Lewisgale Hospital Pulaski

“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: 33906 Based on clinical record review, interviews and document reviews, the facility failed to ensure compliance with EMTALA requirements at 42 CFR 489.24: Special Responsibilities of Medicare Hospitals in Emergency Cases. 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 facility staff failed to provide a Medical Screening Examination (MSE) for a patient who presented for evaluation of depression. The hospital staff informed the patient, after their arrival to the ED (Emergency Department), that they would not be able to receive behavioral health services because they had a dog with them. Cross reference: §489.24(a) (1)(i) - Applicability of Provisions of this Section”

“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: 33906 Based on clinical record review, interviews and document review, the facility staff failed to provide a Medical Screening Examination (MSE) for one (1) patient (Patient #3) who presented to the Emergency Department (ED) requesting an evaluation for depression. 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 include: Review of the medical record for Patient #3 revealed that Patient #3 was brought to the ED by EMS (Emergency Medical Services) at 2:16 AM on February 13, 2025. According to the information documented in the EMS “Prehospital Care report”, Patient #3 had been found outside of the local train station by police who called EMS. Upon EMS arrival Patient #3 stated they had a brain injury, had been very depressed and needed to talk to someone. Patient #3 denied suicidal or homicidal ideation. Patient #3 was triaged in the ED at 2:22 AM as alert, ambulatory and having a dog in their jacket. Staff #7 completed a suicide and violence assessments placing Patient #3 at low risk and small risk. Emergency note by Staff #8 at 2:20 AM, revealed “Security and supervision at bedside. Pt (patient) appears to have a dog in (their) shirt.” Emergency note by Staff #8 at 2:31 AM, revealed “Pt left ED ambulatory with security.” No medical screening exam was conducted, no medical tests were obtained. The medical record failed to provide evidence of any conversation with Patient #3 concerning the dog and it’s status as a service animal. The record didn’t include AMA documentation and or discussion about th risks and benefits of refusing treatment. Total time in ED according to documentation was 15 (fifteen minutes). Review of the video footage for this event revealed Patient #3 arrived via EMS and was taken to room #3. At 2:19 AM, Staff #10 (security) and Staff #9 (house supervisor) entered room #3, out of sight of camera. Staff #8, appeared briefly at the doorway of room #3 at 2:21 AM, then continued down the hall. At 2:27 AM, Patient #3 was observed leaving room #3, accompanied by Staff #9 and #10. Staff #10 walked with Patient #3 to the waiting area where Patient #3 paused and sat for a moment, with Staff #10 waiting a few feet away. Patient #3 walked accompanied by Staff #10 to the exit . The surveyor was not able to determine from the video if Patient #3 had a dog with them. Staff #9 explained that the dog was in the patient’s shirt and was the size of a small Chihuahua or terrier. The surveyor conducted interviews with involved staff on March 3, 2025 which revealed following: Staff #7 - indicated they were at the desk taking report from EMS and entered the triage information in the record. Patient #3 was triaged at a level 2 (urgent) and taken to room #3. Staff #8 then came to their desk and stated “(Patient #3) has the dog, I’m going to call (Staff #9)”. Staff #9 saw Patient #3. Staff #7 recalled, “I heard (Staff #9) say they’re not going to let (Patient #3) have a dog on BHU (Behavioral Health Unit). So, (Patient #3) said, I’m not staying, she (the dog) goes where I go.” Staff #7 explained that shortly after that the security was walking Patient #3 out. Staff #8 - indicated they didn’t go in the room, but saw Patient #3 on the monitor “shuffling around and seemed to have something in (their) shirt”. Staff #8 had cared for Patient #3 before and knew they had a dog. Staff #8 explained that all behavioral health patient’s get wanded by security, so they called security upon Patient #3’s arrival. Staff #8 asked Staff #9 to care for Patient #3. Staff #9 - indicated they were house supervisor that night and in charge of the hospital. Staff #8 called them stating they needed help in ED with a patient in room #3. Staff #8 stated “this is the guy that has the dog.” Staff #9 told Staff #8 they have not had issues with the dog before. Staff #9 recalled that upon arrival to the ED, Staff #8 and Staff #14 were sitting at the desk and Staff #8 said “I’m not dealing with this”. Staff #9 went to room #3 and explained to Patient #3 that they knew that on the medical unit they had always made accommodations for their dog, but they didn’t know if they would on the behavioral health unit. Patient #3 said, “I’m just going to leave if I can’t take my dog”. Staff #9 recalled telling Patient #3 they didn’t have to leave. At that time, Patient #3 did not say anything about hurting themselves and left. Staff #9 explained that later they got a call from security that “cops” had sent the patient down the road. Staff #9 confirmed that they did not ask any questions to determine if the dog was a service animal and they didn’t perform a medical screening exam on Patient #3 to determine a need for placement on the behavioral health unit. Staff #10 - indicated they were called to the ED to wand a patient presenting with depression and arrived there about the same time as Staff #9. Staff #10 indicated that the process is, they ask patients who present with animals, “Is this a service animal and what service does the animal provide for you?” Staff #10 recalled Patient #3 stating, “She’s all I have.” Staff #10 explained that Patient #3 then gathered their dog and stuff and they walked them out. Staff #10 clarified that Staff #9 never said that we wouldn’t help just that we needed to get help with the dog. The patient was never aggressive nor was the dog. It was a little dog and was under their shirt. Staff #10 added, “It is not policy that we escort all patient’s out, I was just there”. Patient #3 left, went to the bus stop area but kept coming back in. Staff #10 asked Staff #9 if it was okay to get the police to ask patient to move on, and they said yes. Review of hospital policy “Accommodating Persons with Service Animals” effective 5/1/18 indicates that if it is not readily apparent the dog is a service animal staff should only ask: If the animal is required because of a disability? and What work or task has the animal been trained to perform? Staff should never attempt to separate the service animal from the person with the qualified disability. A patient will only be asked to remove their service animal from the premises if the animal is out of control or not house broken. The hospital has arrangements in place for the care of a service animal in a boarding facility. Review of hospital policy “EMTALA - Definitions and General Requirements, LL.EM.001” effective 06/24 indicates if a patient presents to the ED and requests services and indicates a desire to leave before the medical screening exam, staff should discuss with the individual the risks and benefits involved in leaving prior to the medical screening and document the discussion; describe in the medical record the examination or treatment that was refused or the request for treatment was withdrawn and sign, date and time the form. Review of ED logs found Patient #3 visited this ED on 20 (twenty) occasions since 04/06/22. On two occasions, Patient #3 was admitted, and it is documented that Patient #3 had been allowed to keep the dog with them during those admissions. Interviews with staff who are familiar with Patient #3 confirmed that they always have the dog with them when they come to the ED and it has never been a problem. The hospital failed to provide a medical screening exam for Patient #3 and the patient was given the understanding they would not be able to keep the dog with them and receive services. The patient was encouraged to leave as evidenced by the patient being escorted out of the hospital and hospital security asking local police to have Patient #3 move off the property. There is no documentation of any further conversations with Patient #3 other than those noted above and no AMA (against medical advice) forms were signed. Staff #1 (CEO), was alerted about Patient #3’s return to the ED by Staff #15 at around 9:00 AM on February 13, 2025. Staff #4, Staff #2, and Staff #16 began investigating the incident because of the concern for a possible EMTALA. ED staff and full time providers were educated by February 26, 2025 on hospital policy “ADA: Accommodating Persons with Service Animals” and “EMTALA: Virginia EMTALA Medical Screening Examination and Stabilization”. At the time of survey, corporate approval of additional training to be assigned to ED staff was going through committee and is to include: compassion fatigue, ADA, Trauma Informed Care, accountability. ADA training will be provided for supervisors, registration, environmental services and security staff. At the time of survey, the hospital had not self-reported this event.”