Longview Regional 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: 36827 Based on review of records and interviews, the facility failed to ensure that Emergency Department (ED) medical records contained complete entries documenting the course and results of care, treatment and services that were documented by the person responsible for providing or evaluating the services for 9 out of 14 medical records reviewed on-site. The records were found to be missing information such as the placement of IV catheters (a device place in a vein to administer medications directly into a vein), the removal of IV catheters, and the total time required to administer a medication through an IV catheter had been completed as required by hospital policy and evidence-based practice standards of care followed by the nursing department. Findings include: On 7-1-2026 during record review, Staff #4 stated that nursing staff were required to follow Dynamic Health procedures for nursing tasks. Dynamic Health was an online medical reference that healthcare professionals could use to look up the safest and most up-to-date ways to care for patients. It was based on current medical research and expert recommendations. Staff #2 confirmed that the hospital had quit writing policy and procedures for each nursing task and had adopted the practice of following a recognized Evidence-Based Practice reference source. Staff #2 explained that the hospital had previously followed Mosby but had changed to Dynamic Health. Copies of Dynamic Health guidelines for inserting, removing, and administering medications through an IV catheter were provided by the hospital. On 7-1-2026 at 12:30 PM, medical records were reviewed in the administrative conference room. Record review was as follows: Patient #2 Patient #2 presented to the ED on 5-30-2026 at 10:39 AM. Nursing notes recorded “05/30 12:02 Inserted saline lock: 20 gauge RAC.” That was an IV catheter that was a 20 gauge size placed in a vein the right antecubital (inside bend of the arm) area. No other information about the IV insertion was found. Review of Inserting a Peripheral IV in Adults from the Dynamic Health reference source showed on page 8 of 10 under Documentation that the following information had not been documented as required: “Update patient’s place of care and medical, as appropriate. Include: ... Number of IV insertion attempts and techniques used ... Device patency and function ... Pain management and patient’s tolerance of IV placement or venipuncture Further review of the patient’s medical record showed that there were no notes about the removal of the IV catheter. Review of Removing a Peripheral IV in Adults from the Dynamic Health reference source showed on page 4 of 6 under Documentation that the following information had not been documented as required: “Update the patient’s plan of care and medical record, as appropriate. Include: Date/time and reason for PIV (peripheral IV) removal Whether catheter was removed intact Presence of any exudate or drainage upon removal Patient response to procedure Any unexpected patient events or outcomes, interventions performed, and whether treating clinician was notified Patient/family education, such as topics presented, response to education, plan for follow-up education, or any communication barriers, and techniques that promoted successful communication” Patient #6 Patient #6 presented to the ED on 5-28-2026 at 10:03 AM. Review of medical records showed on the medication orders summary that medication had been administered through a peripheral IV that was in the RAC. The record showed that 1000 milliliters of normal saline IV Bolus (a large dose of medication or fluid that is given quickly through an IV so that it starts working right away) had started at 11:27 AM but the record did not reflect how long the administration of fluid took/how rapidly it was given. The patient was given 4 milligrams of Zofran (a medication for nausea) at “1 calculated rate” but did not indicate what the rate had been calculated at and given. It started at the same time as the normal saline. No record was found for the nursing procedure of the insertion of the IV catheter or the removal of the IV catheter with required documentation elements were found. Review of Dynamic Health reference source material for Administering IV Bolus or IV Push Medication (medication pushed into the IV catheter from a syringe) to Adults showed the following documentation requirements starting on page 4 of 7: “Update patient’s plan of care and medical record, as appropriate. Include: Date/time medication was prepared and administered Name of medication/diluent and speed of infusion Patient status before and after administration of medication Any unexpected events or outcomes, interventions performed, and whether treating clinician was notified Patient/family education, such as topics presented, response to education provided/discussed, plan for follow-up education, any communication barriers, and techniques that promoted successful communication.” Staff #4 stated she remembered on that day that there had been 2 (two) nurse callouts and she had to pull nurses from the off-site ED. Additional patients for that day, 5-28-2026, were selected for review to see if documentation problems were isolated or widespread. Four additional patients were selected (Patient #21, #22, #23, and #24) with problems found with 3 (Patient #21, #22, and #23) of the 4 additional records reviewed. Patient #21 Patient #21 presented to the ED on 5-28-2026 at 10:28 AM. The record reflected that a 20 gauge IV was placed in the RAC. No recorded documentation of the IV removal was found. Patient #22 Patient #22 presented to the ED on 5-28-2026 at 10:38 AM. The patient arrived via ambulance with a peripheral IV already placed by EMS (Emergency Medical Services) personnel. The patient was given a 1000 milliliters normal saline IV fluid bolus starting at 11:34. No end time was documented. The record did not reflect how long the administration of fluid took/how rapidly it was given. The patient was admitted to the hospital, so no IV catheter removal was necessary. Patient #23 Patient #23 presented to the ED on 5-28-2026 at 10:30 AM. No physician order for an IV catheter was found. No nursing note for the placement of the catheter was found. No IV medication was ordered or administered. A nursing note was found for 5/28/2026 at 3:02 PM that read, “Discontinued IV catheter intact, bleeding controlled, dressing applied, No redness/swelling at site. Patient #8 Patient #8 presented to the ED on 5-21-2026 at 02:54 AM. Documentation of peripheral IV insertion and medication administration were found. No record of removal of peripheral IV was found. Patient #10 Patient #10 presented to the ED on 5-15-2026 at 02:37 AM. Record was found of IV insertion as follows: “05/15 03:00 Inserted Peripheral IV: 20-gauge right ac and blood collected. Labs drawn Sent per order to lab. Blood drawn by ED RN.” No record was found of the removal of the IV catheter. Patient #16 Patient #16 presented to the ED on 5-8-2026 at 01:41 AM. A record of a failed attempt at inserting a peripheral IV catheter was found as follows: “05/08 02:50 Missed attempts X 2 right hand and palmar aspect of left forearm Bleeding controlled, dressing applied, catheter tip intact.” The record reflected that the patient received IV medications. And that an IV catheter was removed at discharge. However, no record was found of a successful IV catheter insertion. Patient #20 Patient #20 presented to the ED on 5-5-2026 at 11:59 PM via ambulance. The patient had an IV catheter placed by EMS personnel. Records of removal prior to discharge was found. The record showed that 1000 milliliters of normal saline was ordered. It started at 02:11 AM but the record did not reflect how long the administration of fluid took/how rapidly it was given.”

“INTRAOPERATIVE ANESTHESIA RECORD CFR(s): 482.52(b)(2) [The policies must ensure that the following are provided for each patient:] An intraoperative anesthesia record. This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure anesthesia records were complete and accurate in 4 of 13 sampled patients (Patient ‘s 8, 9, 10 and 12). The facility failed to: A.) Ensure medication administration was accurately documented on Patient #’s 8, 9 and 12. B.) Ensure complete documentation of a safe hand off of duties on Patient #;s 9 and 10. This deficient practice had the likelihood to affect all patients receiving surgery services. Findings include: Patient #8 Review of the clinical record on Patient #8 revealed she was a 57-year-old female who presented to the facility on 12/30/2025 for a surgical procedure. According to a procedural consent Patient Heard was having a laser lithotripsy and possible right stent placement. According to a history and physical dated 12/29/2025 Patient #8 was allergic to aspirin, opioids, prednisone eyedrops and propofol. According to the anesthesia intra-operative dated 12/30/2025 the following were listed as administered: Lopamidol- low -osmolar iodine based contrast Ketamine- anesthetic agent Zemuron -neuromuscular blocking agent Ofimev- acetaminophen Zofran- antiemetic Lidocaine- anesthetic Sevoflurane- inhaled anesthetic agent Neo-synephrine- decongestant Glycopyrrolate- anticholinergic Etomidate- anesthetic agent Precedex- sedative The medications Propofol (anesthetic agent), Fentanyl (opioid), and Succinylcholine (paralytic agent) were on the form, but were all marked through (indicating not being given).There was no documentation as to who marked through the medications. There was a section on the form for staff to document each medication total that was administered during the procedure. The only medication that staff gave a total amount for that was administered during the procedure was Ketamine (anesthetic). During an interview on 05/12/2026 after 11:06 a.m., Staff #’s 4 and 16 confirmed the documentation. Patient #9 Review of the clinical record on Patient #9 revealed she was a 66-year-old female who was admitted into the facility on 10/27/2025 for a surgical procedure. Review of the anesthesia consent dated 10/27/2025 revealed the anesthesiologist Staff #20 and Certified registered nurse anesthetist (CRNA) Staff #19 would be providing anesthesia. Review of anesthesia records revealed some of the following: Patient #9 received anesthesia from 09:29 a.m.-2:32 p.m. There was documentation that Staff #21 was a relief CRNA who was in the room from 11:25 a.m. to 11:54 a.m. During this time frame the medications Etomidate and albumin were administered. There was no way in the record to tell who administered the medication. Staff were not initialing or documenting who administered the medications when there were multiple anesthesia staff working on a case. Staff #19 (CRNA) was not listed on the anesthesia consent as being on the surgery case. Staff failed to ensure documentation showed a safe handoff of duties. There was also documentation underneath medication list that the total amounts that Patient #9 received of the medications Propofol and Dilaudid. The medications were listed as follows: The total amount of Propofol administered was listed on the line where the total of amount of Zemuron was to be documented. The total amount of Dilaudid administered was listed on the line where the total amount of Decadron was to be documented. During an interview on 05/12/2026 after 3:21 p.m. Staff #’4 and 6 confirmed the documentation. Patient #10 Review of the clinical record of Patient #10 revealed he was a 68 year-old male who presented to the facility on 05/11/2026. According to a pre/post anesthesia evaluation form dated 05/11/2026 revealed Patient #1 had a lower anterior resection. There was a section on the anesthesia evaluation form that read” Discussed Anesthesia Plan and Risks/Benefits/Alternatives of Anesthesia with Patient/Family Who Voiced Understanding and Consent. The physician signed and dated the area but failed to document a time to indicate this was done prior to the start of the procedure. Review of the anesthesia intra-operative sheet dated 05/11/2026 revealed Staff # 23 (CRNA) and Staff #22 was the anesthesiologist on the case. According to the anesthesia intra-operative sheet anesthesia start time was 2:34 p.m. and the stop time was 5:20 p.m. There was a relief CRNA who replaced another Staff #23 CRNA at 4:20 p.m. The relief CRNA signature was not legible and they failed to document their time out of the procedure. After 4:15 p.m. to 5:15 p.m. Patient #10 received the medications Zemuron, Precedex and was receiving Sevovlurane. There was no documentation as which CRNA was administering the medication. Staff failed to ensure documentation showed a safe handoff of duties. During an interview on 05/12/2026 after 1:29 p.m., Staff #15 confirmed the documentation Patient #12 Review of an anesthesia form dated 05/13/2026 on Patient #12 revealed she was a 31-year-old female who had a laparoscopic bilateral tubal ligation on 05/13/2026. Review of the anesthesia form revealed Patient #12 was given the sedative Precedex. Etamidine had been marked through and the sedative Precedex written in, but staff failed to mark out the mg (milligrams). Precedex is a sedation which is measured in micrograms not milligrams. There was not a total amount of the Precedex given which included if it was administered in micrograms. There was no documentation to show to who marked out the medication on the form and failed to document identifying information. During an interview on 05/13/2026 after 11:11 a.m., Staff #18 confirmed the documentation. Staff #18 confirmed that they did not have a way of determining what medications the relief CRNA’s administered. Review of a facility’s policy named “Pharmacy-Medication Administration Policy” revealed the following: “ ...Each dose of medication administered is to be properly recorded in the patient’s medical record ...” Review of a facility policy named “Medical Record Documentation Policy” dated 02/14/2025 revealed the following: “ ... It is the policy of the practice to assure the medical record is legible, documented appropriately and with clarity, signed and authenticated with a date, and completed in a timely manner..” ...General Documentation Requirements ... ...14. The medical record will not be altered. Errors will be legibly corrected so that the reviewer can draw inference as to their origin. These corrections or additions will be dated, timed, and legibly signed or initialed ... ...19. All notes will be dated, preferably timed, and signed by the author ...””

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 10135 Based on observation, interview and record review the facility failed to ensure supplies were maintained in a safe manner. The facility to ensure expired supplies were not available for patient use in 1 of 1 emergency department (ED) carts (crash cart and airway box). This deficient practice had a likelihood to affect all patients who presented to the ED. Findings include: During an observation of the ED on 09/16/2025 after 2:44 p.m., the following was found in an ED crash cart and airway cart: Two Pro-Vent Arterial Blood Sampling Kits expired on 07/23/2025 One Sterile intravenous start kit expired on 08/31/2025 Three intravenous catheters expired on 08/31/2025 McGill clamps which had been sterilized in a closed position and were in a closed peel package. The expiration date of the package was 08/28/2024 (over 1 year ago). Taper Guard Evac Oral Tracheal tube expired on 06/02/2025 Staff #6 confirmed the expired items. During an interview on 09/16/2025 at 4:06 p.m., Staff #16 revealed she was overseeing the stocking of the carts. The carts were supposed to be checked monthly for expired items. She had a unit clerk who was responsible for that, but the unit clerk said she was behind on checking them. Review of a facility’s policy named “Materials Management-Stock Rotation and Expiration Policy” dated 06/15/2022 revealed the following: “..Policy Expired products and devices shall not be made available for patient use. All stock will be rotated and expiration dates on products should be checked and products with the longer expiration date moved to the back ...””

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure the emergency department (ED) was organized in a manner to provide safe patient care in 5 of 22 sampled patients (Patient #’s 1, 2, 3, 5 and 8). The facility failed to ensure: A) Patient #1 who presented with suicide ideation and who was deemed as high suicide risk had documentation of supervised monitoring. B) Patient #2 who presented with complaints of edema had a complete assessment which included an emergency severity index (ESI) and vitals signs on presentation or before discharge. C) Patient #3 had physician’s orders for dressing changes that were provided and received pain medication in a timely manner. D) Patient #’s 5 and 8 had documentation of explanation of risk when leaving against medical advice (AMA). This deficient practice had the likelihood to cause harm to all patients presenting to the Emergency department (ED). Findings include: Patient #1 Review of an ED record on Patient #1 revealed he returned to the ED on 07/31/2025 at 12:17 a.m.. Patient #1 complained of having thoughts of hanging himself. There was documentation that Patient #1 was schizophrenic and had not taken his medications for 3 years. At 1:24 a.m. a physician’s order was written for suicide precautions. At 1:43 a.m. Patient #1 was triaged as an ESI level 2 (high risk situation) and was assessed to be at moderate suicide risk. At 2:09 a.m., the physician documented that Patient #1 had acute psychotic break, anxiety disorder, depression, drug induced psychosis, drug withdrawal and homicidal ideation. At 2:30 a.m., there was documentation that Patient #1 walked out, but security found Patient #1 in the parking lot and escorted him back into the facility. At 6:53 a.m., Patient #1 was discharged home. At 8:19 a.m., the physician documented that Patient #1 was allowed to metabolize to sobriety. Denies suicidal /homicide ideation. During an interview 09/16/2025 at 11:14 a.m., Staff #6 confirmed that Patient #1 should have been on 1:1 monitoring, but she could not find documentation of the monitoring. During an interview on 09/16/2025 after 12:14 p.m., Staff #8 said that staff were supposed to download a packet which included a form for monitoring. They physically completed the form and then it was scanned into the chart. Staff #8 said she could not find that one was completed on Patient #1. According to the facility’s from named “Suicide Conversion to Safe Room Check List” dated 10/2021 revealed the following: “On initiation of Suicide Precautions and at the beginning of every shift (and every 12 hours), complete safety checks below. Place initials next to safety check item in appropriate time slot.” According to the facility’s from named “Suicide Patient Observer Monitoring Checklist” dated 04/2020 revealed the following: “Level of Suicide Risk (C-SSRS): ...Moderate (Nurse to notify MD and MD to order Mental health professional face-to-face consult before leaves the area/unit, Consider more frequent observation (every 15 min. checks) ...” Patient #2 Review of the Emergency department (ED) record on Patient #2 revealed she was a 57-year-old female who presented to the ED with complaints of increased fluid and swollen feet on 06/09/2025 at 6:52 p.m. There was documentation at 7:07 p.m., 7:17 p.m. and 7:32 p.m. that Patient #2 was called for triage during patient rounding and there was no response. At 7:56 p.m. staff documented that Patient #2 had left the ED. Admission paperwork dated 06/09/2025 revealed documentation that the patient left without being seen. At 9:10 p.m. on 06/09/2025 (same day) there was documentation that Patient #2 arrived at the ED. At 9:25 p.m., an intravenous catheter was inserted and at 9:40 p.m. it was discontinued. At 9:42 p.m. there was physician documentation that Patient #2 was there for bilateral edema. The patient had been seen at Hospitality ED that morning for the same and was discontinued with a diagnosis of edema. Her daughter brought her here because she was saying her feet hurt, but she denies symptoms at this time. There was documentation that Patient #2 said she was fine and wanted to go home. At 9:48 p.m., there was documentation that Patient #2’s daughter screamed at the registered nurse (RN) to mind her business and security was called to the bedside. There was documentation that Patient #2 refused treatment with the provider at bedside. Patient #2’s daughter insisted that they were not doing anything for her, but the nurse explained that Patient #2 was denying treatment and stating that her daughter insisted she come when she otherwise felt fine. At 9:49 p.m. Patient #2 was discharged home and at 9:50 p.m. she left the ED. There was no documentation of an ESI level during triage or vital signs at all on the chart. Review of the facility’s policy named “ED-Standards of Care” dated 08/2024 revealed the following: “...A. Assessments All patients, including pediatric patients, will have a complete documented assessment and reassessment to include subjective and objective data ... ...2. Emergency Severity Index (ESI) levels will be used to determine frequency of reassessments. All reassessments will be completed according to ESI level as well as with any change or deterioration in patient condition ... ...4.ESI levels to determine frequency of vital signs. All VS to be taken and documented more frequently if condition warrants. a. ESI level 1 to have vital signs completed and documented at minimum every 15 minutes until stable, then documented at a minimum of every 1 hour. b. ESI level 2 and ESI level 3 to have vital signs completed and documented at minimum every 1 hour c. ESI level 4 and ESI level 5 to have vital signs completed and documented at minimum every 2 hours d. All patients to have a full set of vitals done within 60 minutes of discharge ...” Patient #3 Review of the ED record on Patient #3 revealed she was a 26 -year- old female who presented to the ED on 04/19/2025 at 6:28 p.m. Patient #3 had complaints of cutting the tip of her right thumb off and was given an ESI level of 4 (semi-urgent). At 6:43 p.m. Patient #3 was assessed as having a pain score of 9 out of 10 (severe pain). At 7:11 p.m. the finger was described as having a laceration to the palmar aspect of the distal phalanx of the right thumb, full thickness, 0.5 to 2.5 centimeters long and bleeding moderately. At 7:12 p.m., a Coban wrap and Telfa 4x4 times two dressings were applied to the right thumb. At 7:14 p.m., a physician’s order was written for “Wound Care”. There was no directive on what type of wound care to provide. At 7:42 p.m.(30 minutes after first dressing change), Patient #3 received an intramuscular dose of the nonsteroidal anti-inflammatory medication Toradol 30 milligrams and 1000 milligrams of Tylenol by mouth. At 7:49 p.m. (7 minutes later), there was documentation of Quit clot and pressure dressing to right thumb wound. Quit clot being a dressing impregnated with a mineral which stops bleeding. At 8:04 p.m., Patient #3 was discharged home. The pain medication was administered 30 after the first dressing change and 7 minutes before the pressure dressing was applied. The pain medication was not administered timely to assist with pain relief prior to the dressing changes. There were no orders for the dressing changes that were provided on Patient #3. During an interview on 09/16/2025 after 12:29 p.m., Staff #6 confirmed there were no specific orders for wound care and confirmed the time the medication was given for pain relief. During an interview on 09/17/2025 at 1:05 p.m., Staff #10 confirmed he gave the pain medication and the dressing changes. Staff #10 said the physicians normally give the wound care orders verbally.”They say what the want on it or say put what you think it needs on it.” Staff #10 said he could not remember the physician giving him a wound care order for Patient #3. He remembered they talked about the wound and the physician said it was fine what had already used. Patient #5 Review of the ED record of Patient #5 revealed she was a 57- year -old female who presented to the ED on 07/16/2025 at 6:40 a.m. with complaints of chest pain. Patient #5 was triaged at 6:44 a.m. and given an ESI level of 2 ((high risk situation). Patient #5 had a blood pressure of 137/77, pulse of 63, respirations of 18, temperature of 98.3 degrees Fahrenheit and an oxygen saturation of 95 percent on room air. At 6:41 a.m. an electrocardiogram (EKG) was done. At 6:49 a.m. the following was documented “Pt states she was brought to the wrong hospital and would like to go to CGSMC, MD notified and aware.” At 6:51 a.m. there was documentation on Patient #5’s admission consents that she had eloped. There was another form dated 07/17/2025 at 7:02 a.m., that showed that Patient #5 was coded as leaving against medical advice. There was no documentation of a disposition in the record of the Patient #5 at discharge or documentation about a discussion about the risk of leaving against medical advice (AMA). During an interview on 09/16/2025 at 12:29 p.m., Staff #6 confirmed not being able to find why Patient #5 left or her disposition before leaving. There was no AMA form that could be found on the record. Patient #8 Review of the ED record of Patient #8 revealed she was a 26- year -old female who presented on 07/17/2025 at 8:25 a.m.. Patient #8 had complaints of pelvic pressure with contracting and gushing vaginal bleeding. At 8:30 a.m. Patient #8 was triaged and assessed with an ESI level of 3(semi-urgent). Patient #8 had a blood pressure of 130/91, pulse of 91, respirations of 17, temperature of 98.6 degrees Fahrenheit, oxygen saturation of 99 percent on room air and a pain level of 8 out of 10. At 9:03 a.m. an intravenous (IV) catheter was started and labs started. At 10:30 a.m. Patient #8 stated “Just gonna go somewhere else.” Nursing staff documented that Patient #8’s (IV) catheter was discontinued. At 10:31 a.m. there was documentation that Patient #8 left the ED and that she eloped. There was a form dated 07/18/2025 at 10:42 a.m., staff documented that Patient #8 was coded as leaving against medical advice. There was no documentation of a disposition in the record of the Patient #8 at discharge or documentation about a discussion about the risk of leaving against medical advice (AMA). During an interview on 09/17/2025 after 11:15 a.m., Staff #8 confirmed not being able find documentation of Patient #8’s status at discharge nor being able to find an AMA form on the record. Review of the facility’s policy named “Disposition of ED Patients” dated 05/16/2023 revealed the following: “ ...2. Discharge ...d. Complete disposition shall be documented in the Emergency Department Medical Record ...” ...5. AMA a. Patients who have refused/declined to complete care as expressed in the patient’s best interest by the Provider on Duty shall have a disposition of AMA (Against Medical Advice) on the Emergency Department Record by the Provider on Duty. b. Reasonable efforts shall be made by the Provider on Duty &/or the Registered Nurse to discuss the risks and complications with patient &/or family prior to disposition of AMA on the Emergency Department Record c. AMA form shall be completed and placed on the patient’s medical record d. Documentation in the medical record shall be made to include communications with patient &/or family about risk, complications, and efforts made to prevent AMA disposition. e. Disposition shall be documented in the Emergency Department Medical Record. 6. Eloped a. Patients who have been discover to no longer be in the department after being Triaged and /or Treated shall have a disposition of Eloped on the Emergency Department Record b. Provider on Duty shall be informed of the patient’s elopement c. Complete disposition shall be documented in the Emergency Department Medical Record ...””

“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: 10135 Based on interview and record review the facility failed to provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed in 1 of 22 patients who presented to the Emergency department (Patient #22). Patient #22 had presented to Emergency department (ED) on 06/19/2025 for suicide ideation and was discharged. Patient #22 had a return visit to the ED on 06/19/2025 for complaints of a headache. The facility failed to maintain a central log on Patient #22 on second ED visit on 06/19/2025. Refer to tag A 2405 for additional information. The physician refused to medically screen Patient #22 on the second ED visit on 06/19/2025. Refer to tag A 2406 for additional information.”

“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: 10135 Based on interview and record review, the facility failed to maintain a central log on 1 of 22 patients who presented to the emergency department (ED) seeking assistant (Patient #22). Patient #22 had presented to Emergency department (ED) on 06/19/2025 for suicide ideation and was discharged. Patient #22 had a return visit to the ED on 06/19/2025 for complaints of a headache and the physician refused to medically screen the patient and staff failed to document the Patient #22 on the central log. This deficient had the likelihood to cause harm to all patients presenting to the ED seeking a medical screening. Findings include: Review of the ED record on Patient #22 revealed she was a 52- year- old female who presented on 06/19/2025 at 9:47 a.m.. At 9:52 a.m. Patient #22 was triaged and voiced complaints of suicidal ideations. Patient #22 was classified with an emergency severity index of 2 (high risk). There was documentation that Patient #22 had diagnoses which included bipolar disorder, diabetes mellitus, and schizophrenic affective disorder. During the ED visit Patient #22 received a triage, labs, mental health assessment, monitoring, and a physician screening. At 3:04 p.m., the physician wrote an order to discharge Patient #22. At 6:52 p.m., there was documentation that Patient #22 left the ED prior to her transportation getting there. An emergency medical transport trip report dated 06/19/2025 revealed they arrived at their destination to pick up Patient #22 at 8:25 p.m. and she was taken to the hospital at 8:35 p.m. Patient #22 had complaints of her head hurting. There was documentation in the facility’s ED record that Patient #22 arrived at the hospital at 8:35 p.m. via the fire department and left the ED with the fire department at 8:45 p.m. (10 minutes later). There was no triage or medical screening performed on Patient #22 during the second visit. Review of the central log for 06/19/2025 revealed no documentation of Patient #22 returning to the ED. During an interview on 09/17/2025 after 1:41 p.m. with the Staff #3 Chief nursing officer (CNO), Staff #6 Quality Director and Staff #5 Risk Manager all in attendance the following was revealed: Staff #3 CNO reported that they had received notification that Patient #22 had been in the ED, evaluated by community health, cleared and discharged home. Within an hour after leaving Patient #22 was picked up at a gas station by emergency medical services and brought back to their hospital. Staff #18 (Physician) did not make a good decision. He told Patient #22 he was not going to see her and told the charge nurse not to triage the patient and to call security. Staff #18 (Physician) and Patient #22 ended up on the floor and the doctor started pulling the patient by her leg down the hallway a few feet. A full investigation was completed and Staff #18 (Physician) was no longer there and the charge nurse was written up. The Medical Director was talked to after Staff #18’s (Physician ) next work rotation which was Friday night June 20th. Staff #3 CNO said they had re-trained staff on their policies, but they had not self-reported the incident to anyone. Review of the facility’s “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy dated 07/14/2022 revealed the following: “... 1.GENERAL EMTALA OBLIGATIONS;CENTRAL LOG... ...B. Central The Hospital shall maintain a Central Log on each individual who comes to the Emergency Department seeking assistance. The purpose of the Central Log is to track the care provided to each individual who comes to the Hospital seeking care for an emergency medical condition, and should include all patients regardless of whether they actually received treatment...””

“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: 10135 Based on observation, interview and record review, the facility failed to provide an appropriate medical screening exam (MSE) to determine if an emergency medical condition existed in 1 of 22 patients who presented to the Emergency department (Patient #22). Patient #22 had presented to Emergency department (ED) on 06/19/2025 for suicide ideation and was discharged. Patient #22 had a return visit to the ED on 06/19/2025 for complaints of a headache and the physician refused to medically screen the patient.. This deficient had the likelihood to cause harm to all patients presenting to the ED seeking a medical screening. Findings include: Review of the ED record on Patient #22 revealed she was a 52- year- old female who presented on 06/19/2025 at 9:47a.m. At 9:52 a.m. Patient #22 was triaged and voiced complaints of suicidal ideations. Patient #22 was classified with an emergency severity index of 2 (high risk). There was documentation that Patient #22 had diagnoses which included bipolar disorder, diabetes mellitus, and schizophrenic affective disorder. During the ED visit Patient #22 received a triage, labs, mental health assessment, monitoring, and a physician screening. At 3:04 p.m., the physician wrote an order to discharge Patient #22. At 6:52 p.m., there was documentation that Patient #22 left the ED prior to her transportation getting there. An emergency medical transport trip report dated 06/19/2025 revealed they arrived at their destination to pick up Patient #22 at 8:25 p.m. and she was taken to the hospital at 8:35 p.m. Patient #22 had complaints of her head hurting. There was documentation in the facility’s ED record that Patient #22 arrived at the hospital at 8:35 p.m. via the fire department and left the ED with the fire department at 8:45 p.m. (10 minutes later). There was no triage or medical screening performed on Patient #22 during the second visit. Review of the facility’s “Emergency Department/Critical Care Committee minutes” dated 07/02/2025 revealed documentation of an incident involving Patient #22. It was documented that on 06/19/2025 at 8:35 p.m.”patient arrived by Longview Fire Department, presenting to be seen. Physician met the LFD EMS Crew at the nurse’s station at (8:37 p.m.) and stood in close proximity to the patient. The patient was animated and appeared to be upset. As the patient rurned (meant turned) from her back to the provider to facing the provider, her arm grazed the provider’s abdomen. The provider reached out and the patient fell to the floor. The provider grabbed the patient by the leg and physically drug the patient 3-5 feet on the floor. The provider then reached down in an attempt to assist the patient to her feet. The patient was escorted out of the building by police. The provider directed ED staff to not re-register the patient.” The facility documented in the “Emergency Department/Critical Care Committee minutes” the “Physician displayed behavior incompatible with code of conduct at LMRC, committee to send letter to physician. Review Outcome Score:3- Treatment inappropriate, but adverse impact on the patient was minor or minimal, temporary or permanent harm. A. Care by the Physician:5. Treatment was not timely or not performed in the proper sequences. B. Contributing Causes: 2. Judgement of the physician 3. Failure by physician to comply bylaws, rules and regulations.” During an interview on 09/17/2025 after 1:41 p.m. with the Staff #3 Chief nursing officer (CNO), Staff #6 Quality Director and Staff #5 Risk Manager all in attendance the following was revealed: Staff #3 CNO reported that they had received notification that Patient #22 had been in the ED, evaluated by community health, cleared and discharged home. Within an hour after leaving Patient #22 was picked up at a gas station by emergency medical services and brought back to their hospital. Staff #18 (Physician) did not make a good decision. He told Patient #22 he was not going to see her and told the charge nurse not to triage the patient and to call security. Staff #18 (Physician) and Patient #22 ended up on the floor and the doctor started pulling the patient by her leg down the hallway a few feet. A full investigation was completed and Staff #18 (Physician) was no longer there and the charge nurse was written up. The Medical Director was talked to after Staff #18’s (Physician ) next work rotation which was Friday night June 20th. Staff #3 CNO said they had re-trained staff on their policies, but they had not self-reported the incident to anyone. Staff #5 Risk manager said they watched the video footage on Friday 06/20/2025 and that’s when they called it to the Medical Director’s attention. Observation of the video on 09/17/2025 after 1:41 p.m. confirmed what was documented in the committee minutes, medical record and the interviews. Review of the facility’s “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy dated 07/14/2022 revealed the following: “ ...II.MEDICAL SCREENING EXAMINATION ...B. Medical Screening When an individual comes to the emergency department (ED) requesting medical treatment, an appropriate MSE, within the capabilities of the ED(including ancillary services routinely available to the ED), shall be provided to determine whether an emergency medical condition (EMC) exists or, with respect to a pregnant woman having contractures, whether the woman is in labor. Pregnant women may be directed to the labor and delivery area of the hospital for their MSE, if the hospital has adopted and approved such a policy. These same requirements apply if a prudent layperson would believe the individual is in need of an emergency examination or treatment. The Hospital must apply the screening process that it would perform on any individual coming to the ED in a non-discriminatory manner and regardless of payor source or ability to pay ...” “..The MSE includes both a generalized assessment and a focused assessment based on the patient’s chief complaint, with the intent to determine the presence or absence of an EMC; all medical screenings do not have to be equally extensive..””

“SELF-ADMINISTRATION - DRUGS FROM HOME CFR(s): 482.23(c)(6)(ii) [The hospital may allow a patient (or his or her caregiver/support person where appropriate) to self -administer both hospital-issued medications and the patient’s own medications brought into the hospital, as defined and specified in the hospital’s policies and procedures.] (ii) If the hospital allows a patient to self-administer his or her own specific medications brought into the hospital, then the hospital must have policies and procedures in place to: (A) Ensure that a practitioner responsible for the care of the patient has issued an order, consistent with hospital policy, permitting self-administration of medications the patient brought into the hospital. (B) Assess the capacity of the patient (or the patient’s caregiver/support person where appropriate) to self-administer the specified medication(s) and also determine if the patient (or the patient’s caregiver/supplier person where appropriate) needs instruction in the safe and accurate administration of the specified medication(s). (C) Identify the specified medication(s) and visually evaluate the medication(s) for integrity. (D) Address the security of the medication(s) for each patient. (E) Document the administration of each medication, as reported by the patient (or the patient’s caregiver/support person where appropriate), in the patient’s medical record. This Standard is not met as evidenced by: 47892 Based on document review and interview, the hospital failed to follow its policy titled “Pharmacy- Patient’s Own Medication Storage and Destruction Policy” in 1 (patient #1, #2, and #3) of 3 patient medical records reviewed. A medical record review of Patient #1 was conducted on 6/25/25 after 1:00 PM. During the document review, it was noted that Patient #1was complaining of a headache. Patient #1 stated that the pain in his head was related to his blood pressure. Patient #1 explained to Staff RN #13 that it had been hurting since he woke up this morning and that his blood pressure medication alleviates the headache. Patient #1 stated that his daughter had his blood pressure medication and asked if he could take one of his pills. Staff #13 called and got a verbal order from Physician #18 to give the patient his home blood pressure medication. Staff #13 gave Patient #1 his home medication around 6:15 AM on 4/29/25. An interview with Staff #13 was conducted on 6/25/25 after 1:00 PM. Staff #13 was asked if she had the Pharmacist come down and verify that the medication she was giving Patient #1 was the correct medication. Staff #13 stated that she did not verify the medication with the Pharmacist. Staff #13 agreed that she did not follow the facilities policy titled “Pharmacy- Patient’s Own Medication Storage and Destruction Policy”. A document review was conducted with Staff #1 on 6/25/2025 after 1:00 PM. The document was the hospital policy titled “Pharmacy- Patient’s Own Medication Storage and Destruction Policy,” effective date 10/2003 and reviewed on 01/2024. The policy states: “Policy: Medications that have been brought in by patients at admission will be sent home with the family. If not, the medications will be stored in the Pharmacy Department in a specific location and according to a specific procedure. Procedure: Drugs that are not to be used during the patient’s stay at the hospital will be given to the patient’s family to take home. In the event that the medications cannot be sent home, the medications are sent to the Pharmacy department along with a copy of the “Patient’s Personal Medications” sheet provided by the pharmacy. This sheet provides the patient’s name and an itemized list of the medications. The sheet indicates the patient’s name, room number, patient ID number, physician, who identified the medication as well as the signature of the nurse forwarding the bag to the pharmacy and the patient’s signature ...” An interview was conducted with staff #1 on 6/25/2025 after 1:00 PM. Staff #1 was asked if the hospital followed their policy titled “Pharmacy- Patient’s Own Medication Storage and Destruction Policy”. Staff #1 confirmed that they did not follow their policy.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 48749 Based on interview and record review, the facility failed to ensure that a patient presenting to the Emergency Department (ED) with an injury received stabilizing treatment before discharge in 1 of 1 patient (Patient #2). This deficient practice had the likelihood to cause harm to all patients presenting to the ED with injuries. Patient #2 was a 14-month-old child who had been bitten on the face by a dog, patient presented to the ED on 07/06/24, there was no documentation of wound care prior to discharge. Patient #2 was taken by the mother to facility #2 where the patient was assessed, wound care was provided, antibiotics were administered, and the patient was admitted for observation. Findings include: A review of the Electronic Health Record (EHR) for Patient #2 revealed the patient presented to the ED on 07/06/2024 at 2:32 PM with a complaint of a dog bite to the right cheek. Staff #11(Registered Nurse) documented that the wound was “red and swollen.” In addition, Staff # 11 documented that the bite “occurred around 1:00 PM and no care was given before coming to the ED.” Further review of the EHR, revealed there was no documentation found that the wound was cleaned by Staff # 11. A review of the Electronic Health Record (EHR) revealed Patient #2 was evaluated by the Emergency Room Physician (Staff #16) on 07/06/2024 at 4:23 PM. Staff #16 documented that Patient # 2 had “2 minor abrasions/lacerations to the right cheek. These are both about 5 millimeters in length. Neither of them is gaping and neither requires any kind of cosmetic closure. They did not go through into the oral mucosa at all, and dentition is intact.” A review of the progress note for Physician #16 revealed there were no orders written for wound care, antibiotics, and/or antibiotic prescriptions. Patient #2 was discharged home with instructions to clean the wound. A review of the facility’s “ED Standards of Care Manual” policy dated 07/16/2024 revealed: “PURPOSE: * To provide evidence based medical care in the Emergency Department (ED) * To provide guidelines for Emergency Department (ED) staff to follow to ensure high quality, safe patient care.” A review of the facility’s “Emergency Medical Treatment and Active Labor Act (EMTALA)” policy dated 07/14/2022 revealed: “INTRODUCTION The purpose of this policy is to define the relevant terms and provide an overview of the Emergency Medical Treatment and Labor Act (EMTALA), the regulations and rules promulgated thereunder, and the State Operations Manual interpretive guidelines. This Emergency Medical Treatment and Patient Transfer policy is based on federal law relating to the obligations of hospitals to provide screening and emergency medical treatment and the appropriate transfer of individuals between hospitals. The treatment and transfer of an individual shall not be predicated upon arbitrary, capricious, or discrimination based upon race, color, religion, national origin, age, sex, sexual orientation or identification, diagnosis, physical condition, economic status, payor source, ability to pay, or other protected category. (Individual Hospitals should determine whether their state laws and regulations have any additional or different requirements than those set forth herein and ensure the Hospital’s emergency medical treatment and patient transfer policy and procedures are in compliance with all applicable laws. Any apparent conflict between the state and federal laws should be discussed with the Legal Department.) Stable for Discharge: A patient is stable for discharge, when within reasonable clinical confidence, it is determined that the patient has reached the point where his/her continued care, including diagnostic work-up and/or treatment, could reasonably be performed as an outpatient, provided the patient is given a plan for appropriate follow-up care with the discharge instructions; or the patient requires no further treatment and the treating physician has provided a written documentation of his/her findings.” The surveyor requested a wound care policy from the facility. No policy was provided. An interview was conducted with Staff #13 (Director of ED- offsite) on 08/20/2024 at 10:30 AM. Staff #13 was asked about wound care for a patient with a dog bite. Staff #13 reported, “I’m sure it was cleaned.” The chart was reviewed with Staff #13 and the Surveyor. Staff #13 stated, “I do not see any documentation that wound care was done.” Staff #13 was asked if the facility or Emergency room staff receive any training related to wound care. Staff #13 stated, “There is not any specific wound care training that we do with the staff.” An interview was conducted with Staff #10 (Risk Manager) on 08/20/2024 at 10:45 AM. Staff #10 stated, “I am sure our nurses did wound care and maybe just forgot to document it. We should have at least done some wound care.” A review of the medical record with the Risk Manager and the Quality manager revealed there was no wound care documentation for Patient #2. A review of the EHR from facility #2 revealed that Patient # 2 reported to the ED on 07/07/2024 at 4:59 PM with a complaint of worsening signs and symptoms of a dog bite to the face. The triage nurse documented “right side of face, now draining, hot to touch.” Further review of the EHR for facility #2 revealed Patient #2 was admitted to the facility for observation for facial Cellulitis, Acute Thrombocytosis, Acute Leukocytosis, and Acute Dehydration. Patient #2 received lab work, wound cultures, intravenous fluids, intravenous antibiotics, pain medication, and wound care during the admission. A review of the Centers for Disease Control and Prevention reveals the following recommendations for dog bites; “1. Make sure your pets are up-to-date on their rabies vaccines. 2. Keep wildlife away for both human and animal safety. 3. Wash bites or scratches immediately with soap and water. 4. Seek medical care shortly after potential exposures. 5. Rabies Postexposure Prophylaxis (PEP) includes wound washing, human rabies immune globulin (HRIG), and a four-dose series of vaccines.””