Riverside Regional Medical Center

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 41450 Based on patient interview, clinical record review, staff interview, and facility documentation review, hospital staff failed to adhere to hospital policy for one patient, Patient (P) #3, out of a survey sample of 9 patients seeking care at the hospital’s Emergency Department (ED). The findings include: For P #3, hospital staff failed to follow hospital policy to provide timely reassessments while seeking medical care in the ER on 7/30/25. On 9/30/25 at approximately 11:40 AM, a telephone interview was conducted with P #3 who stated, “I arrived at the ED by ambulance, I was having chest pain like I have never experienced before and it would not go away, the nurse checked my blood pressure and got an EKG then put me out front in the waiting room with everyone else, I was sitting in the waiting room for at least 4 hours without being seen or updated by anyone, my chest pain would not go away and I was really getting more concerned, I went up to the front desk to see how much longer my wait would be to see a doctor and to report that I was still having chest pain, I was told that everyone was busy in the back and was told that I could just leave if I wanted to, I asked for my records because I wanted to go to another hospital to be seen and was told ‘there is no paperwork’”. On 9/30/25 at approximately 12:15 PM, a clinical record review was conducted for P #3 and revealed the following: P #3 arrived to the ED on 7/30/25 at 22:46 PM via ambulance, with complaints of chest pain. At 22:47 PM, vital signs were obtained which included blood pressure 142/90, heart rate 84, respiratory rate 17, oxygenation on room air 100%, and temperature 98 F. At 22:50 PM, “full triage” was “complete” with “Patient Acuity: Urgent, Acuity 3 Selected”. At 22:56 PM, an EKG was obtained. At 23:24 PM, P #3 was placed in the waiting room/intake waiting. At 02:37 AM on 7/31/25, “LWBS [Left Without Being Seen] after Triage--Patient dismissed”. There were no nursing notes/narratives or healthcare provider notes documented in P #3’s medical record. The assigned triage nurse was unavailable for interview. On 9/30/25 at approximately 2:30 PM, an interview was conducted with Staff Member (SM) #1 and SM #6, the ED Director, and they were updated on the findings. SM #6 stated, “It is my expectation that my nursing staff will provide ongoing monitoring for changes in clinical condition and reassessments for patients while waiting to see a provider, we would re-prioritize getting a patient in front of a provider if needed”. SM #6 reviewed P #3’s medical encounter in the ED on 7/30/25 and confirmed the above findings and stated, “Based on our hospital policy and the assigned acuity level 3, vital signs were not obtained at the expected frequency for assessments, a level 3 gets vital signs every 2 hours per policy”. On 9/30/25 at approximately 2:45 PM, a review of the hospital’s policy titled, “[name redacted]-Assessment/Reassessment Policy”, effective date 9/08/2023, subheading, “Purpose”, page 1, read, “The purpose of this policy is to provide an assessment/reassessment framework to ensure patients receive a timely assessment of their individual clinical presentation by qualified individuals within the organization”. Also, subheading, “Emergency Department/Emergency Observation Unit”, page 5, item A, read, “All patients presenting to the emergency room receive a quick triage assessment to determine the severity of the presenting chief complaint. An acuity level is assigned to each patient during the initial assessment. Patients are reassessed based on acuity, interventions, and changes in condition ...” and page 6, item F “Vital Signs”, item 1 “Frequency ...ESI [Emergency Severity Index used to assign Acuity Level] ESI Level 3: minimum every two hours ...”.”

“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 interview and document review, it was determined the facility failed to implement less restrictive measures prior to placing a patient in restraints in one (1) of four (4) medical records reviewed in the survey sample (Medical record #4). Findings: The medical record for Patient #4 contained a physician’s order for bilateral secured mitts to protect the integrity of lines and tubes at 3:23 PM on October 28, 2024. It was unclear from the medical record when the restraints were initiated. The first documentation of the restraints by nursing staff occurred on October 28, 2024 at 7:24 PM. This documentation revealed that restraints were “continued.” The documentation did not indicate what if any less restrictive alternatives were considered prior to initiation of the restraints and at the start of each order as mandated by facility policy. Less restrictive measures were first documented at 11:25 AM on October 29, 2024 (the following day). Additionally, documentation indicated the restraints were discontinued at 2:54 PM on October 29, 2024. The last restraint monitoring was completed by nursing staff at 11:25 AM on October 29, 2024, approximately three and a half hours before the restraints were discontinued. The hospital’s policy, Restraint Policy was reviewed and reads in part: Nonviolent/Nondestructive patients in restraints shall have their behavior reassessed and documented....2. Description of alternatives or other less restrictive interventions attempted. Documented at the start of each order and as indicated....7. Patient monitoring: a. At least every two hours for all other non-behavioral patients. This assessment includes, as appropriate to the type of restraint employed: signs of any injury associated with the application of restraint; skin integrity; nutrition/hydration needs (while awake); circulation; elimination needs; physical and psychological status and comfort; readiness for discontinuation of restraint. An interview was conducted with Staff Member #2 on December 3, 2024 who confirmed less restrictive alternatives and every two hour monitoring should be documented in all patients in restraints.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 41450 Based on clinical record review, staff interview, and facility documentation review, hospital staff failed to conduct appropriate transfers for 2 patients (Patient (P) #45 and P #50) of 4 patients reviewed for transferring from the Emergency Department (ED) to an outside facility. The findings include: Prior to transferring P #45 and P #50 from the ED, hospital staff failed to obtain an agreement and acceptance with a receiving hospital, to include verification that the receiving hospital could provide appropriate medical treatment, had available space, and qualified personnel for the treatment of the patients and failed to ensure all medical records were sent to the receiving hospital. On 11/13/24 between 10:00 AM and 12:15 PM, clinical record record reviews were conducted for P #45 and P #50 and revealed the following: P #45 walked into the ED on 5/11/24 at 1:59 PM, accompanied by spouse, with complaints of headache and anxiety. A medical screening exam was performed with findings of hypertension, headache, and an abnormal EKG. The provider’s medical decision making note read, “...911 was called and patient will be transported to a medical ED for further workup and management”. P #45 was transferred out of the ED on 5/11/24 at 3:14 PM. The medical record failed to contain evidence of a hospital accepting the transfer of P #45, the name of an accepting physician at the receiving hospital prior to transfer, and failed to contain evidence of any records sent to the receiving hospital at the time of transfer. P #50 walked into the ED on 6/12/24 at 4:15 PM, accompanied by family, with complaints of feeling suicidal and stated he took some pills and drank a lot of alcohol. A medical screening exam was performed and the provider’s medical decision making note read, “The patient is a poor/unreliable historian and not forthcoming with adequate/accurate information [about] his attempted overdose/suicide attempt on pills [and] alcohol, the patient [is] unsteady on his feet, with slurred speech and somewhat incoherent...patient will be sent out 911 for medical clearance”. P #50 was transferred out of the ED on 6/12/24 at 4:56 PM. The medical record failed to contain evidence of a hospital accepting the transfer of P #50, the name of an accepting physician at the receiving hospital prior to transfer, and failed to contain evidence of any records sent to the receiving hospital at the time of transfer. On 11/13/24 at approximately 2:30 PM, a group meeting was conducted with Staff Member (SM) #1, SM #2, and SM #8 and they were updated on the findings. SM #2 verified that 911 Emergency Services was used to transfer P #45 and P #50 from their ED without advance arrangements made to the receiving hospital. The hospital’s policy titled, “[name redacted]-ED-EMTALA-Medical Screening Examination, Stabilization and Transfer”, effective date 10/04/2023, page 9, subheading, “Appropriate Transfers” reads, “An appropriate transfer is one where:”, item 2, “The receiving hospital has available space and qualified personnel to provide care for the individual and has agreed to accept the transfer” and item 3, “The transferring hospital send the receiving hospital all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of transfer”.”