Inova Alexandria Hospital

“PATIENT RIGHTS: EXERCISE OF RIGHTS CFR(s): 482.13(b) Patient Rights: Exercise of Rights This Standard is not met as evidenced by: 40084 Based on interview and document review, it was determined the facility failed to safeguard medication brought from home for one (1) of five (5) patients (Patient #1) and failed to document and safeguard the personal effects of one (1) of five (5) patients (Patient #2). The findings include: During the afternoon of June 21, 2026, a review of the medical record for Patient #1 with Staff Member #1 and Staff Member #2, and an interview with Staff Member #3 and Staff Member #4, revealed during Patient #1’s inpatient stay in early June 2026, the patient’s difluprednate eye drops that were brought from home, were lost by hospital staff. Staff Member #4 advised that when staff went to retrieve the drops for administration during the hospitalization based on a physician order, the eye drops could not be located in the storage bin of unit 25 designated for medications brought from home. Additionally, an interview with Staff Member #5, revealed that a security report was not completed for the lost property. During the afternoon of June 21, 2026, a review of the medical record for Patient #2 with Staff Member #1 and Staff Member #2, revealed the medical record failed to contain an inventory of the patient’s personal effects for the service date on December 4, 2025. Patient #2 expired in the emergency department (ED) and was transported to a funeral home. A nursing note in the medical record documented, “Pt’s [significant other] called and stated that pt was transported to funeral home with no belongings. RN reached out to security, awaiting callback. Staff Member #1 and Staff Member #2 advised there is a section in the medical record to document personal effects, but they would need to review the facility’s policy to examine the requirement. A review of the facility policy titled “IHS Patient Supplied Medication Storage Procedure” states in part: “...This policy aims to prevent medication loss, theft, or misuse while ensuring patients receive appropriate medications during their stay... Patient medications for storage during admission will be kept in a secure, locked area (e.g., medication storage room, locked cabinet...Discrepancies related to patient medications, including lost, stolen, or mishandled drugs, must be reported immediately to hospital security, nursing, hospital administration.” A review of the facility policy titled “ Patient Property Management” states in part: “...If a patient expires in the Emergency Department, property shall be given to the family or companion... If no family or companion is present, belongings will be sent to the morgue with the body... Valuables shall be inventoried and placed in the hospital safe with a copy of the receipt being placed in the chart.””

“PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES CFR(s): 482.13(a)(2)(ii) At a minimum: The grievance process must specify time frames for review of the grievance and the provision of a response. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined the hospital failed to follow its established policies related to grievance review timelines in two (2) of four (4) patient grievances reviewed in the survey sample. Medical records (MR1 and MR4). Findings: The facility’s policy, “IHS Patient Complaint/Grievance Process in the Hospital Policy,” last revised August 7, 2023, was reviewed and reads in part, “ ...All grievances are responded to in writing. It is expected that many grievances can be resolved within 7 days. If the grievance cannot be resolved within 7 days, the hospital will provide a written acknowledgement within that time period. In the acknowledgement, the hospital will notify the complainant of the expected period of time (in most cases, 30 days) needed in order to resolve the grievance. If the grievance is not immediately resolved, it is expected the grievance can be resolved the resolution communicated in writing within 30 days...” Four (4) written grievances received by the hospital were reviewed. The grievance related to MR1 was received by the hospital on December 18, 2025. The hospital’s grievance response letter with the results of the investigation was sent to the grievant on April 16, 2026, approximately four (4) months after the grievance was received. A grievance related to MR4 was received by the hospital on December 30, 2025. The hospital’s grievance response letter with the results of the investigation was sent to the grievant on April 20, 2026, approximately four (4) months after the grievance was received. An interview was conducted with EMP2 on May 20, 2026, at 1:45 PM. EMP2 indicated that grievances have increased in volume and complexity in the past few months. EMP2 acknowledged that the grievance investigations and responses were delayed in some cases recently. EMP2 indicated that according to facility policy, a grievance should be resolved within 7 days, but if it cannot be resolved in that time, a letter is sent to the grievant explaining the circumstances and informing them they would receive a response in another 30 business days. If the grievance was still not resolved in this timeframe, another extension may be required with a corresponding letter to the grievant. EMP2 indicated the patient relations department was not in timely communication with the grievant related to MR1. EMP2 indicated that the hospital had recognized the delay in grievance responses and is working on a new process to streamline investigations and responses.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it as determined the hospital failed to ensure less restrictive interventions were determined ineffective before placing a patient in restraints in one (1) of two (2) medical records reviewed of patients in violent restraints. Medical Record (MR9). Findings: The facility’s policy, “IHS Restraints and Restraint Alternatives Policy,” last revised June 25, 2024, was reviewed and reads in part, “ ...Definitions ...Violent or self-destructive reasons for restraints or seclusion - When a patient is violent, self-destructive and a restraint is necessary to prevent injury to patient, staff and/or others ...Patient Care/Monitoring/Documentation - Continuous 1:1 observation documented q15; vital signs, patient behavior requiring restraints, and any less restrictive methods attempted previously documented at time of application ...” MR9 was reviewed and contained documentation from the Registered Nurse (RN) as follows on May 17, 2026, “At 700 patient became agitated and runs out of the bed and grabs clothes and goes into the bathroom. Patient began to run off the unit as I began to follow patient, patient began to attempt to elope. Security alert was called and security met us in the hallway and captured the patient. Patient was escorted back to the room and restraints were applied again.” The medical record contained no documentation of any less restrictive interventions attempted before applying restraints. An interview was conducted with EMP5 on May 18, 2026 at 2:45 PM who indicated less restrictive alternatives should be attempted if safe prior to applying restraints.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36946 Based on review of medical records (MR), review of documents, observations, and interviews with staff (EMP), it was determined the facility staff failed to obtain an order for violent restraints for one (1) of two (2) restrained adult patients’ records reviewed, MR9. Findings: The facility’s policy, “IHS Restraints and Restraint Alternatives Policy,” last revised June 25, 2024, was reviewed and reads in part, “ ...Definitions ...Violent or self-destructive reasons for restraints or seclusion - When a patient is violent, self-destructive and a restraint is necessary to prevent injury to patient, staff and/or others ...Use requires an active order by an appropriate privileged physician or licensed practitioner ...Removal of Restraints/Seclusion - Restraints may be removed for care without requiring a new order ...There is no trial release period, if the restraints are removed because discontinuation criteria have been met, a new order must be obtained ...Once restraints have been discontinued, a debriefing session will be held within 24 hours on all inpatient units to include behavioral health units ...” MR9 was reviewed and contained documentation from the Registered Nurse (RN) as follows on May 17, 2026, “At 700 patient became agitated and runs out of the bed and grabs clothes and goes into the bathroom. Patient began to run off the unit as I began to follow patient, patient began to attempt to elope. Security alert was called and security met us in the hallway and captured the patient. Patient was escorted back to the room and restraints were applied again.” There was no documentation in the medical record of a physician order for these restraints. The record contained no documentation of what restraints were used or what limbs were restrained. At 1:34 PM, the RN documented, “...Patient swung at security officer. Patient was immobilized by security and another IM Zyprexa (a medication given via injection into the muscle for agitation) given, soft restraints placed...” There was no documentation in the medical record of a physician’s order for the physical hold to administer medication. The order for MR9’s four point violent restraints expired on May 18, 2026, at 7:30 AM. The order was not renewed until May 18, 2026, at 1:07 PM. Despite having no order for violent restraints, the patient remained in four limb violent restraints from 7:30 AM to 1:07 PM with no physician order. Observations were conducted on May 18, 2026 at 10:30 AM. The surveyor observed MR9 with soft restraints to right and left ankle and right wrist. A handcuff was present on the patient’s left wrist and a police officer was observed outside the patient’s door. An interview was conducted with EMP13 (MR9’s assigned nurse) during observations. EMP13 indicated they were not sure what type of restraints the patient was in or ordered and could not tell the surveyor if the patient was in restraints for violent or non-violent behavior. EMP13 indicated they had been the patient’s nurse all morning and had also been the patient’s assigned nurse for a portion of a shift the day before starting around noon. An interview was conducted with EMP5 on May 18, 2026, at 2:15 PM. EMP5 indicated that orders for violent restraints in adults must be renewed by the provider at least every four (4) hours and that an order is required for continued restraints. EMP5 confirmed per hospital policy, there is no trial period for restraint discontinuation. Once a restraint is removed for meeting criteria, they cannot be reapplied without a new order.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36946 Based on staff (EMP) interview and document review, it was determined hospital staff failed to conduct a debriefing session after violent restraints were discontinued as required by hospital policy in two (2) of two (2) patients reviewed who were in violent restraints. Medical record (MR) MR9 and MR13. Findings: The facility’s policy, “IHS Restraints and Restraint Alternatives Policy,” last revised June 25, 2024 was reviewed and reads in part, “ ...Definitions ...Violent or self-destructive reasons for restraints or seclusion - When a patient is violent, self-destructive and a restraint is necessary to prevent injury to patient, staff and/or others ...Once restraints have been discontinued, a debriefing session will be held within 24 hours on all inpatient units to include behavioral health. Debriefing should include identification of the behavior that led to the use of restraints, what actions or responses could have been different to avoid restraints, and modification of the treatment plan, if necessary...” MR9 contained documentation that a physical hold was performed to administer medication at 1:34 PM on May 17, 2026. The medical record contained no documentation that a debriefing was done per hospital policy after the physical hold. MR13 was placed in violent restraints to all four limbs from 11:39 PM on May 11, 2026, to 00:03 AM on May 12, 2026. The record contained no documentation that a debriefing was done per hospital policy after the restraint episode. An interview was conducted with EMP17 on May 20, 2026, at 2:30 PM. EMP17 indicated that a debriefing was required after all episodes of violent restraints and that the above noted records did not have documentation of such a debriefing occurring.”

“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: 49355 Based on medical record reviews, interviews and document reviews, the facility failed to provide a Medical Screening Examination (MSE) to one (1) [Patient #2] out of twenty (20) [Patients #1 - #20] records reviewed of Springfield HealthPlex Emergency Department patients. At the time of this survey, the facility was in complaince, but was previously out of compliance, with the EMTALA requirements at 42 CFR §489 (Rev. 02-21-20)) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases. The findings: The facility’s policy entitled, “IHS EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act Policy,” PolicyStat ID 17200541, effective date January 14, 2025, reads in part: ... “I. Policy Any individual who comes to an Inova Dedicated Emergency Department requesting, or for whom a request is made, examination or treatment for a medical condition, shall be given an appropriate medical screening. ... II. Purpose To provide guidelines to ensure compliance with EMTALA - Emergency Medical Treatment and Active Labor Act - which requires that (i) a medical screening must be done to determine if an emergency medical condition exists for anyone who comes to an Emergency Department seeking an evaluation or treatment .... ... III. Applies to All hospitals, hospital property areas, including any building owned by the hospital that are within 250 yards of the hospital, and provider-based facilities, and off-campus dedicated Emergency Departments. ... V. Expected Outcomes 2. All hospitals and dedicated emergency departments will meet the guidelines required by the Emergency Medical Treatment and Active Labor Act.” The facility’s policy entitled, “EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act, Addendum Title: Medical Screening Procedure, Addendum Letter: A,” effective date November 2024, reads in part: “A. Medical Screening Examination b. Medical Screening Exam Required ii. An appropriate Medical Screening Examination, within the capability and capacity of the facility, shall be provided to any individual who (i) comes to an Inova Dedicated Emergency Department requesting, or for whom a request is made for, examination or treatment for a medical condition ....” A review of the medical record revealed that Patient #2 was taken to the Springfield HealthPlex Emergency Department [ED] with an accidental self-inflicted gunshot wound [GSW] to the left leg on December 21, 2024, at 11:36 P.M. Patient #2 was transported by a friend and entered the main entrance of the facility’s ED through a metal detector monitored by a security guard.. During triage, Patient #2 denied having any weapons or hazardous materials with them. Patient #2 was provided with a MSE and stabilizing treatment before transfer to another Inova facility at 00:39 A.M. on December 22, 2024. During an interview on February 4, 2025, at 10:57 A.M., Staff Member #4 indicated that the HealthPlex ED was shut down from 11:40 P.M. on December 21, 2024, until 12:20 A.M. on December 22, 2024, approximately forty (40) minutes total, by Staff Member #6. Staff Member #6 notified security to lock the ED down shortly after Patient #2 arrived. Staff Member #6 did not seek approval from an appropriate administrator prior to the lockdown. Staff Member #4 indicated that it was totally inappropriate for Staff Member #6 to lock the HealthPlex ED down. Staff Member #4 was aware of two (2) patients that were turned away at the main entrance by security during the lockdown. Staff Member #4 indicated that the two (2) patients that were turned away required MSEs, per EMTALA requirements and facility policy. During an interview on February 5, 2025, at 8:57 A.M., Staff Member #8 indicated they received a text from Staff Member #6 on December 22, 2024, at approximately 12:20 A.M., notifying Staff Member #8 that they [Staff Member #6] had put the ED on lockdown. The lockdown had already been underway for thirty-five to forty (35-40) minutes. Staff Member #8 indicated that two (2) patients had been turned away by security from the main entrance to the ED during the lockdown. A patient presenting with chest pain was allowed to enter the ED during the lockdown. Staff Member #8 indicated that Staff Member #6 did not have the authority to lockdown the ED and should have called Staff Member #8, the administrator at Inova Alexandria Hospital or Staff Member #4. Staff Member #8 indicated that there were no EMS calls during the lockdown. Staff Member #8 d that indicatethe two (2) patients that were turned away required MSEs per EMTALA regulations. During an interview on February 5 2025, at 9:56 A.M., Staff Member #7 indicated during the lockdown, two (2) patients were turned away, a toddler and a young boy. On February 5, 2025, the surveyor reviewed all education and changes implemented as a result of the reported incident. EMP1, EMP4 and EMP6 reported reeducation was provided to the ED and security staff. Attendance rosters were provided and reviewed by this surveyor to include: diversion and lockdown protocols, a tabletop drill to assess and review restricted access and lockdown procedures, and the”escalation tree” document detailing procedures and step-by-step instructions posted at the ED charge nurse’s desk.”

“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: 49355 Based on medical record reviews, interviews and document reviews, the facility failed to provide a Medical Screening Examination (MSE) for Patient #2, as evidenced during the medical record review of twenty (20) Emergency Department patients. At the time of this survey, the facility was in complaince, but was previously out of compliance, with the EMTALA requirements at 42 CFR §489 (Rev. 02-21-20)) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases. The findings: The facility’s policy entitled, “IHS EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act Policy,” effective January 14, 2025, reads in part: “I. Policy Any individual who comes to an Inova Dedicated Emergency Department requesting, or for whom a request is made, examination or treatment for a medical condition, shall be given an appropriate medical screening. Likewise, any individual who is on Inova Hospital Property other than in a Dedicated Emergency Department, and who requests, or for whom a request is made, examination or treatment for an emergency medical condition, shall be given an appropriate medical screening. ... II Purpose ... (i) a medical screening must be done to determine if an emergency medical condition exists for anyone who comes to an Emergency Department seeking an evaluation or treatment .... III. Applies to All hospitals, hospital property areas, including any building owned by the hospital that are within 250 yards of the hospital, and provider-based facilities, and off-campus dedicated Emergency Departments. ... V. Expected Outcomes ...2. If... an ambulance brings an individual to the Hospital Property or off-campus Dedicated Emergency Department, regardless of any diversionary status, a Medical Screening Examination and any required treatment for stabilizing the individual must be provided.” The facility’s policy entitled, “EMTALA - Compliance with the Emergency Medical Treatment and Active Labor Act, Addendum Title: Medical Screening Procedure, Addendum Letter: A,” with a date of November, 2024, reads in part: “A. Medical Screening Examination a. Medical Screening Exam Required i. An appropriate Medical Screening Examination, within the capability and capacity of the facility, shall be provided to any individual who (i) comes to an Inova Dedicated Emergency Department requesting, or for who a request is made for, examination or treatment for a medical condition .... ii. If an individual comes to an Inova Dedicated Emergency Department and shows signs or symptoms that a prudent layperson would believe indicate the possibility of a medical condition, a Medical Screening Examination is required. ... v. A Medical Screening Examination and stabilizing treatment, as appropriate, are also required for ... (ii) individuals who are in nonhospital-owned ambulances ...on hospital property for purposes of examination or treatment for a medical condition.” Patient #2 was taken to Oakville ED, a free-standing facility of Inova Alexandria Hospital (IAH), at approximately 2:00 A.M. on November 27, 2024, by an Emergency Medical Services (EMS) unit owned by Alexandria City. Once the unit arrived, a clinical team member [Staff Member #7] recommended to the EMS unit that Patient #2 should be transferred to the ED at IAH for further evaluation and possible admission. Patient #2 was never off boarded from the unit into the Oakville ED, was never registered as a patient at the facility and did not receive a Medical Screening Exam (MSE) while there. Patient #2 was transported to the IAH November 27 at 2:16 A.M. where the Patient did receive a MSE and was ultimately admitted. There was no mention in Patient #2’s medical record that the Patient had been transported to Oakville ED initially. The trip log from the City of Alexandria Fire Department reveals that EMS unit transported Patient #2 to the Oakville ED on November 27, 2024, with a chief complaint of “trouble breathing,” noting Patient #2’s level of distress as “mild.” A note on the report states, “PT [patient] transport to INOVA Oakville. Staff met EMS in the ambulance Bay and stated that [Patient #2] should have been transported to INOVA Alexandria due to oxygen administration. EMS then transported PT to INOVA Alexandria ED.” During an interview on January 21, 2025, at 10:32 A.M., Staff Member #5 indicated that any patient that presents to an ED must receive a MSE upon presentation to the ED per EMTALA regulations and per the facility’s policies. During an interview on January 22, 2025, at 9:10 A.M., Staff Member #6 indicated agreement that any patient that presents to an ED must receive a MSE. On January 21, 2025, and January 22, 2025, the surveyor reviewed all changes implemented as a result of the reported incident. According to EMP3, EMP5 and EMP8, one hundred percent (100%) of the ED RNs at the location were reeducated on the facility’s policy concerning EMTALA prior to this survey. A training session, including a question and answer session, was also held for all ED nurses at the affected site. Nurses were also required to take additional Health Streams training on EMTALA that is typically only required annually. All content was reviewed, participant lists were provided and reviewed and interviews with nursing staff confirmed participation in the additional training modules.”

“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: 36946 Based on staff interview and document review, it was determined that the facility failed to maintain an accurate central log of each individual who comes to the emergency department (ED). Specifically, the facility failed to document Patient #3, who was refused treatment, on the central log. Findings: Review of the facility policy titled “EMTALA – Compliance with the Emergency Medical Treatment and Labor Act” dated December 2021, revealed “ ... Each INOVA Dedicated Emergency Department shall maintain a central log (i.e. a triage sign in sheet) that includes the name of each individual who presents to the Dedicated Emergency Department seeking medical attention. The following information shall also be maintained in the central log: a. whether the individual refused treatment; b. whether the individual was refused treatment; or c. whether the individual was: i. transferred, treated and admitted; ii. Stabilized and transferred; or iii. discharged.” Review of the facility ’ s central log from November 1, 2023, through December 26, 2023, identified it did not contain any patients that were refused treatment including P3 who presented November 29, 2023. This was confirmed in an interview with Staff Member (SM) 4, nurse.”

“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: 36946 Based on staff interview and document review, it was determined the facility failed to provide an appropriate MSE to determine whether an EMC existed in one of twenty cases reviewed in the survey sample (P3). Findings: Review of the facility policy titled “EMTALA - Compliance with the Emergency Medical Treatment and Labor Act” dated December 2021, revealed “An appropriate Medical Screening Examination, within the capability of the facility, shall be provided to any individual who (i) comes to an INOVA dedicated emergency department requested, or for whom a request is made, examination or treatment for a medical condition; or (ii) is on INOVA Hospital Property other than in a Dedicated Emergency Department and who requests, or for whom a request is made for an emergency medical condition..” Review of P3 ’ s ambulance trip record dated November 29, 2023, at 11:10 PM revealed the medic “arrived on grounds at Alexandria Hospital. Paramedic [name] went into Alexandria Hospital ED to speak with ER (emergency room) doctor ... [upon return to the ambulance] stated MD (medical doctor) would not accept patient or evaluate injuries was told to leave hospital and go to [name of other hospital].” Interview with SM3, emergency room physician, on December 27, 2023, at 11:10 AM confirmed that they told the paramedic to “take the patient to another hospital” after EMS arrived onsite and that Patient #3 did not receive an MSE prior to leaving the facility. Interview with SM1 and SM2 (Hospital Administration) on December 27, 2023, at 11:15 AM confirmed that a medical screening exam was not performed on P3 prior to directing EMS to take the patient to another hospital. Both SM1 and SM2 indicated that P3 should have received an MSE.”