Highline Medical Center

“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: 45888 . Based on document review and interviews, the hospital failed to implement policies and procedures for the transfer of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to implement policies and procedures for the transfer of emergency care patients in accordance with EMTALA requirements places patients at risk for delays in care, poor health outcomes, and death. Findings included: The hospital failed to complete an informed written consent for transfer signed by a physician and the patient or patient representative, indicating the risks and benefits of the transfer, in 2 of 4 patients transferred to another facility (Patients #8 and #20). Cross-reference: Tag A2409 .”

“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: 45888 . Based on document review and interviews, the hospital failed to implement policies and procedures for transferring patients with an emergency medical condition to another medical facility by failing to ensure a written consent for transfer indicating the risks and benefits of the transfer was signed by a physician and the patient or patient representative in 2 of 4 patients transferred to another facility (Patients #8 and #20). Failure to implement policies and procedures for written consent when transferring patients with emergency medical conditions places patients at risk of an inappropriate or unsafe transfer, delayed care, and poor patient outcomes. Findings included: 1. Document review of the hospital policy titled, “EMTALA - Examination, Treatment and Transfer of Individuals in Need of Emergency Services, 345.00,” last reviewed 01/13/22, and the document titled, “Interfacility and EMTALA Transfer Consent,” last reviewed 03/29/24, showed when transferring a patient with an emergency medical condition to another facility, a physician must sign a transfer consent form indicating the benefits of the transfer outweigh the risks. The patient or their representative must also sign the consent demonstrating understanding of the risks and benefits of the transfer. The hospital will send the receiving facility a copy of the signed consent. 2. Document review of patient medical records showed the following: Patient #8 - On 11/14/25 at 3:49 PM, Patient #8 presented to the hospital emergency department (ED) for emergency care. The hospital provided a medical screening exam during which Patient #8 was medically cleared, but concerns of active suicidal ideation and auditory hallucinations were identified. The hospital does not provide inpatient psychiatric services. The hospital contacted another facility that provides inpatient psychiatric services. The other facility accepted the patient. Patient #8 transferred to the other facility on 11/15/25 at 2:22 AM via ambulance. - Patient #8’s medical record showed no evidence of a transfer consent form. Patient #20 - On 07/04/25 at 1:26 AM, Patient #20 presented to the hospital ED for emergency care. The hospital provided a medical screening exam during which Patient #20 was medically cleared, but concerns of active suicidal ideation were identified. The hospital does not provide inpatient psychiatric services. The hospital contacted another facility that provides inpatient psychiatric services. The other facility accepted the patient. Patient #20 transferred to the other facility on 07/04/25 at 2:40 PM via ambulance. - Patient #20’s medical record showed a transfer consent form containing no patient or provider signatures. 3. On 12/08/25 at 10:42 AM, Investigators #1 and #2 interviewed the hospital’s Emergency Department Nurse Manager (Staff #1) who reviewed medical records with the investigators. Staff #1 confirmed review of medical records showed no evidence of complete informed written consent for transfer in 2 of 4 patients transferred to another facility. 4. On 12/09/25 at 11:40 AM, Investigator #1 interviewed the hospital’s Regional Compliance Manager (Staff #2) regarding transfer consents. Staff #2 confirmed that a transfer consent form could not be located for Patient #8, and a signed transfer consent form could not be located for Patient #20. Staff #2 stated that the hospital contacted the receiving facilities for Patients #8 and #20, but the receiving facilities were unable to produce copies of the transfer consent forms. .”

“PATIENT RIGHTS CFR(s): 482.13 A hospital must protect and promote each patient’s rights. This Condition is not met as evidenced by: 49702 . Based on interview and document review, the hospital failed to ensure that patients were provided care in a safe environment, free from abuse or neglect. Failure to protect patients from abuse places patients at risk for serious physical and/or psychological harm. Findings included: The hospital failed to implement interventions to prevent and respond to allegations of sexual abuse or assault. Cross reference: Tag A-145 Due to the severity of deficiency under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET. .”

“PATIENT RIGHTS: INFORMED DECISION CFR(s): 482.13(b)(3) The patient has the right to formulate advance directives and to have hospital staff and practitioners who provide care in the hospital comply with these directives, in accordance with §489.100 of this part (Definition), §489.102 of this part (Requirements for providers), and §489.104 of this part (Effective dates). This Standard is not met as evidenced by: 49702 . Based on interview, record review, and review of hospital policies and procedures, the hospital failed to implement its policy regarding documentation of advance directives in the medical record for 2 of 5 patient records reviewed (Patient #104 and Patient #105). Failure to obtain direction for life-sustaining treatment could result in resuscitating a patient or prolonging the patient’s life against the patient’s wishes. Findings included: 1. Document review of the hospital’s policy and procedure titled, “Advance Directives,” PolicyStat ID 10773953, last revised 12/21, showed the following: a. CHI Franciscan Health will provide each adult inpatient with information about their rights to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate advance directives. b. At the time an individual is admitted as an inpatient, the registrar shall inquire if the patient has an advance directive. If the patient has an advance directive, the registrar shall insert the type in the electronic health record. c. A copy of the advance directive shall become a permanent part of the patient’s electronic health record (EHR). d. The registrar shall inform the patient/family that written information pertaining to the patient’s right to make decisions is available. If the patient/family would like some information, the registrar can provide the patient with a Decisions booklet that describes Living Will and a Healthcare Power of Attorney. The booklet includes these forms. If information is provided, this is noted in the electronic health record. e. In addition to the registration record, information regarding the status of the advance directive is documented in the electronic health record nursing admission assessment, unless otherwise specified by unit standards. f. If the patient has an advance directive but it is not available, the nurse requests the family or surrogate decision-maker to bring a copy to the hospital for the medical record. The Plan of Care should note the status and availability of the advance directive. g. The Plan of Care is a dynamic plan for treatment, care and services that is created and maintained by the multidisciplinary care team and individualized to specific assessed needs of the patient. It includes the Patient Storyboard, Medication Administration Record, Patient Education Record, Care Plan templates, and Patient Summary page. Document review of the hospital’s policy and procedure titled, “Patient Admission Assessment and Reassessment Policy,” PolicyStat ID 9494721, last revised 03/21, showed the following: a. The registered nurse (RN) is responsible for performing the nursing admission assessment. b. Within 12 hours of admission, the RN is to ask if the patient has an advanced directive, check filed documents for previous visit advance directives, or request a copy from family/friends. c. If components of the initial assessment are not completed due to the patient’s condition or other reasons, the RN must document on the admission record in the EHR the reason pertinent information has not been able to be obtained. Attempts to contact significant others, family, other facilities, or providers is noted if indicated. d. Upon admission to the unit, the RN is responsible for verifying and documenting the evidence of an Advance Directive (AD) on the Admission Assessment in the EHR. The RN is responsible for assuring the document is filed appropriately in the patient’s medical record, if available. The RN should request the patient/family provide the AD as soon as possible, if not available at the time of admission. 2. On 05/21/24 at 3:11 PM, the investigator and Intensive and Progressive Care Clinical Manager (Staff #117) reviewed medical records for 2 hospital patients admitted between 04/01/24 and 05/20/24. The review showed the following: Patient #104 a. On 04/02/24 at 10:10 AM, Patient #104 was admitted to the hospital, and the registered nurse (RN) documented a nursing admission assessment. Admission Navigator documentation showed that Patient #104 had an Advance Directive, but the investigator found no evidence of an Advance Directive on file in the patient’s EHR. b. At the time of the review, Staff #117 confirmed that it did not appear that documentation of advance directives was present in nursing views of the electronic health record. Patient #105 c. On 05/03/24 at 7:44 PM, Patient #105 was admitted to the hospital, and the RN documented a nursing admission assessment. Review of the Admission Navigator showed documentation that Patient #105 did not have an advance directive. The investigator could find no evidence that Patient #105 was provided with information regarding the right to formulate an advance directive or offered a Decisions booklet. d. At the time of the review, Staff #117 confirmed that it did not appear that documentation of advance directives was present in nursing views of the electronic health record. 3. On 05/22/24 at 12:36 PM, the investigator interviewed the Patient Access Manager (Staff #119). Staff #119 confirmed the investigator’s findings of the missing Advance Directive documentation and verified that Patient Access/Registration staff failed to complete the documentation process according to hospital policy. .”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 49702 . Based on interview and record review, the hospital failed to develop and implement an effective system to prevent and respond to allegations of sexual abuse or assault for 2 of 2 patients reviewed (Patient #101 and Patient #102). Failure to protect patients and to ensure care in a safe environment by preventing patient sexual abuse or assault and responding appropriately when allegations occur risks violation of patient rights, serious injury, and/or psychological harm. Findings included: 1. Document review of the hospital’s policy titled, “Reporting Alleged Harassment, Abuse or Neglect of Patients While in Our Care,” PolicyStat ID 15350531, last revised 03/24, showed the following: a. No judgment should be made by the workforce member regarding whether the patient’s complaint or allegation is real or perceived. b. Staff are responsible and obligated to immediately report any form of sexual abuse/assault or inappropriate behavior perpetrated by staff, another patient, or a visitor to department leadership, the house supervisor, or the charge nurse or lead. c. The department leadership or designee immediately assures patient safety and privacy by removing the alleged abuser from the environment or premises if indicated. d. When there is suspected abuse, assault, or possible crime it must be reported to the local police or appropriate law enforcement agency within 48 hours. Document review of the hospital’s policy titled, “Incident Reporting Information System (IRIS) Guidelines and Management, 418.00,” PolicyStat ID 9305091, last revised 07/21, showed the following: a. An incident is any happening that is not consistent with the routine care and could have an impact on a patient. b. Reporting unprofessional conduct of any licensed Health Care Practitioner (to include agency staff, employed providers, pharmacists, and nursing personnel) should be documented within the reporting system. If the incident is serious, it should also be reported immediately to the unit/clinic manager or designee and risk management. Document review of the hospital’s policy titled, “Reporting Abuse/Neglect of Vulnerable Adults Policy,” PolicyStat ID 10794950, last revised 12/21, showed the following: a. A vulnerable adult is defined as including persons 60 years of age or older who have the functional, mental, or physical inability to care for themselves. b. For instances of alleged abuse or neglect, a formal report will be made by the physician, clinic, or hospital delegate verbally and immediately to DSHS/Division of Home & Community Services (Adult Protective Services - APS). c. Staff should call 9-1-1 in cases of sexual assault. Patient #101 2. Medical record review showed that on 04/23/24 at 3:50 PM, a 67-year old patient (Patient #101) reported to a social worker (Staff #101) that that overnight, a staff member touched her inappropriately while providing peri-care (hygiene care that involves cleaning of the genital or anal area) after a bowel movement. The medical record showed that Staff #101 filed a report with Adult Protective Services (APS) and informed Patient #101’s assigned nurse (Staff #107), attending physician (Staff #102), and the department manager (Staff #108) of the allegation. The medical record showed that a male certified nursing assistant (CNA) (Staff #111) had performed peri-care for Patient #101 on 04/22/24 at 9:00 PM and on 04/23/24 at 6:00 AM. 3. On 05/20/24 at 12:20 PM, the investigator interviewed Staff #101. The interview showed that Patient #101 talked about the alleged sexual abuse as being inappropriate and discussed involving legal representation. Staff #101 stated that on 04/23/24, he reported the incident to Patient #101’s physician (Staff #102), Patient #101’s assigned nurse (Staff #107), and a department leader whose name he could not recall. Staff #101 confirmed that he did not file an incident report. 4. On 05/13/24 at 11:42 AM, the investigator interviewed the inpatient nursing department supervisor (Staff #103) and department manager (Staff #108). During the day shift (7:00 AM to 7:00 PM) on 04/23/24, Staff #101 informed Staff #103 that Patient #101 requested to have only female caregivers assigned to her care. Staff #103 and Staff #108 stated that they were not made aware of allegations of sexual abuse or assault involving Patient #101. 5. On 05/14/24 at 1:28 PM, the investigator interviewed Patient #101’s physician (Staff #102). The interview showed that Staff #101 informed Staff #102 of Patient #101’s request to have only female caregivers assigned to her care. Staff #102 asked Patient #101 directly about this request. Patient #101 told Staff #102 that she did not like how a staff member the night before had touched her clitoris during an episode of peri-care. Patient #101 told Staff #102 the alleged staff member’s name. Staff #102 asked department nursing staff who had been on the schedule the night before, and the staff member that Patient #101 had named had not been working. Staff #102 stated that his conversation with Patient #101 regarding the incident had been brief, and he did not ask whether she felt the touching of her clitoris had been intentional or inadvertent. Staff #102 stated that he felt that sexual abuse or assault had not occurred, but that Patient #101 was uncomfortable with the care she had received. Staff #102 stated that since Staff #101 was completing a report to APS and female caregivers were assigned to Patient #101 as requested, no further reporting or action was needed. Staff #102 stated that he did not file an IRIS report or otherwise escalate reporting of the incident. 6. On 05/13/24 at 5:05 PM, the Regulatory Compliance Program Manager (Staff #104) confirmed that no incident reports regarding Patient #101 existed within the hospital’s incident reporting system, the hospital leadership had not been aware of the incident prior to 05/13/24, and that hospital staff had not reported the incident to law enforcement. Patient #102 7. Review of Patient #102’s medical record showed that on 12/09/22, Patient #102, a 61-year old female, alleged that she had been raped over night on 12/08/22 by a staff member, and that the staff member grabbed her arm causing pain and leaving marks on her knuckles. Patient #102 provided a physical description of the alleged staff member. Document review showed that on 12/09/22 at 2:00 AM, Staff #111 provided peri-care for Patient #102. Medical record review and review of hospital documents showed no evidence that staff notified law enforcement of Patient #102’s sexual assault allegation. 8. On 05/22/24 at 4:20 PM, the investigator interviewed a physician (Staff #110) regarding training and communication he had received from the hospital about actions to take if a patient alleges sexual abuse or assault while under the hospital’s care. The investigator asked whether Staff #110 had ever received such a report from a patient and what actions had been taken. Staff #110 stated that about a year prior, a patient (Patient #102) had reported being made to feel sexually uncomfortable by a staff member overnight. Staff #110 stated that he documented the incident in Patient #102’s medical record, completed an incident report, alerted the department charge nurse, alerted the head of the social work department, and connected the patient with the patient advocate to facilitate completing a grievance. 9. On 05/22/24 at 5:20 PM, the investigator interviewed the department manager (Staff #117) who had documented the investigation of Patient #102’s allegation. Staff #117 stated the following: 2 CNAs matching the physical description provided by Patient #102 were working on the night shift between 12/08/22 and 12/09/22. Staff #111 was 1 of 2 CNAs matching the physical description provided by Patient #102. No staff members were removed from the schedule and law enforcement was not notified during the hospital’s investigation of the incident because a single suspected staff member could not be identified. 10. On 05/23/24 at 1:00 PM, the investigator interviewed the Division Director of Patient Safety (Staff #112). The interview showed the following: Patient allegations of sexual abuse or assault alone would not lead to a report to local law enforcement. Hospital leaders would investigate the allegation, convene a multidisciplinary focused assessment team to review information from the investigation, and determine if an incident was suspicious enough to report. The hospital did not file a report with law enforcement regarding Patient #101 because no other staff members had awareness of the incident and, when interviewed by by members of the focused assessment team, Patient #101 stated that she felt uncomfortable with the care she had received but did not repeat her allegation of sexual abuse. The hospital did not file a report with law enforcement regarding Patient #102 because 2 CNAs matching the physical description of the alleged perpetrator were working during the 12/08/22 night shift, and Patient #102 did not repeat the allegation that she had been raped when interviewed by members of the focused assessment team. 11. On 05/23/24 at 11:00 AM, the investigator interviewed the Chief Nursing Officer (CNO) (Staff #116). The CNO stated that Staff #111 was never removed from the schedule or patient care activities following either allegation of abuse. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(ii) [The use of restraint or seclusion must be--] (ii) implemented in accordance with safe and appropriate restraint and seclusion techniques as determined by hospital policy in accordance with State law. This Standard is not met as evidenced by: 49702 . Based on document review and interview, the hospital failed to implement its policy to ensure that patients placed in violent/self-destructive restraints or seclusion were continuously observed for safety per hospital policy for 1 of 4 patients reviewed (Patients #103). Failure to monitor patients in restraints places patients at risk for physical and psychological harm, decline in status, loss of dignity and violation of patient rights. Findings included: 1. Document review of the hospital’s policy titled, “Restraint and Seclusion Policy,” PolicyStat ID 12719679, last revised 12/22, showed the following: a. Seclusion describes the involuntary confinement of a person in a locked room or a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behaviors. b. Violent or self-destructive restraint/seclusion is used in an emergency when a patient’s behavior is violent, aggressive, or destructive and jeopardizes the immediate physical safety of the patient, staff, or others. c. Staff must assess and monitor a patient’s condition on an ongoing basis to ensure that the patient is released from restraint or seclusion at the earliest possible time, regardless of the scheduled expiration of the order. d. Appropriate care, monitoring, and interval for re-assessment are based on the patient’s needs, condition and type of restraint used. e. Violent/self-destructive restraint and seclusion monitoring requires continuous observation with documentation every 15 minutes to ensure correct restraint placement, injury prevention, circulation and skin integrity, and emotional well-being. Fluids, food, and toileting are offered every 1 to 2 hours. 2. Medical record review showed that Patient #103 was brought to the St. Anne Hospital emergency department (ED) on 04/12/24. On 04/14/24 at 10:50 PM, Patient #103 was placed into seclusion following an episode of agitation and threats to leave the department from which he could not be verbally redirected. Seclusion orders were renewed for Patient #103 on 04/15/24 at 2:00 AM. Seclusion orders were discontinued on 04/15/23 at 5:30 AM when Patient #103 was placed into 2-point nonviolent restraints for administration of IV medication. The investigator could find no evidence of continuous monitoring being documented every 15-minutes for the 6 hours and 40 minutes that Patient #103 remained in seclusion. 3. On 05/22/24 at 10:30 AM, the Intensive and Progressive Care Clinical Manager (Staff #117) confirmed the investigator’s finding of the missing required monitoring documentation. .”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 49702 . Based on interview and document review, the hospital failed to ensure completion and documentation of a 1-hour face-to-face evaluation after placing a patient in seclusion or violent restraints for 1 of 4 patients reviewed (Patient #103). Failure to ensure completion of a 1-hour face-to-face evaluation puts patients at risk for adverse outcomes, physical and psychological harm, and death. Findings included: 1. Document review of the hospital’s policy titled, “Restraint and Seclusion Policy,” PolicyStat ID 12719679, last revised 12/22, showed that appropriate care, monitoring, and interval for re-assessment are based on the patient’s needs, condition and type of restraint used. For violent/self-destructive restraint and seclusion, a 1-hour face to face evaluation that includes the patient’s immediate situation, patient’s reaction to the intervention, patient’s medical and behavioral condition, and the need to continue or terminate the restraint or seclusion must be documented. 2. Medical record review showed that Patient #103 was brought to the St. Anne Hospital emergency department (ED) on 04/12/24. Patient #103 was involuntarily detained for grave disability. On 04/14/24 at 10:50 PM, Patient #103 was placed into seclusion following an episode of agitation and threats to leave the department from which he could not be verbally redirected. The investigator could find no evidence that the patient received a face-to-face evaluation within 1 hour of being placed in seclusion. 3.On 05/22/24 at 10:30 AM, the Intensive and Progressive Care Clinical Manager (Staff #117) confirmed the investigator’s finding of the missing required documentation. .”