Confluence Health Hospital

“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: 43837 . Based on observation, interview, record review and review of hospital policies and procedures and medical staff bylaws, the hospital failed to develop and implement policies and procedures for evaluation and treatment of patients presenting for emergency care in accordance with the Emergency Medical Treatment and Labor Act (EMTALA). Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death. Findings included: 1. The hospital failed to identify in medical staff bylaws the providers qualified to perform medical screening examinations. The hospital failed to conduct a medical screening examination for a patient that presented to the Emergency Department via ambulance that required decontamination. Cross reference: C-2406 .”

“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: 43837 . Item #1 Authorized personnel to perform Medical Screening Examinations . Based on interview, review of hospital policies and procedures, review of medical staff bylaws and rules and regulations, the hospital failed to identify and approve the medical personnel who were qualified to perform Medical Screening Examinations (MSE). Failure to identify and approve the medical personnel who were qualified to perform Medical Screening Examinations risks examinations performed by unqualified staff and failure to identify emergency medical conditions. Findings included: 1. Review of credentialing applications for Emergency Department (ED) providers (Medical Doctor and Doctor of Osteopathy) showed that providing Medical Screening examinations was included in core privileges for Emergency Services. Credentialing applications for initial privileges and reapplication for privileges were approved by the governing board. 2. On 01/10/24 at 2:23 PM, during an interview with the investigator, the Provider Services Director (Staff #3) stated that there was no statement in the hospital medical staff bylaws or rules and regulations that identify who was authorized by the governing body to perform MSE at the hospital. 3. On 01/18/24 at 2:00 PM, during an interview with the investigator, the Director of Obstetrics (Staff #4) stated that there were no documents that showed that Labor and Delivery Registered Nurses were authorized to perform Medical Screening Examinations to rule out labor. 4. On 01/18/24 between 11:30 AM and 12:30 PM, during interviews with the investigator, two Labor and Delivery Registered Nurses (Staff # 5and Staff #6) stated that there were patients seen in the Labor and Delivery unit that were assessed by the nurses, and report was called to the patient’s obstetric provider. The provider gave orders for the patient to be discharged home with instructions to follow up at the obstetric clinic within a specified timeframe. The provider did not come to the hospital to perform a Medical Screening Examination. Item #2 Failure to provide Medical Screening Examination, Stabilization, and Appropriate Transfer Based on staff interview, record review and review of other hospital documents, the hospital failed to ensure that an emergency patient who was on hospital grounds received a Medical Screening Examination (MSE) to rule out or stabilize a medical emergency condition prior to sending the patient to another hospital for 1 of 7 records reviewed of patients who were transferred to another hospital (Patient #25). Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment prior to transfer or discharge risks poor health care outcomes, injury, and death. Findings included: 1. Document review of the hospital policy titled, “Scope of Service: Emergency Department,” number 14058343, revised 08/07/23, showed that all patients presenting to the ED receive, at minimum, a medical screening exam (MSE) by an ED provider. 2. Review of the complaint subject’s ambulance record showed that the Lifeline Ambulance was dispatched on 10/31/23 at 11:31 PM, for a patient with chest pain. The report showed that the call was revised because the patient had no chest pain but was having breathing difficulty. The narrative note showed that the patient told ambulance personnel that they had a sore throat and laryngitis and was seen at a clinic earlier in the day. During transportation the patient was noted to have insects on them. On arrival at CWH [Confluence Health Hospital formerly known as Central Washington Hospital], the patient was moved on the stretcher to the entrance hallway. Staff diverted to Valley [Confluence Health Hospital Mares Campus formerly known as Valley Hospital] for decontamination. On arrival at Valley, the patient was moved on the stretcher to the decontamination room and assisted into a wheelchair for decontamination. Report was given to the nurse (Patient #25). 3. Review of the complaint subject’s medical record showed that the patient arrived at Mares Campus (MC) on 11/01/23 at 12:21 AM. The arrival complaint was documented as bed bugs. The triage note showed that the patient was first at Central but was found to have bed bugs and then was transferred to MC [Mares Campus] ED to use the Decontamination room. The ED provider saw the patient, ordered intravenous (IV) access with a saline lock, laboratory testing, and an electrocardiogram. The ED Provider note dated 11/01/23 at 12:21 AM, showed that the patient complained of not feeling well for 2 days, was seen at a clinic and prescribed antibiotic and steroids. The provider also documented that the patient initially taken by ambulance to CWH. EMS apparently noted bedbugs and he was thus sent here [MC] for decontamination. A venous blood gas was collected at 1:08 AM and showed that the patient’s venous pH was less than 7.00 (reference range 7.32-7.43), venous carbon dioxide was 24.0 (reference range 38.0-56.0), and venous oxygen was 60.0 (reference range 30.0-55.0). Vital signs at 1:16 AM, showed that the patient’s heart rate was 93, respiratory rate was 35, and blood pressure was 152/84. Oxygen saturation was 100% with the patient on oxygen at 2 liters/minute via nasal cannula. At 1:17 AM, the patient’s temperature was documented as 95.8 degrees Fahrenheit (35.4 degrees Celsius). Multiple laboratory test results were abnormal. The provider note showed that the patient’s labs showed acute renal failure and metabolic acidosis with etiology unclear. The plan to admit the patient was documented at 2:16 AM, with bed requested in the Intensive Care Unit at the Confluence Health Hospital. The patient was seen by the consulting physician while in the ED. Nursing report was given to the ICU nurse and the Paramedic who would transport the patient to the other campus (Patient #25). 4. On 01/10/24 at 10:25 AM, during an interview with the investigator, the Chief Nurse Officer (Staff #1) stated that the Confluence Health Hospital Mares Campus did not have an Intensive Care Unit, so patients that needed critical care would be admitted to the Confluence Health Hospital Intensive Care Unit. 5. On 01/10/24 at 10:15 AM, during an interview with the investigator, the Emergency Department Director (Staff #2) stated that as soon as they found out about a patient being sent to Mares Campus without receiving a medical screening examination, they began an investigation. The decontamination shower was out of service due to a leak. The hospital had an alternative option to shower a patient outside with a tent but the temperature outside was 30 degrees so staff thought it would be safer for the patient to have decontamination done indoors at Mares Campus. An Emergency Department Charge Nurse meeting was held on 11/13/23 with staff from both campuses in attendance. The minutes showed that a patient was sent to Mares, however, ALL patients who enter [hospital] property need a physician screening before transfer even if it is between campuses. .”