purpose of the Hospital is to provide a facility supporting qualified medical professionals in providing quality health care to patients treated in the Hospital. The primary responsibility and goal of the Advisory Board (the “Board”) is to further the role and purpose of the Hospital by providing oversight of the Hospital and advice to the Corporation and the Corporation’s Board of Directors (the “Corporate Board”), thereby facilitating the establishment of policies, the maintenance of quality patient care, and the provision of institutional management and planning, all in a manner that is responsive to the needs of the community area...The Corporate Board serves as the governing body of the Hospital and retains ultimate responsibility for the Hospital’s compliance with all applicable federal, state and local laws and regulations...The Corporate Board, through its officers and the CEO, retains authority for the Hospital’s business decisions, but may request the advice of the Board on such matters...The Board shall advise the Corporation...making recommendations to the CEO and the Corporation regarding the Hospital’s operating budget, which shall be developed by the CEO...” Review of the facility’s policy “Scope of Services” revised 8/23/2021 showed, “...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel...Any patient presenting to the Emergency Department for care will be evaluated and treated... All services provided by [named facility] will be evaluated on an ongoing basis to ensure the needs of the patients and community are being met to the highest capabilities of the facility...” Review of the ED physician schedule for 1/2024 showed a physician was not scheduled from 12:00 AM on 1/22/2024-1/25/2024 at 7:00 PM. Review of the ED log for 1/1/2024-1/24/2024 showed the last patient listed on the ED log arrived on 1/21/2024 at 10:00 PM and was discharged on 1/21/2024 at 11:45 PM. Review of a facility handwritten document titled “Diversion Log” showed 16 patients listed by number (no patient names included) presented to the ED seeking treatment as follows: *Patient #1 arrived on 1/21/2024 at 11:30 PM with complaint of (c/o) neck pain. *Patient #2 arrived on 1/22/2024 at 1:30 AM with c/o high fever. *Patient #3 arrived on 1/22/2024 at 3:00 AM with c/o possible kidney stone. *Patient #4 arrived on 1/22/2024 at 9:04 AM with c/o panic attack. *Patient #5 arrived on 1/22/2024 at 9:26 AM with c/o fall. *Patient #6 arrived on 1/22/2024 at 11:56 AM with c/o head laceration (wound). *Patient #7 arrived on 1/22/2024 at 12:04 PM with c/o wrist pain. *Patient #8 arrived on 1/22/2024 at 2:55 PM with c/o cough/not feeling well. *Patient #9 arrived on 1/22/2024 at 3:10 PM with c/o psychiatric evaluation. *Patient #10 arrived on 1/22/2024 at 3:55 PM with c/o fall. *Patient #11 arrived on 1/22/2024 at 4:19 PM with c/o chest pain. *Patient #12 arrived on 1/22/2024 at 9:23 PM with c/o intoxication. *Patient #13 arrived on 1/23/2024 at 7:00 AM with c/o wrist pain. *Patient #14 arrived on 1/23/2024 at 2:01 PM and asked for a wheelchair. *Patient #15 arrived on 1/23/2024 at 8:30 PM with c/o nausea and vomiting. *Patient #16 arrived on 1/23/2024 at 9:45 PM with c/o shortness of breath and chest pain. Staff called 911 for the patient. Observation of the facility’s main entrance door on 1/24/2024 at 9:45 AM showed a sign was posted stating the ED was on diversion. Observation of the ED on 1/24/2024 at 10:09 AM showed a sign stating the ED was on diversion was posted on the ED entrance from within the facility and the ED main entrance. The ED was staffed with 1 Registered Nurse and 1 Licensed Practical Nurse. No physician or midlevel provider was in the ED. During an interview on 1/24/2024 at 10:54 AM, the CEO stated the company contracted to provide ED physicians/midlevel providers informed him a specific provider, who had not received payment for his services for the end of 12/2023, as well as other ED providers would not provide services for the ED unless they were paid in advance. The CEO reported the facility was 1 month behind in payment to the contracted company. The CEO confirmed the ED had been on diversion since 12:00 AM on 1/22/2024 because there was no physician or midlevel provider to staff the ED. The CEO confirmed the ED remained on diversion on 1/24/2024. During an interview on 1/24/2024 at 12:45 PM, the ED Nurse Manager stated the CEO notified her on Sunday (1/21/2024) the ED would be going on diversion at midnight (1/22/2024) because there was no physician to staff the ED. During a telephone interview on 1/24/2024 at 3:25 PM, the ED Medical Director, stated the expectation was the facility make “on time” payments for services provided by the ED physicians. He stated the facility had occasionally gotten behind but had been able to make it up. The ED Medical Director reported the facility started getting behind with payment around 9/2023 or 10/2023. According to the ED Medical Director, the facility had not paid the contracted company who provided ED physicians (ED Medical Director’s employer) for services provided in 11/2023, 12/2023 and 1/2024. The Medical Director stated, “...[named contracted company] is saying not paying money until [facility corporate office] pays them...the docs [doctors] aren’t getting paid...They owe me for December [2023] and January [2024]...no doctor coverage because they aren’t paying the doctors...” The Medical Director stated the contracted company is not guaranteeing payment if the ED physicians work their scheduled shifts, “...None of the doctors are wanting to return to work until they are paid. The truth of the matter is they [the facility] are behind on payments...” During a telephone interview on 1/25/2024 at 2:48 PM, the CEO stated the contracted company who provided the physicians for the ED had been paid for services through mid-December. The CEO stated he collaborated with the corporate office to handle the facility’s cash flow. When asked who was responsible for ensuring accounts were paid, the CEO responded, “...would have to be me locally...” He went on to say the contracted company was paid through the corporate office. During a telephone interview on 1/26/2024 at 12:45 PM, the Community Advisory Board Chairperson stated the facility CEO shared information regarding hospital operations, environment of care report, administrative report, brief recap from medical staff meeting, quality improvement, human resources and nursing. The Advisory Board Chairperson understood there was an issue with the contracted company who provided ED physicians and the physicians “...bucked...” on providing services for the ED. She was not aware of the facility making late payments to the contracted company. The Community Advisory Board Chairperson stated, “...I was told they were paid up through mid-December. I assume by being paid up through mid-December they are up to date...” During a telephone interview on 1/26/2024 at 1:05 PM, the Corporate CEO stated it was his responsibility to “...Watch and manage cash flow...financial management...” The Corporate CEO stated the facility had paid the contracted company who provided ED physicians through 12/15/2023 or 12/20/2023 for the second part of December and stated “...We have paid them as cash flow has come in...” The Corporate CEO stated the contracted provider group had been paid consistently until 5/2023. He stated, “...probably slipped a little in July [2023]...consistently been behind [with payment] 4-6 weeks...since that time.” The Corporate CEO stated some of the ED providers insisted on being paid in advance, but the facility was unable to meet their request which resulted in the ED going on diversion.”