Mitchell County Hospital District

“PREMISES ARE CLEAN AND ORDERLY CFR(s): (4) The premises are clean and orderly; and This Standard is not met as evidenced by: 51905 Based on observation, record review, and interviews, Facility A failed to maintain a physical environment where patients and staff can function safely, and equipment and supplies are stored in proper spaces for 1 or 5 emergency department rooms. This failure had the potential to expose patients, staff, and visitors to injury from unsecured sharps. Observation of Facility A’s Emergency Department: At 9:46 A.M., upon examination of trauma room #2, it revealed multiple unsecured sharps. The sharps were located on an open cart and in unlocked cabinets and shelves. The unsecured sharps included: 4 Laceration Trays 4 5-0 Ethilon Suture Kits 1 4-0 Vicryl Suture Kit 1 3-0 Chromic Gut Kit 4 Suture Tray Kits 2 Pleural Vac Kits 2 Arrow Needles 5 Spine Needles 3 2-0 Ethilon Suture Kits 1 Central Line Kit 7 Scalpels 2 19g Filter Needles 2 18g Filter Needles 1 20g IV Needle 1 Thorapara 8fr Catheter At 9:50 A.M., the Chief Nursing Officer, Staff A, and the Director of Quality, Staff B, collected the supplies and temporarily moved them in secure locations until the facility developed a long-term solution. Interview: On 3/30/2026 at 9:46 A.M., the Chief Nursing Officer, Staff A, stated that an ED Supply Checklist is maintained by the Facility’s House Supervisor to monitor the supplies. Staff A stated the facility would add monthly audits during rounds to ensure items remain secured and up-to-date.”

“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: 51905 Based on observation, record review, and interview, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Based on observation, record review, and interviews, Facility A failed to perform an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if 1 of 20 patients (Patient #1) had an emergency medical condition (EMC). Patient #1 presented to Facility A’s emergency department requesting medical care with a chief complaint of a fall with head strike. Staff at Facility A directed the patient to another hospital because the CT [computed tomography] scanner was out of service. Patient #1 did not receive a medical screening exam (MSE) to determine if they were experiencing an emergency medical condition before leaving the facility.”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to maintain a central log on each individual who came to the emergency department for 1 of 20 patients (Patient #1). This failure had the potential to impede patient tracking and hinder EMTALA oversight. Record Review: Review of Patient #1’s Medical Record from Facility A: On 02/05/2026, Patient #1 presented to Facility A’s emergency department requesting medical care with a chief complaint of a fall with head strike. The facility had no documentation that Patient #1 presented to the facility ED. There was no chart for Patient #1 created. Patient #1 did not receive a medical screening examination to rule out any emergency medical conditions. Review of the ED Registration Security Footage: On 02/05/2026 at 1:01 P.M., Patient #1 was seen presenting to Facility A’s emergency department registration desk with a jailer via wheelchair. 1:02 P.M.: The clerk, Staff F, was seen walking behind the desk to the physician area. 1:03 P.M.: Staff F spoke with Patient #1 and the jailer. 1:04 P.M.: Patient #1 and the jailer were seen leaving the facility. The video footage did not have audio capabilities. Review of Facility A’s Policy & Procedure, Effective 3/5/2008: “Admission Priorities Priorities of admission are directly related to the degree of medical urgency of the patient’s condition: Patients will be promptly upon verification of the medical need for non-elective admissions, either as emergency admissions through the emergency departments at [Facility A], or as other emergency admissions including emergency transfers from other facilities” (Admission Priorities, Page 1). “B. Urgent Admissions Admitting Receive admission notice; document encounter, travel to patient’s location for interview ...” (Urgent Admission, Page 4). “B. Urgent Admissions Patient Registrar Enter patient demographic, financial and admission information into the computer system; generate an inpatient admission;” (Urgent Admissions, Page 6). Interviews: On 3/30/2026 at 2:33 P.M., the ED Registration Clerk, Staff F, stated that Patient #1 and the jailer presented to the ED registration desk on 02/05/2026. Staff F stated that they did not register Patient #1 because the jailer stated that they would take Patient #1 to another facility. On 3/30/2026 at 3:46 P.M., the ED Physician Assistant, Staff C, stated he remembered Patient #1 presenting to the ED on 2/5/2026 with a chief complaint of dizziness. Staff C verified that the patient was not registered and had no paperwork. 3/31/26 at 12:06 P.M, Director of Quality, Staff B, after reviewing the video footage of the reception desk, stated that Patient #1 presented to the ED registration desk on 02/05/2026 at 1:01 P.M.”

“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: 51905 Based on observation, record review, and interviews, Facility A failed to perform an appropriate medical screening examination (MSE) in the emergency department (ED) to determine if 1 of 20 patients (Patient #1) had an emergency medical condition (EMC). Patient #1 presented to Facility A’s emergency department requesting medical care with a chief complaint of a fall with head strike. Staff at Facility A directed the patient to another hospital because the CT [computed tomography] scanner was out of service. Patient #1 did not receive a medical screening exam (MSE) to determine if they were experiencing an emergency medical condition before leaving the facility. Record Review: Review of Patient #1’s Medical Record from Facility A: On 02/05/2026, Patient #1 presented to Facility A’s emergency department requesting medical care with a chief complaint of a fall with head strike. The facility had no documentation that Patient #1 presented to the facility ED. There was no chart for Patient #1 created. Patient #1 did not receive a medical screening examination to rule out any emergency medical conditions. Review of the ED Registration Security Footage: On 02/05/2026 at 1:01 P.M., Patient #1 was seen presenting to Facility A’s emergency department registration desk with a jailer via wheelchair. 1:02 P.M.: The clerk, Staff F, was seen walking behind the desk to the physician area. 1:03 P.M.: Staff F spoke with Patient #1 and the jailer. 1:04 P.M.: Patient #1 and the jailer were seen leaving the facility. The video footage did not have audio capabilities. Review of Patient #1’s Medical Record from Facility B: On 02/05/2026 at 1:46 P.M., Patient #1 presented to Facility B’s emergency department with a chief complaint of a fall. The physician’s documentation noted that Patient #1 had fallen the previous night from ground-level and was also experiencing right shoulder pain and headaches (HPI, Page 2). Patient #1’s physical exam was within normal limits (Physical Examination, Page 3). Patient #1 received a CT head scan that revealed no acute intracranial abnormalities (CT Head, Page 4). Patient #1 was discharged with a diagnosis of an acute head injury and ground-level fall (Impression and Plan, Page 4). Review of Facility A’s EMTALA [Emergency Medical Treatment and Labor Act] Policy, Unknown Date: “1. Purpose To ensure compliance with the Emergency Medical Treatment and Labor Act by providing appropriate medical screening, stabilization, and transfer of all individuals presenting for emergency care, regardless of ability to pay” (Purpose, Page 1). “3. Policy Statement “ Provide an appropriate Medical Screening Examination (MSE) to all individuals requesting evaluation “ Determine whether an Emergency Medical Condition (EMC) exists “ Provide stabilizing treatment within the hospital’s capability “ Arrange appropriate transfer if necessary “ No individual will be delayed, denied, or transferred based” (Policy Statement, Page 1). Review of Facility A’s EMR Failure in ED Policy, Effective 5/2012: “IV. Policy: In the event of EMR failure, the ED staff will utilize the attached forms to document patient care” (Policy, Page 1). On pages 3 and 5 of the policy, blank forms for patient assessments are available to staff. Interviews: On 3/30/2026 at 1:38 P.M., the ED Registered Nurse, Staff E, stated that EMTALA means that if a patient presents for treatment to the facility, the facility cannot refuse care. On 3/30/2026 at 2:33 P.M., the ED Registration Clerk, Staff F, stated that Patient #1 and the jailer presented to the ED registration desk on 02/05/2026. Staff F spoke with the jailer, who stated the patient needed a CT scan. Staff F stated that the provider said they were happy to see the patient, but the CT scanner was down. Staff F said the provider said they could transfer the patient to the facility, or it’d be quicker if they drove to another local hospital. On 3/30/2026 at 3:46 P.M., the ED Physician Assistant, Staff C, stated that Patient #1’s chief complaint was dizziness. Staff C stated that Patient #1 was alert and oriented at the time and more than likely needed a CT scan. They stated that the patient probably had a concussion. Staff C also noted that the patient was not registered and had no paperwork. On 3/31/2026 at 9:03 A.M., the ED Medical Director, Staff D, stated that any patient who presents from the parking lot to the door will be seen and cared for. On 3/31/26 at 12:06 P.M, the Director of Quality, Staff B, after reviewing the video footage of the reception desk, stated that Patient #1 presented to the ED registration desk on 02/05/2026 at 1:01 P.M.”