Astria Toppenish 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 interview, document review and review of hospital policies and procedures, 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 ensure that patients refusing stabilization or treatment recieved information about the risks of leaving against medical advice for 1 of 3 patients reviewed (Patient #8). Cross Reference: A 2407 2. The hospital failed to provide a medical screening examination without delay when a patient arrived in a vehicle at the main hospital entrance for 1 of 25 patients reviewed (Patient #23). Cross Reference: A 2408 .”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 43837 . Based on interview, document review and review of hospital policies and procedures, the hospital failed to ensure that patients who refuse stabilization or treatment for an emergency medical condition are aware of the risks associated with their decision to leave against medical advice for 1 of 3 patients that left the Emergency Department against medical advice (Patient #8). Failure to ensure that patients are aware of the risks associated with leaving the hospital against medical advice puts patients at risk for poor health outcomes, injury, or death. Findings included: 1. Document review of a medical record showed that the patient arrived on 08/02/23 complaining of vomiting and was registered at 6:03 PM. The patient was triaged at 6:05 PM. The ED provider note showed that the patient was seen at 7:45 PM. The patient reported left sided abdominal pain and vomiting for 4 days and no bowel movements. Review of systems and physical examination were completed and laboratory testing was done. The patient received intravenous hydration and medication for pain and nausea. Lab results showed abnormalities that needed additional investigation. The provider planned to admit the patient to the hospital, but the patient refused and decided to leave the hospital against medical advice. The risks of leaving against medical advice were documented in the provider’s note. The provider gave the patient a prescription for nausea and discharge instructions that included encouragement to return to the Emergency Department. The medical record did not include a hospital form “Against Medical Advice (AMA)” (Patient #8). 2. Document review of the hospital policy titled, “Leaving Against Medical Advice (AMA), Left Without Treatment (LWOT), and Elopement Policy and Procedure,”no number, effective 06/27/23, showed that when a patient, or their legal representative requests to leave AMA, the provider or nurse will: a. Read and review the AMA form with the patient or legal representative b. Obtain signature of the patient or legal representative on the AMA form c. Witness the signature of the patient or legal representative d. If the patient or legal representative refuses to sign, document the refusal in the medical record 3. On 11/27/23 at 5:15 PM, during an interview with the investigator, the Quality Manager (Staff #2) and Risk Manager (Staff #1) verified that the medical record for Patient #8 did not include an AMA form. .”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 43837 . Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that patients who present at the main hospital entrance requesting emergency services do not experience delays in examination or treatment. Failure to ensure that patient examination or treatment is not delayed puts patient’s health and safety at risk. Findings included: 1. Document review of the patient registered on the date and time included in the complaint showed that on 11/01/23 at 9:04 AM, a patient was brought to the hospital by a family member who stated that the patient had been found on the side of the road. The provider note dated 11/01/23 at 9:09 AM, showed that the patient had been driving and did not feel well, so they pulled over to the side of the road. The patient did not remember what happened after pulling over. Review of systems and physical examination were documented. Laboratory testing, electrocardiogram, echocardiogram, computed tomography of the chest and abdomen were completed. The patient was admitted to the hospital with syncope (fainting), acute renal insufficiency (kidneys working less than normal), hypotension (low blood pressure), and coronary artery disease (Patient #23). 2. On 11/27/23 at 4:20 PM, during an interview with the investigator, a Registered Nurse working in the Emergency Department (Staff #5) stated that it was safer to assist patients out of a car if the car was in the hospital’s ambulance bay. If a patient arrived at the front desk of the hospital and needed help getting out of the car, they would tell them to drive around to the Emergency Department ambulance entrance. Staff #5 stated that having a patient drive around to the ambulance entrance has been their practice at the hospital. 3. On 11/27/23 at 4:58 PM, during an interview with the investigator, a Patient Access Representative (Staff #8) stated that if a patient walked into the front of the hospital and said they needed to be seen in the ED, they would walk the patient down to the ED, or call the ED nurse if the patient needed a wheelchair. If a patient needed assistance in getting out of the car, they would let the ED nurse know. The nurses sometimes say to have the patient drive around to the ambulance bay. Staff #8 stated that early this month, that situation happened. A girl walked in to get help to get her dad out of the car. She said that she found her father unconscious, and looked like she was panicking. Staff #8 told the daughter to drive around to the ambulance bay. 4. Document review of the hospital policy titled, “Emergency Medical Treatment and Labor Act (EMTALA),” no number, effective date 03/30/23, showed that if an individual presents on hospital property that was located outside of the dedicated Emergency Department and appeared to be suffering from an Emergency Medical Condition, the patient shall be triaged and transported to the dedicated Emergency Department in the hospital that is capable of providing a Medical Screening Examination and delivering emergency services appropriate to the patient’s condition. 5. Document review of the EMTALA training PowerPoint that was presented to hospital staff during the skills fairs held in October 2023, showed that the EMTALA law ensured public access to emergency services and that it was established to prevent improper decisions, delays in care, or no care at all. The training showed that EMTALA applied when a person asks for help for an emergency medical condition (an injury, a symptom, or illness) and applied anywhere on the hospital campus or on the hospital property within 250 yards of the main hospital building, including the parking lot, sidewalks, and ambulance bay. 6. On 11/27/23 at 5:15 PM, during an interview with the investigator, the Quality Manager (Staff #2) stated that hospital staff had not followed policies and procedures when they directed that a patient be driven around the building to the hospital’s ambulance bay before being seen by medical personnel. .”