Medical City Alliance

“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: 45521 Based on record review and interviews, the facility failed to provide stabilizing treatment to one of twenty patients (Patient # 1) experiencing a psychiatric emergency. Patient #1 presented to the emergency department with suicidal ideation and made threats to harm facility staff. Facility A failed to ensure the patient was safe and secure, which resulted in the patient eloping from the facility. Refer to A2407 for additional information.”

“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: 45521 Based on record review and interviews, the facility failed to provide stabilizing treatment to one of twenty patients (Patient # 1) experiencing a psychiatric emergency. Patient #1 presented to the emergency department with suicidal ideation and made threats to harm facility staff. Facility A failed to ensure the patient was safe and secure, including placing an involuntary hold and provide chemical/physical restraint, which resulted in the patient eloping from the facility. Findings: Record Review: A review of the document titled, “Free Text HPI (History of Present Illness)” by Staff # 1, Emergency Department MD, on 01/13/2025 at 8:07 PM revealed the following: A 43-year-old male arrived stating he was suicidal and requested a 24-hour hold. Patient # 1 reported a history of prior evaluations by behavioral health, he is not on any current medications but has had a 72-hour hold in the past. Patient # 1 denied any suicidal attempts. He did report ideation with a few different plans, but not one specifically. Care was transferred to Staff #3, Emergency Department (ED) MD at 2200. A review of the document titled “Risk-Psychiatric Illness-Re-Evaluation” by Staff # 3, ED MD, on 01/14/2025 at 1:18 AM revealed the following: “At this time patient continues to be suicidal and continues to endorse suicidal ideation. Currently no specific plan only intent. Patient continues to be lying down in no acute distress. PD [Police Department] had been contacted by RN staff due to patient’s repeated statements of wanting to leave and to be restrained/wanting to fight. After assessment initially by PD the patient was requesting to speak with supervisor of PD. PD supervisor arrived and also evaluated the patient. Currently the patient is still waiting for a transfer to psychiatric facility as he is yet to receive an acceptance. PD states that an emergency detention order can be placed, and patient can be transferred to facility on acceptance of transfer. PD believe that the patient is attempting to goad someone into physically restrain him in order to file a lawsuit. Prior to acceptance at psychiatric facility the patient eloped from the emergency department and went into police custody. “Disposition Decision Time 0418 Date 01/14/25 Against Medical Advice ELOPEMENT” A review of the document titled “Emergency Notes” by Staff # 6, RN, on 01/14/2025 at 3:36 AM revealed the following: The patient wanted to be placed in restraints and said the Police should be called because he wanted to fight them. Charge nurse and provider aware. Summary: Patient #1 asked for a 24-hour hold (involuntary detention) while at Facility A due to being suicidal. On 01/14/2025 at 1:08 AM it is documented that the Police were called due to Patient # 1 stating he needed to be restrained because he wanted to leave and fight. Staff # 5, RN explained that Patient # 1 said he was going to take the staff down. The Police arrived at Facility A and Patient # 1 told the police officer that he had a plan to kill himself by taking the officers duty weapon and killing himself. Patient # 1 was pacing and walked outside the Emergency room. The Police Department took custody of Patient # 1 and left the facility. Staff # 5 reported she was trained in physical restraints and Staff # 3 is a physician that can order chemical restraints. No restraints were used to ensure Patient # 1 safety related to elopement while having suicidal thoughts with a plan. A review of the document a report by Officer # 1, on 1/14/2025 at 5:38 AM, revealed the following: “On January 14th, 2025, at approximately 0337 hours, I, Officer # 1, was dispatched to Facility A in reference to a welfare concern. On arrival, Officer # 1 spoke with hospital staff who said Patient # 1, turned himself in for suicide watch. Patient # 1 had hospital staff call PD. On arrival, I spoke with Patient # 1 who stated he was suicidal, a registered sex offender, and a pedophile. I asked Patient # 1 why he was there in the hospital he stated he wanted to kill himself. I asked Patient # 1 if he had a plan and he stated yes. I asked Patient # 1 what the plan was and Patient # 1 stated he was going to take my duty weapon and shoot himself. Patient # 1 was not aggressive during the interaction I had with him. Facility A ER Staff were trying to get him to a psych unit and did not have a time when he would go. Patient # 1 turned himself in to the hospital on 1/13/2025 at 2000 hours and was upset that he was still there 8 hours later. Patient # 1 stated that he had the hospital staff call us to speed up the process of getting him help. Patient # 1 stood up and walked outside of the Emergency Room. When we followed him outside he got down on his knees and placed his hands behind his back. Patient # 1was detained for a emergency detention order.” Policy Review: A review of the policy titled “EMTALA- Medical Screening Examination and Stabilization Policy” reference number EC.EM.002, Page 9 of 15, Section 4, subsection b ii revealed the following: “Psychiatric QMP [Qualified Medical Professional]. The ED (Emergency Department) physician shall consult the QMP providing the behavioral assessment for psychiatric purposes but shall remain the primary decision-maker with regard to transfer and discharge of the individual presenting to the DED (Dedicated Emergency Department) with psychiatric or behavioral emergencies. Should an individual with a psychiatric or behavioral emergency present to a behavioral department of a hospital that meets the requirements of a DED, that department is responsible for ensuring that the individual has the appropriate MSE, including any behavioral examination, and providing necessary stabilizing treatment.” Page 12 of 15, Section 7-Stabilizing Treatment Within Hospital Capability revealed the following: “The determination of whether an individual is stable is not based on the clinical outcome of the individual’s medical condition. An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility,” ... A review of the Policy titled “Psychiatric and/or Substance Abuse Emergencies-Commitments” Reference number: PC.888.100 page 2 of 3 reveled the following: “Apprehension by Peace Officer without Warrant (Emergency Detention) The Warrantless Apprehension is the method used by a Peace Officer, i.e. policeman, when there is not time to obtain a warrant, but a person, because of mental illness or chemical dependency poses a potential risk of serious harm to him or herself or others if not immediately restrained. The risk of harm must be imminent and may be demonstrated by the patient’s behavior or severe emotional distress to the extent that the person may not remain at liberty. The Emergency Detention allows a proposed patient to be apprehended and taken to a mental health facility for an evaluation for possible involuntary commitment, based on application by an adult who believes the person is mentally ill or chemically dependent. The criteria involves the patient who poses a substantial risk of serious harm to him/herself, or others. The Emergency Detention only allows the proposed patient to be detained for 48 hours. Within that time the physician either files for an Order for Protective Custody or releases the proposed patient.” Interviews: 1. An interview with Staff # 5, RN, on 04/03/2025 at 10:38 AM revealed the following: “The patient arrived and said he was suicidal. We immediately did the suicide ideation checklist. The staff was always with him. The patient was very excited and talked loudly and fast. The doctor was notified immediately. Suicidal Ideation Protocol was started. Behavioral Health was notified for an assessment. The patient told the staff that he needed to be put in a hold. He advised us he was on the sex registry. He was agreeable with inpatient therapy. He was becoming agitated while waiting to be accepted at an inpatient facility. He had been waiting for about seven hours. He said he was ready to go and told us he needed to be restrained. The doctor and Staff # 4, de-escalated him for a while. A little later, we needed to call the police because he threatened to harm the staff. The Police Department was notified, and two officers arrived very quickly. The police were in the room with the patient, and the patient told the police that he needed to be restrained. He demanded to see the police supervisor, and two additional police officers arrived. The police moved across the hall to the nurse’s station and started filling out the paperwork for an Emergency Detention Order (EDO). The police decided on an EDO due to the patient’s escalated behavior with the police. The patient was asked to return to his room, and Patient # 1 said, “You will need to restrain me”. The patient continued to walk in and out of his door and pace in the lobby to the exit door. The patient would turn to be sure the police were looking, and when he saw they weren’t looking, he went out the exit door of the facility. The police stopped working on the EDO and went after the patient. The police officers took the patient to Facility B. I don’t know why they took him to Facility B rather than return him to our ED. When we have a psych patient who leaves the ED against medical advice (AMA), we always notify the police. I am trained to restrain”. 2. An interview with Staff # 4, Emergency Department (ED) RN on 04/03/2025 at approximately 11:05 AM revealed the following: “Patient # 1 came in and complained of suicidal ideation. We started his medical clearance and called Behavioral Health (BH). BH completed their assessment and recommended a transfer to an inpatient facility. We started the process to find a facility and kept him updated. Patient # 1 became upset and asked to be restrained. He then started pacing for 20-25 minutes. He was on a psychiatric hold, and we would have to find other ways to keep him calm. He said we need to call the big guys, which were the police, because he needed to be in handcuffs. I called the house supervisor and was told If he leaves, we call the police. I called the police to let them know a psych patient was trying to leave the facility. The patient heard the call and calmed down. When the police arrived at the ED, the patient was in the hallway and involved himself in a conversation with the police and staff. He told the police he needed to be in handcuffs because he was going to do something crazy. He started pacing to and from the exit door. Police were there for about 15 minutes when the patient went to the waiting room, then out the exit door. Police followed him out the door, the patient exited the facility, and the Police took custody”.”

“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 staff interviews, Facility A failed to comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. Facility A failed to provide stabilizing treatment for one (1) or twenty-one (21) patients (Patient #1) experiencing an emergency medical condition. Patient #1 arrived at Facility A on 03/03/2025 at 8:58 P.M., for right-sided facial swelling and an increase in both the swelling and pain. Facility A failed to provide stabilizing treatment. Patient #1 deteriorated after a diagnosis of Parotitis and discharge home. Patient #1 sought treatment the same day at 5:06 P.M., at Facility B, with the same complaint of increased swelling and pain of the face. Patient #1 was hospitalized for airway monitoring and intravenous antibiotic treatment. . See Tag 2407”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 51905 . Based on observation, record review, and staff interviews, Facility A failed to provide adequate physician on-call coverage consistent with the services provided at the hospital and the resources the hospital has available, including the availability of specialists, subjecting patients seeking emergent treatment to probable harm. . Findings: . 1. Record review of the on-call physicians’ schedule at Facility A: . A. October 2024- 1 of 30 days did not have a diagnostic radiology on-call. B. December 2024- 1 of 31 days did not have a diagnostic radiology on-call. C. January 2025- 1 of 31 days did not have a diagnostic radiology on-call. D. September 2024- 8 of 30 days did not have a gastroenterology on-call. E. January 2025- 2 of 31 days did not have a gastroenterology on-call. F. March 2025- 2 of 31 days did not have a gastroenterology on-call. G. November 2024- 3 of 30 days did not have a hospitalist on-call. H. December 2024- 1 of 31 days did not have a hospitalist on-call. I. March 2025- 2 of 31 days did not have an interventional radiology on-call. J. September 2024- 5 of 30 days did not have maxillofacial trauma on-call. K. November 2024- 3 of 30 days did not have maxillofacial trauma on-call. L. December 2024- 4 of 31 days did not have maxillofacial trauma on-call. M. January 2025- 4 of 31 days did not have maxillofacial trauma on-call. N. March 2025- 1 of 31 days did not have OR anesthesia on-call. O .December 2025- 5 of 31 days did not have spine on-call. P. March 2025 1 or 31 days did not have spine on-call. . 2. Interview: . During an interview with the Director of Medical Staff Services, Staff M was provided with a copy of the on-call physician schedule. Staff M was asked to identify the notations on the schedule. When asked if the days selected in red and labelled “no coverage” meant there was not a physician available, Staff M responded, “That’s correct.” When asked if the days selected in purple with no physician listed meant there was not a physician available, Staff M responded, “That’s correct.” . 3. Policies: . Review of Facility A’s Rules and Regulations: Revision Approved June 2024, A-6: Response Time: Page 7 of 35: “ED - If the patient’s clinical situation warrants the presence of the attending physician, designee, or on- call physician, as determined by the ED physician, such physician is expected to arrive at the hospital within 30 minutes after responding to the call or page. Physicians must respond within 30 minutes of being paged. . In the event, a particular specialty is not available or the on-call physician cannot respond due to circumstances beyond the physician’s control, the emergency department physician should attempt to make one (1) additional contact to a physician in the same specialty on the medical staff. If this attempt is unsuccessful and/or the response takes longer than 30 minutes, the chain-of-command must be invoked and immediate arrangements should be secured for patient transfer to an appropriate facility.” . B-16: Call responsibility: Page 11 of 35: “All Active Medical Staff members may be required to take emergency room call for emergency room patients if there is a designated call rotation schedule for their specialty. The physician’s responsibility while on call to the ED includes evaluating and treating a patient when the patient is referred from the Emergency Department to the on-call physician for office follow-up and/or further care. If the on-call physician is unable or unwilling to provide patient care, the on-call physician shall arrange coverage by a back-up or alternate physician; the back-up or alternate physician must contact the Emergency Department within thirty (30) minutes of the original request for consult by the ED to discuss a resolution to the patient care need. If the on-call physician is unable to be contacted or unwilling to arrange alternate coverage, the back-up physician listed on the call schedule or covering the physician’s practice must assume those responsibilities. . In the event that both the on-call physician and back-up/covering physician are unable to be contacted or are unwilling to provide patient care, the Department Chief shall be immediately contacted and will attempt to arrange with another appropriate physician to care for the patient, if there is such a physician available. If no such physician is available, the Department Chief will contact the administrator on-call and the administrator on-call may contact the Chief of Staff, and together, all three will determine the next course of action. In all circumstances, the safety and well-being of the patient will be of primary concern. As such, at any point, a physician may initiate a transfer of the patient if he/she deems it necessary after having considered the potential impact on the patient of the prevailing circumstances and delays in securing the needed specialists or other physicians.””

“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: 51905 . Based on observation, record review, and staff interviews, Patient #1 arrived at Facility A on 03/03/2025 at 8:58 P.M., for right-sided facial swelling and an increase in both the swelling and pain. Facility A failed to provide stabilizing treatment. Patient #1 deteriorated after a diagnosis of Parotitis and discharge home. Patient #1 sought treatment the same day at 5:06 P.M., at Facility B, with the same complaint of increased swelling and pain of the face. Patient #1 was hospitalized for airway monitoring and intravenous antibiotic treatment. . Findings . 1.Medical Record Review of Patient #1’s medical record from Facility A: On 03/03/2025 at 8:58 A.M., Patient #1 arrived at Facility A’s emergency department with complaints of right-sided facial swelling. During triage Patient #1’s vital signs included a blood pressure of 147/95, a heart rate of 99, and a temperature of 99.0 Fahrenheit. At 9:02 A.M., Patient #1’s medical screening examination was completed by Staff N. Staff N’s note states that Patient #1 claims that the facial swelling “has rapidly increased in size and become more painful,” and that Patient #1 “reports pain with swallowing but is able to tolerate fluids without difficulties.” At this time, Staff N reports “no acute distress” and “airway patent.” At 9:11 A., Patient #1 was worked up for sepsis. Patient #1 was administered intravenous antibiotics (Clindamycin) and a 2,300 mL (milliliter) bolus of normal saline. The patient received a chest x-ray, blood cultures, labs, pain medications, and a CT (computed tomography) scan. Per the testing results, there was no evidence of sepsis, however, the CT scan findings did indicate right sided parotitis. At 11:45 A.M., per the provider’s note, “the patient’s (Patient #1) condition is stable and appropriate for discharge.” “Follow up information for ENT (ear, nose, nose, and throat physician) provided in the discharge paperwork.” Patient #1 was diagnosed with parotitis, discharged charged home 03/03/2025 at 11:45 A.M., and was not admitted for further observation of the swelling that could restrict the airway. . Review of Patient #1’s medical record from Facility B: On 03/03/2025 at 4:32 P.M Patient #1 arrived at Facility B’s emergency department with complaints of previous salivary gland infection with large amount of facial swelling.” At 5:06 P.M, Patient #1 was administered steroids, pain medication, antibiotics, labs, blood cultures, a 2,500 mL (milliliter) electrolyte-a bolus, and a CT (computed tomography) scan. CT scan findings indicated “extensive nonspecific inflammatory changes of the right face and neck with mass effect and moderate narrowing of the airway. Additional nonspecific prevertebral soft tissue edema.” At 7:55 P.M., The provider noted that Patient #1’s “swelling has progressed; patient (Patient #1) reports some difficulty speaking and breathing as well as managing secretions.” Vital signs at this time were within normal limits. Facility B’s provider consulted ICU (intensive care unit) providers for admission of Patient #1 for “airway watch.” Provider noted Patient #1’s “acute distress,” “ill-appearing,” and “Massive R (right) sided swelling from upper cheek to upper neck,” and “breathing with mild stridor.” At 8:04 P.M., ENT (ear, nose, and throat physician) was consulted. At 8:14 P.M., Patient #1 was admitted to the ICU (intensive care unit). Patient #1 was diagnosed with facial swelling and admitted to the ICU (intensive care unit) for airway monitoring due to the narrowing of the airway, per the CT (computed tomography) scan. Patient remained in the ICU (intensive care unit) at Facility B for three (3) days, per the complainant. . 2.Policies Review of Facility A’s document EMTALA- Medical Screening Examination and Stabilizing Policy EC.EM.002 Page 12 of 15: 7. Stabilizing Treatment Within Hospital Capability “An individual has been provided sufficient stabilizing treatment when the physician treating the individual in the DED (dedicated emergency department) has determined, within reasonable clinical confidence, that no material deterioration of the condition is likely ...” . 3.Interviews On 03/25/2025 at 12:15 P.M. an in-person interview with Medical Director Staff F was conducted. Staff F stated, “a medical screening exam under law by a qualified professional, advanced practice provider, or MD, to make sure there isn’t a medical emergency or to meet the needs of an emergency. There are additional parts to EMTALA, but that is the main one I focus on.” Staff F explains, “We did start with the sepsis protocol just to make sure. Vitals were within normal range, labs were unremarkable, and the CT scan showed no signs of abscess. A CT scan would provide me with big evidence. I was not concerned for any airway compromise, if I were, I would have admitted him.” “His speech was fine, the airway was patent, he only had unilateral external swelling around the mandible.” “There was no abscess to drain with this patient, so it was just symptomatic management. 99% of the time, salivary gland infections resolve themselves.””

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 45847 . Based on a record review and interviews, the facility failed to ensure that all drugs were administered in accordance with Federal and State laws and regulations and the approved medical staff policies and procedures for one of 20 (Patient #1) patients whose medical records were reviewed. . The Findings were as follows: Medical Record Review: There were two Medical Records for Patient #1 provided. One on 02/12/2024 at 1210 PM (16 pages) provided by the Co-Ethics and Compliance Officer, Staff #11. Later, the Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages). . The two Medical Records both showed documentation that a medication, Norco 5/325 mg, was given by Staff #6 on 12/10/2023 at 0246 AM. A reassessment to ensure the effectiveness of the pain medication was not documented in either of the two provided Medical Records for Patient #1 before her discharge on 12/10/2023 at 0255 AM. . Policy Review: The Facility’s Policy titled, “Pain Assessment & Reassessment”, last revised and implemented on 08/2023, stated on page 1: “ ....DEFINITIONS: 1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by actual or potential tissue/nerve damage. Medical City Alliance’s philosophy is that no two people experience or express their pain alike and all manifests their own perception and symptoms in response to pain. 2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a long-acting pain medication. 3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on numeric pain scale.” . and on page 2: “ .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10 numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability (FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale (NIPS), and/or the Non-Verbal Pain Scale: 1. Pre-operatively 2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain 3. At initial assessment per unit protocol 4. With each new report of pain 5. Within one (1) hour after a pain-relieving intervention using one of the approved methods of pain measurement ....” . Interviews: In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a reassessment following the documented administration. .”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 45847 Based on record review, observation, and interview the facility failed to ensure medical records were accurately written in one of 20 records reviewed (Patient #1) when incomplete documentation surrounding the administration of pain medication was noted during medical record and policy reviews. . The Findings were as follows: . Medical Record Review: There were two Medical Records for Patient #1 provided. One on 02/12/2024 at 1210 PM (16 pages) provided by the Co-Ethics and Compliance Officer, Staff #11. Later, the Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages). The records did not match. The first Medical Record included nursing’s “Rapid Initial Assessment”, which is the beginning assessment in Triage. The second Medical Record did not include the “Rapid Initial Assessment.” The second Medical Record included “Discharge Instructions” that were not seen in the first Medical Record provided. The first Medical Record provided documented within the “Rapid Initial Assessment” documented a priority level of “2/Emergent” on 12/10/2023 at 0149 AM. . The total time Patient #1 was in the ED was one hour and seven minutes. The time from arrival on 12/10/2024 at 0148 AM to medical screening assessment on 12/10/2023 at 0151 AM was three minutes. The patient had only one set of vital signs obtained upon her admission on 12/10/2023 at 0149 AM documented a blood pressure of 180/110 (considered “abnormal per Facility Policy), a pulse rate of 118 (considered “abnormal per Facility Policy), and a pain level of 10 (considered “severe” pain per Facility Policy). No follow-up/reassessment of Patient #1’s vital signs or pain level could be located in either of the two provided Medical Records for Patient #1. . The second Medical Record that was provided included nine pages of “Discharge Instructions.” The two Medical Records did not include documentation by nursing that discharge instructions were provided to Patient #1. The facility was unable to produce a signed copy of discharge instructions for Patient #1. There was a place for Patient #1 to have signed the instructions, but no signature was observed. The documented discharge time was on 12/10/2023 at 0255 AM. . Policy Review: The Facility’s policy titled, “Admission and Discharge Criteria”, last reviewed and implemented on 08/2022, stated on page 16: “ ....3. Discharge criteria may include: a. The patient/family/significant other is informed of the diagnosis and offered the opportunity to ask questions b. The patient/family/significant other has received appropriate education regarding the patient’s injury or illness. Written information/instruction is provided to the patient and may include, but is not limited to: i. Safe effective use of medication, when applicable ii. Nutritional information when applicable iii. Safe and effective use of medical equipment iv. Signs and symptoms that should be reported v. Instances when patient should seek immediate help or return to the emergency room vi. Suggested time for follow-up care c. The patient/family/significant other are instructed on the treatment plan d. Follow-up care is arranged if required ....” . And on pages 3 - 4: “ ....4. Discharge criteria may include, but not limited to: b. Stable vital signs b. Nutrition/hydration adequate for condition, emesis controlled c. Hematology/chemistry lab values stable d. Mental status/level of consciousness improving or stable e. Pain controlled/managed ....” . The Facility’s Policy titled, “Emergency Department Abnormal Vital Signs”, last revised and implemented on 12/2023, defined abnormal vital signs on page 2: “ ....Vital sign parameters requiring notification for an adult patient sixteen years old and older: “ Systolic blood pressure less than 90 mmHg or greater than 200 mmHg “ Diastolic blood pressure less than 50 mmHg or greater than 120 mmHg “ Temperature greater than 38.0 Celsius or 100.4 Fahrenheit “ Heart rate of less than 50 bpm or greater than 110 bpm “ Sp02 less than 90% Room Air ....” . The Facility’s Policy titled, “Triage Assessment and Acuity Level Assignment”, last revised and implemented on 12/2023, stated on page 1: “ ....Triage serves to identify life or limb-threatening illnesses/injuries, and patients are prioritized according to acuity and expected resources needed; according to the Emergency Severity Index (ESI) 5-Level Triage System. The priorities are categorized as follows: “ Level 1/Resuscitative: Patients presenting in cardiopulmonary arrest/unresponsive “ Level 2/Emergent: Patient is at significant risk and requires multiple resources for evaluation and treatment, and may have vital signs within a danger zone, as defined by the ESI 5-Level Triage System ....” . and on page 3: “ ....Reassessments are performed by an RN periodically to re-evaluate patient condition and symptoms, based upon the patient’s initial acuity determination prior to the initiation of the MSE. Reassessment may include vital signs, a focused physical assessment, pain assessment, general appearance, and responses to interventions and treatments. Patient reassessment guidelines are as follows: “ Prior to MSE . - Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition . - Level 2/Emergent: Every 15 minutes, and based upon clinical condition .... . “ After MSE - Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition. No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable . - Level 2/Emergent: At least hourly, based on clinical condition, for a minimum of 4 hours, and more frequently if indicated by clinical condition ....” . The Facility’s Policy titled, “Pain Assessment & Reassessment”, last revised and implemented on 08/2023, stated on page 1: “ ....DEFINITIONS: 1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by actual or potential tissue/nerve damage. Medical City Alliance’s philosophy is that no two people experience or express their pain alike and all manifests their own perception and symptoms in response to pain. 2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a long-acting pain medication. 3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on numeric pain scale.” . and on page 2: “ .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10 numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability (FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale (NIPS), and/or the Non-Verbal Pain Scale: 1. Pre-operatively 2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain 3. At initial assessment per unit protocol 4. With each new report of pain 5. Within one (1) hour after a pain-relieving intervention using one of the approved methods of pain measurement ....” . Interviews: In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a pain level reassessment following the documented administration. . In an interview on the afternoon of February 12, 2024, at 1228 PM and on February 13, 2024, at 0816 AM, Staff #5, the treating ED Physician, confirmed that Patient #1 did not receive stabilization and monitoring of an elevated blood pressure per the Facility’s policy. . In an interview on the morning of February 13, 2024, at 1126, Staff #8, the Facility’s ED Medical Director, it was confirmed that Patient #1 did not have blood pressure monitoring per the Facility’s Policy, that the Facility could not accurately confirm that Patient #1 had received discharge instructions, and that stabilization of Patient #1’s emergency medical condition had not occurred before being discharged. The ED Medical Director also confirmed that the current discharge policy and process were insufficient. . In an interview on the afternoon of February 12, 2024, at approximately 1300 pm, Staff #2, the Director of Nursing Operations, it was confirmed that the Facility could not accurately confirm had received discharge instructions, It was also confirmed that the current discharge policy and process were insufficient. . Patient #1 also alleged that she was not provided discharge instructions. Patient #1 provided a screenshot following the incident of Patient #1’s “myhealthone” patient portal was provided that was taken on 12/10/2023 at 0531 AM, which was 2 hours and 36 minutes following her discharge. The screenshot shows: “Discharge Summaries. You have no discharge instructions on file.” .”

“ADMISSION, TRANSFER, AND DISCHARGE RIGHTS CFR(s): §482.58(b)(2) Admission, transfer, and discharge rights (§483.5 definition of transfer and discharge, §483.15(c)(1), (c)(2)(i), (c)(2)(ii), (c)(3), (c)(4), (c)(5), and (c)(7)) • §483.5: definition of transfer and discharge: Transfer and discharge includes movement of a resident to a bed outside of the certified facility whether that bed is in the same physical plant or not. Transfer and discharge does not refer to movement of a resident to a bed within the same certified facility. • §483.15(c)(1): Facility requirements— (i) The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless— (A) The transfer or discharge is necessary for the resident’s welfare and the resident’s needs cannot be met in the facility; (B) The transfer or discharge is appropriate because the resident’s health has improved sufficiently so the resident no longer needs the services provided by the facility; (C) The safety of individuals in the facility is endangered due to the clinical or behavioral status of the resident; (D) The health of individuals in the facility would otherwise be endangered; (E) The resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the facility. Non-payment applies if the resident does not submit the necessary paperwork for third party payment or after the third party, including Medicare or Medicaid, denies the claim and the resident refuses to pay for his or her stay. For a resident who becomes eligible for Medicaid after admission to a facility, the facility may charge a resident only allowable charges under Medicaid; or (F) The facility ceases to operate. (ii)The facility may not transfer or discharge the resident while the appeal is pending, pursuant to §431.230 of this chapter, when a resident exercises his or her right to appeal a transfer or discharge notice from the facility pursuant to §431.220(a)(3) of this chapter, unless the failure to discharge or transfer would endanger the health or safety of the resident or other individuals in the facility. The facility must document the danger that failure to transfer or discharge would pose. • §483.15(c)(2)(i) Documentation in the resident’s medical record must include: (A) The basis for the transfer per paragraph (c)(1)(i) of this section. (B) In the case of paragraph (c)(1)(i)(A) of this section, the specific resident need(s) that cannot be met, facility attempts to meet the resident needs, and the service available at the receiving facility to meet the need(s). • §483.15(c)(2)(ii) The documentation required by paragraph (c)(2)(i) of this section must be made by— (A) The resident’s physician when transfer or discharge is necessary under paragraph (c)(1)(A) or (B) of this section; and (B) A physician when transfer or discharge is necessary under paragraph (c)(1)(i)(C) or (D) of this section. • §483.15(c)(3): Notice before transfer. Before a facility transfers or discharges a resident, the facility must— (i) Notify the resident and the resident’s representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident’s medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. • §483.15(c)(4): Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when— (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident’s health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident’s urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. • §483.15(c)(5): Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii)The location to which the resident is transferred or discharged; (iv) A statement of the resident’s appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii)For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. • §483.15(c)(7): Orientation for transfer or discharge. A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This Standard is not met as evidenced by: 45847 Based on observation, record review, and interview, the Facility failed to provide an appropriate discharge for one of 20 (Patient #1) by discharging Patient #1 without ensuring that Patient #1’s health had improved sufficiently so the patient no longer needed care. . The Findings Included: . Medical Record Review: There were two Medical Records for Patient #1 provided. One on 02/12/2024 at 1210 PM (16 pages) provided by the Co-Ethics and Compliance Officer, Staff #11. Later, the Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages). The records did not completely match. The first Medical Record included nursing’s “Rapid Initial Assessment”, which is the beginning assessment in Triage. The second Medical Record did not include the “Rapid Initial Assessment.” The second Medical Record included “Discharge Instructions” that were not seen in the first Medical Record provided. The first Medical Record provided documented within the “Rapid Initial Assessment” documented a priority level of “2/Emergent” on 12/10/2023 at 0149 AM. There was no documented change made to Patient #1’s priority level. . The total time Patient #1 was in the ED was one hour and seven minutes. The time from arrival on 12/10/2024 at 0148 AM to medical screening assessment on 12/10/2023 at 0151 AM was three minutes. The patient had only one set of vital signs obtained upon her admission on 12/10/2023 at 0149 AM documented a blood pressure of 180/110 (considered “abnormal per Facility Policy), a pulse rate of 118(considered “abnormal per Facility Policy), and a pain level of 10 (considered “severe” pain per Facility Policy). No follow-up/reassessment of Patient #1’s vital signs or pain level was located in either of the two provided Medical Records for Patient #1. . Policy Review: The Facility’s policy titled, “Admission and Discharge Criteria”, last reviewed and implemented on 08/2022, stated on page 16: “ ....3. Discharge criteria may include: a. The patient/family/significant other is informed of the diagnosis and offered the opportunity to ask questions b. The patient/family/significant other has received appropriate education regarding the patient’s injury or illness. Written information/instruction is provided to the patient and may include, but is not limited to: i. Safe effective use of medication, when applicable ii. Nutritional information when applicable iii. Safe and effective use of medical equipment iv. Signs and symptoms that should be reported v. Instances when patient should seek immediate help or return to the emergency room vi. Suggested time for follow-up care c. The patient/family/significant other are instructed on the treatment plan d. Follow-up care is arranged if required ....” . And on pages 3 - 4: “ ....4. Discharge criteria may include, but not limited to: a. Stable vital signs b. Nutrition/hydration adequate for condition, emesis controlled c. Hematology/chemistry lab values stable d. Mental status/level of consciousness improving or stable e. Pain controlled/managed ....” . The Facility’s Policy titled, “Emergency Department Abnormal Vital Signs”, last revised and implemented on 12/2023, defined abnormal vital signs on page 2: . “ ....Vital sign parameters requiring notification for an adult patient sixteen years old and older: -Systolic blood pressure less than 90 mmHg or greater than 200 mmHg -Diastolic blood pressure less than 50 mmHg or greater than 120 mmHg -Temperature greater than 38.0 Celsius or 100.4 Fahrenheit -Heart rate of less than 50 bpm or greater than 110 bpm -Sp02 less than 90% Room Air ....” . The Facility’s Policy titled, “Triage Assessment and Acuity Level Assignment”, last revised and implemented on 12/2023, stated on page 1: “ ....Triage serves to identify life or limb-threatening illnesses/injuries, and patients are prioritized according to acuity and expected resources needed; according to the Emergency Severity Index (ESI) 5-Level Triage System. The priorities are categorized as follows: . -Level 1/Resuscitative: Patients presenting in cardiopulmonary arrest/unresponsive . -Level 2/Emergent: Patient is at significant risk and requires multiple resources for evaluation and treatment, and may have vital signs within a danger zone, as defined by the ESI 5-Level Triage System ....” . and on page 3: “ ....Reassessments are performed by an RN periodically to re-evaluate patient condition and symptoms, based upon the patient’s initial acuity determination prior to the initiation of the MSE. Reassessment may include vital signs, a focused physical assessment, pain assessment, general appearance, and responses to interventions and treatments. Patient reassessment guidelines are as follows: . -Prior to MSE . -Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition . - Level 2/Emergent: Every 15 minutes, and based upon clinical condition .... -After MSE . -Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition. No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable . -Level 2/Emergent: At least hourly, based on clinical condition, for a minimum of 4 hours, and more frequently if indicated by clinical condition ....” . The Facility’s Policy titled, “Pain Assessment & Reassessment”, last revised and implemented on 08/2023, stated on page 1: “ ....DEFINITIONS: 1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by actual or potential tissue/nerve damage. Medical City Alliance’s philosophy is that no two people experience or express their pain alike and all manifests their own perception and symptoms in response to pain. 2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a long-acting pain medication. 3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on numeric pain scale.” . and on page 2: “ .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10 numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability (FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale (NIPS), and/or the Non-Verbal Pain Scale: 1. Pre-operatively 2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain 3. At initial assessment per unit protocol 4. With each new report of pain 5. Within one (1) hour after a pain-relieving intervention using one of the approved methods of pain measurement ....” . Interviews: In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a reassessment following the documented administration. . In an interview on the afternoon of February 12, 2024, at 1228 PM and on February 13, 2024, at 0816 AM, Staff #5, the treating ED Physician, confirmed that Patient #1 did not receive appropriate monitoring of an elevated blood pressure per the Facility’s policy. . In an interview on the morning of February 13, 2024, at 1126, Staff #8, the Facility’s ED Medical Director, it was confirmed that Patient #1 did not have blood pressure monitoring per the Facility’s Policy, that the Facility could not accurately confirm that Patient #1 had received discharge instructions before being discharged. It was also confirmed that the current discharge policy and process were insufficient. . In an interview on the afternoon of February 12, 2024, at approximately 1300 pm, Staff #2, the Director of Nursing Operations, confirmed that the Facility could not accurately confirm that Patient #1 had received discharge instructions. It was also confirmed that the current discharge policy and process were insufficient. . Patient #1 also alleged that she was not provided discharge instructions. Patient #1 provided a screenshot following the incident of Patient #1’s “myhealthone” patient portal was provided that was taken on 12/10/2023 at 0531 AM, which was 2 hours and 36 minutes following her discharge. The screenshot shows: “Discharge Summaries. You have no discharge instructions on file.” . Patient #1 maintains that she had such a violent reaction following ingestion of the Norco, which was taken in combination with her prescribed Ambien, that it would have been impossible and unsafe to have driven home had that been the case. .”

“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: 45847 . Based on interview and record review, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA (Emergency Medical Treatment and Labor Act) requirements when they did not provide an appropriate medical screening exam (MSE) for one out of 20 patients (Patient #1). On 12/10/2023, Patient #1 presented to the emergency department with complaints of leg and hip pain. Medical records show that Patient #1 was provided with an MSE at 0151, given pain medication at 0252, and was discharged from the ED at 0255 without an acknowledgement of discharge instructions. There were no documented follow-ups to the patient’s status which included follow-up pain assessments or reassessments of patient vitals. Furthermore, the physical exam did not include documentation of any evaluation of the back or leg, which was Patient #1’s primary concern. Cross reference to Tag A2406 CFR §489.24(c). .”

“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: 45847 . Based on medical record reviews, facility documentation reviews, and interviews, the facility failed to: . 1. Perform and document an appropriate medical screening examination (MSE) in 1 of 20 patient records reviewed (Patient #1). . 2. Follow its policies regarding medical screening examinations, stabilization, admission and discharge criteria, vital sign assessments and reassessments, physical examination assessments and reassessments, and pain assessments and reassessments in 1 of 20 patient records reviewed (Patient #1). . The Findings Included: Medical Record Review: A Medical Record for Patient #1 on 02/12/2024 at 1210 PM (16 pages) was provided by the Co-Ethics and Compliance Officer, Staff #11. The Chief Administrative Director of Nursing Operations (Staff #2) stated that the record that had been provided was incomplete and provided a second Medical Record for Patient #1 on 02/13/2024 at 2059 pm (21 pages). . The first medical record noted on 12/10/2023 at 0149 AM by Staff #10 (an emergency department registered nurse), “Patients description or reason for visit: C/O (complaints of) sudden left leg pain starting from hip to left knee x 1 week . ... no fall or trauma. Called telehealth and was advised to come to ER .... prescribed Etodolac 1 week ago.” The Medical Record also notes a chief complaint of “joint pain” of the left hip on 12/10/2023 at 0158 AM and a documented pain at a level “10” on 12/10/2023 at 0204 AM. . Patient #1 had one set of vital signs obtained upon her admission/presentation on 12/10/2023 at 0149 AM. The documented blood pressure was 180/110, a pulse rate of 118, and a pain level of 10, which are abnormal findings. No follow-up/reassessment of Patient #1’s vital signs was documented before discharge on 12/10/2023 at 0255 AM in the provided Medical Records for Patient #1. There were no follow-up pain assessments or reassessments documented in for Patient #1. . In the second medical record, there are no nursing notes and no triage notes. The record shows on 12/10/2023 at 0155 AM, the reason for the visit was “1 week of left thigh pain ...not relieved by Toradol” per Staff #5’s (the treating ED Provider) History and Physical. This record does not mention a pain level. . The two Medical Records both showed documentation that a medication, Norco 5/325 mg, was documented as given by Staff #6 on 12/10/2023 at 0246 AM. A reassessment to ensure the effectiveness of the pain medication was not documented in either of the two provided Medical Records for Patient #1. . No further appropriate history regarding the patient symptoms was found. The physical exam does not include any evaluation of the back or leg and there is no focal neurologic exam to evaluate for neurologic referred pain to the leg. There were no reassessments documented in one of the 20 patients whose medical records were reviewed (Patient #1). . Policy Review: The Facility’s policy titled, “Admission and Discharge Criteria”, last reviewed and implemented on 08/2022, stated on page 16: “ ....3. Discharge criteria may include: a. The patient/family/significant other is informed of the diagnosis and offered the opportunity to ask questions b. The patient/family/significant other has received appropriate education regarding the patient’s injury or illness. Written information/instruction is provided to the patient and may include, but is not limited to: i. Safe effective use of medication, when applicable ii. Nutritional information when applicable iii. Safe and effective use of medical equipment iv. Signs and symptoms that should be reported v. Instances when patient should seek immediate help or return to the emergency room vi. Suggested time for follow-up care c. The patient/family/significant other are instructed on the treatment plan d. Follow-up care is arranged if required ....” . And on pages 3 - 4: “ ....4. Discharge criteria may include, but not limited to: c. Stable vital signs b. Nutrition/hydration adequate for condition, emesis controlled c. Hematology/chemistry lab values stable d. Mental status/level of consciousness improving or stable e. Pain controlled/managed ....” . The Facility’s Policy titled, “Emergency Department Abnormal Vital Signs”, last revised and implemented on 12/2023, defined abnormal vital signs on page 2: “ ....Vital sign parameters requiring notification for an adult patient sixteen years old and older: Systolic blood pressure less than 90 mmHg or greater than 200 mmHg Diastolic blood pressure less than 50 mmHg or greater than 120 mmHg Temperature greater than 38.0 Celsius or 100.4 Fahrenheit Heart rate of less than 50 bpm or greater than 110 bpm Sp02 less than 90% Room Air ....” . The Facility’s Policy titled, “Triage Assessment and Acuity Level Assignment”, last revised and implemented on 12/2023, stated on page 1: “ ....Triage serves to identify life or limb-threatening illnesses/injuries, and patients are prioritized according to acuity and expected resources needed; according to the Emergency Severity Index (ESI) 5-Level Triage System. The priorities are categorized as follows: Level 1/Resuscitative: Patients presenting in cardiopulmonary arrest/unresponsive Level 2/Emergent: Patient is at significant risk and requires multiple resources for evaluation and treatment, and may have vital signs within a danger zone, as defined by the ESI 5-Level Triage System ....” . and on page 3: “ ....Reassessments are performed by an RN periodically to re-evaluate patient condition and symptoms, based upon the patient’s initial acuity determination prior to the initiation of the MSE. Reassessment may include vital signs, a focused physical assessment, pain assessment, general appearance, and responses to interventions and treatments. Patient reassessment guidelines are as follows: . Prior to MSE . Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition . Level 2/Emergent: Every 15 minutes, and based upon clinical condition .... . After MSE Level 1/Resuscitative: Every 5-15 minutes, as needed based upon clinical condition. No less frequently than every hour for the first 4 hours, then every 2 hours if clinically stable . Level 2/Emergent: At least hourly, based on clinical condition, for a minimum of 4 hours, and more frequently if indicated by clinical condition ....” . The Facility’s Policy titled, “EMTALA- Medical Screening Examination and Stabilization Policy”, last revised and implemented on 11/20/2023, stated on page 12: . “ .... a. Stable. The physician or QMP providing the medical screening and treating the emergency has determined within reasonable clinical confidence, that the EMC that caused the individual to seek care in the DED has been resolved although the underlying medical condition may persist ....” . and on page 13: “ .... c. Stabilizing Treatment and Individuals Whose EMCs Are Resolved. An individual is considered stable and ready for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his or her continued care, .... The EMC that caused the individual to present to the DED must be resolved, but the underlying medical condition may persist. Hospitals are expected within reason to assist/provide discharged individuals the necessary information to secure follow-up care to prevent relapse or worsening of the medical condition upon release from the hospital ....” . The Facility’s Policy titled, “Pain Assessment & Reassessment”, last revised and implemented on 08/2023, stated on page 1: “ ....DEFINITIONS: 1. Pain is a complex, subjective, unpleasant sensory or emotional experience caused by actual or potential tissue/nerve damage. Medical City Alliance’s philosophy is that no two people experience or express their pain alike and all manifests their own perception and symptoms in response to pain. 2. Breakthrough pain is severe pain that erupts while a patient is already medicated with a long-acting pain medication. 3. Pain is defined as the following: Mild - Level 1-3, Moderate - 4-6, Severe - 7-10 on numeric pain scale.” . and on page 2: “ .... F. All RN staff will reassess and monitor patients for presence of pain using the 0 - 10 numeric scale, Wong- Baker Pain Scale, Faces, Legs, Activity, Cry, Consolability (FLACC), Critical Care Pain Observation Tool (CPOT), Neonatal Infant Pain Scale (NIPS), and/or the Non-Verbal Pain Scale: 1. Pre-operatively 2. Post-operative/post-procedure, as determined by the procedure and severity/intensity of pain 3. At initial assessment per unit protocol 4. With each new report of pain 5. Within one (1) hour after a pain-relieving intervention using one of the approved methods of pain measurement ....” . Interviews: In an interview on the afternoon of February 12, 2024, at 1243, Staff #6, the ED Charge RN confirmed that Patient #1 was provided Norco 5/325 mg (documented as administered on 12/10/2023 at 0246 AM) and Patient #1 was discharged on 12/10/2023 at 0255 AM without a pain level reassessment following the documented administration. . In an interview on the afternoon of February 12, 2024, at 1228 PM and on February 13, 2024, at 0816 AM, Staff #5, the treating ED Physician, confirmed that Patient #1 did not receive stabilization and monitoring of an elevated blood pressure per the Facility’s policy. . In an interview on the morning of February 13, 2024, at 1126, Staff #8, the Facility’s ED Medical Director, confirmed that Patient #1 did not have blood pressure monitoring per the Facility’s Policy, that the Facility could not accurately confirm that Patient #1 had received discharge instructions, and that stabilization of Patient #1’s emergency medical condition had not occurred before being discharged. The ED Medical Director also confirmed that the current discharge policy and process were insufficient. .”