Trios Health

“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: 42597 . Based on interview and document review,the hospital failed to ensure the provision of on-call provider coverage in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations for 1 of 19 patients reviewed (Patient #1). Failure to ensure compliance with on-call physician responsibilities risks delays in stabilizing care and treatment and poor outcomes, including death. Findings included: The hospital failed to ensure the on-call provider met the needs of a patient requiring services for an acute ST elevation myocardial infarction (Patient #1). Cross reference: Tag A2404 .”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 42597 . Based on interview and document review,the hospital failed to ensure the provision of on-call provider coverage in accordance with Emergency Medical Treatment and Active Labor Act (EMTALA) regulations for 1 of 19 patients reviewed (Patient #1). Failure to ensure compliance with on-call physician responsibilities risks delays in stabilizing care and treatment and poor outcomes, including death. Findings included: 1. Review of the policy titled, “Patient Diversion and Capacity Management,” PolicyStat ID 17649830, last revised 02/25, showed: a. The emergency department (ED) physician, in coordination with the administrator on call, the house supervisor and the ED charge registered nurse (RN) will assess the resources available to accept patients into the emergency department for stabilization. b.STEMI (ST elevation myocardial infarction) patients will never be diverted based on hospital capacity and will only be diverted due to mechanical failure in the cardiac catheterization (cath) lab. c. In the event that a STEMI/high risk cardiac patient arrives to Trios Health but the cath lab team is unavailable, the attending physician will immediately facilitate transfer to a percutaneous cardiac intervention capable facility. 2. Review of the document titled, “Trios Health Medical Staff Rules and Regulations,” approved 05/27/21, showed that a physician who has been called from the rotation list may not refuse to respond. 3. Review of the November 2025 specialty on-call schedule showed an interventional cardiologist on-call from 11/07/25 at 6:00 AM through 11/08/25 at 6:00 AM. 4. Review of the electronic cardiac catheterization lab schedule dated 11/02/25 -11/08/25 showed: a. No tech scheduled for call on 11/06/25. b. STEMI Divert 5:30 PM-7:00 AM-no tech c. No tech scheduled on Friday 11/07/25 from 7:00 AM-5:30 PM. d. A tech on call on Friday 11/07/25 from 5:30 PM -7:00 AM. e. A blank space on Friday 11/07/25 in the section labeled STEMI divert (incapable of providing cath lab intervention). 5. On 01/17/25 at 9:10 AM, the investigator interviewed the interim cath lab manager (Staff #6). Staff #6 stated that the event involving Patient #1 occurred during his first week on the job. The hospital was struggling to staff cardiac tech shifts and Staff #6 was aware of coverage gaps. At the last minute, Staff #6 had a tech volunteer to the 11/07/25 day shift. At the time, Staff #5 did not know that it was his responsibility to upload the cath lab team schedule to the software system visible to the house supervisors. Staff #5 was also was unaware that a house supervisor had told Physician #2 that the hospital was on STEMI divert until 11/07/25 at 6:00 PM. 6. Review of the emergency medical services (EMS) patient timeline showed that on 11/07/25 at 2:31 PM, the EMS team responded to a call for someone with chest pain at Patient #1’s residence. At 2:50 PM, the paramedic activated a hospital team pre-arrival alert for Patient #1 for a probable acute STEMI. EMS staff transmitted the 12-lead electrocardiogram (EKG) to the Trios ED and called the ED to verify the hospital was not on divert. Upon arrival to the Trios parking lot, the ED charge nurse called and informed EMS staff that the cardiologist called and said the patient is having a STEMI and to divert Patient #1 to a different hospital. The EMS team proceeded to the next facility and arrived with the patient at 3:31 PM. Patient #1 was taken straight to the cath lab and EMS completed the transfer of care to hospital staff at 3:38 PM. 7. On 01/23/26 at 9:15 AM, the investigator interviewed an ED Charge RN (Staff #1). Staff #1 confirmed that she was working in the ED on 11/07/25 and that she recalled the events the shift involving Patient #1. Staff #1 stated that the house supervisor notified her at the beginning of the shift that the hospital was not on STEMI divert. Just before 3:00 PM she answered the dedicated EMS line and received a request for care for a patient who was having a STEMI. The usual software used to view field EKGs before accepting a patient was not functioning, so she contacted the EMS battalion chief, obtained a cell phone number for one of the EMS staff, and had EMS staff send her a photo of the EKG. She showed the photo to the ED physician (Physician #1), who confirmed a STEMI and accepted the patient. She observed Physician #1 then call the interventional cardiologist (Physician #2). Staff #1 heard Physician #1 repeatedly ask Physician #2 whether he was accepting Patient #1. Physician #1 discontinued the call, and stated that Physician #2 had not accepted Patient #1. Next she heard the house supervisor (HS) (Staff #5) speaking with Physician #2. Staff #5 notified Staff #1 that Physician #2 was still not going to accept the patient. Staff #1 immediately contacted EMS staff, told them that no cardiologist was available, and observed the ambulance pulling out of the bay as they spoke. 8. On 01/23/26 at 3:00 PM, the investigator interviewed an ED Physician (Physician #1). Physician #1 confirmed that he was working on 11/07/25. Physician #1 stated that he vaguely remembered the events related to the incident involving Patient #1. Physician #1 stated that the hospital was not on STEMI divert on the day of the incident, confirmed that he spoke with Physician #2 and that Physician #2 did not accept Patient #1. Physician #1 stated that the house supervisor had an additional conversation by telephone with Physician #2 after which the house supervisor told him that Physician #2 did not accept the patient. Physician #1 stated that he called the receiving facility to let them know Patient #1 was enroute. 9. On 01/23/26 at 10:45 AM, the investigator interviewed Physician #2. Physician #2 stated that he is contracted for on-call shifts through a company named Vital Solutions. Vital Solutions emails him his call schedule and he is typically scheduled for four consecutive on-call shifts. Physician #2 stated that he always confirms his schedule with the house supervisor on the day prior to the start of his on-call shifts and he also verifies STEMI capability because the hospital intermittently lacks cath lab staff. Physician #2 stated that he called the house supervisor on 11/05/25 in the evening and confirmed that he was on call from 11/06/25 at 6:00 PM through 11/10/25 at 6:00 PM. Physician #2 did not remember which HS he spoke with, but stated that she confirmed his schedule and also advised that the hospital was on STEMI divert from 11/06/25 at 5:30 PM until 11/07/25 at 6:00 PM because a cath lab technician was not available. Physician #2 stated he received a call from the ED physician on 11/07/25 shortly after 3:00 PM, with report of an inbound ambulance transporting a STEMI patient and request for cardiac intervention. Physician #2 did not accept the patient because he believed cath lab staff were not available. 10. On 01/23/26 at 12:00 PM, the investigator interviewed a house supervisor (Staff #4). Staff #4 confirmed that she worked evening shift on 11/05/25. Staff #4 stated that she did not remember the specific call with Physician #2 and does not remember telling Physician #2 that the hospital was on STEMI divert for any specific time period. Staff #4 confirmed that Physician #2 did usually call to confirm his on-call schedule the day before starting his call block and that she verifies cath lab staff availability/STEMI divert at that time. 11. On 01/23/26 at 12:30 PM, the investigator interviewed a house supervisor (Staff #5). Staff #5 confirmed that she was working on 11/07/25 and while rounding in the ED just before 3:00 PM, Staff #1 informed her of an incoming STEMI patient arriving by ambulance and that the ED physician was currently speaking with the on-call cardiologist (Physician #2) Staff #5 heard Physician #1 on the phone repeatedly asking Physician #2 if he was going to accept Patient #1. Physician #1 ended the call and told Staff #5 that Physician #2 had not accepted Patient #1. Staff #5 stated that she then called Physician #2 who stated that he was told the hospital was on STEMI divert until 6:00 PM that night due to lack of cath lab staff, and he could not come to the hospital because he was getting a haircut.”

“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, review of hospital policies and procedures, and document review, the hospital failed to develop and implement policies and procedures to provide a medical screening examination for patients presenting for emergency care in accordance with the Emergency Medical Treatment and Active Labor Act (EMTALA). Failure to ensure patients presenting to the emergency department receive a comprehensive medical screening examination (MSE) by a qualified medical professional to rule out an emergency medical condition risks poor health outcomes, injury and death. Findings included: The hospital refused to provide medical screening examinations for 3 of 23 patients when they presented to the emergency department for emergency care. Cross Reference Tag# 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 . Based on interview, review of hospital policies and procedures, and document review, the hospital failed to show evidence that 3 of 23 patients who presented to the hospital for emergency care received a medical screening examination (MSE) by a qualified medical professional (Patients #21, #22, and #23). Failure to ensure patients seeking emergency medical care receive a comprehensive medical screening examination by a qualified medical professional risks poor health outcomes, injury and death. Findings included: 1. A review of the hospital policy titled, “LL.026 EMTALA Medical Screening and Treatment of Emergency Medical Conditions,” #16449378 effective date 09/19/24, showed that individuals coming to the hospital’s dedicated emergency department (ED) seeking assessment or treatment for a medical condition, or coming to the hospital property requesting treatment for an emergency medical condition receive an appropriate medical screening examination by a physician or other qualified medical personnel. A qualified medical person or personnel means an individual other than a licensed physician who has demonstrated current competence in the performance of medical screening examinations and been approved by the hospital’s governing board as qualified to administer medical screening examinations. The hospital’s policy titled, “Controlled Access Operations Procedure/Security Lockdown Levels and Response,” number 13494856, effective date 04/23, showed guidelines for locking down the Trios Southridge Hospital in the event of an emergency situation in which partial, modified, or complete lockdown of the facility would be necessary. The determination to declare and/or initiate total or controlled lockdown will be at the discretion of the Chief Executive Officer (CEO), administrator-on-call, or the highest-ranking administrator in the facility. The policy showed that a Level 4 total hospital lockdown is the highest level of facility and perimeter security and may involve a life-threatening situation. During Level 4 total lockdown, all perimeter doors are secured, and no one is allowed to enter or exit the facility. Security personnel or designees will secure and staff all entry/exit points. 2. A review of the security shift activity report dated 06/08/25, showed that at 3:49 AM, the hospital was put on a Level 4 total lockdown following the arrival of a patient with a gunshot wound in the ED. The lockdown was discontinued at 6:42 AM. There were no additional notations between the lockdown was initiated and the time the lockdown was lifted. 3. On 07/10/25 at 3:24 PM, during an interview with the investigator, a patient access representative (Staff #1) stated that they were on duty in the ED on 06/08/25 when a patient with a gunshot wound arrived. The hospital was put on lockdown, and a security guard stood by the walk-in entrance to the ED. Staff #1 stated that they witnessed the security guard opening the door a few inches when anyone approached or attempted to enter the hospital and heard the security guard say they were not seeing patients right now because the hospital was on lockdown. 4. On 07/09/25 at 2:25 PM, during an interview with the investigator, a hospital supervisor (Staff #2) stated that they had spoken with the Chief Nursing Officer (CNO) at the time of the lockdown on 06/08/25, and the CNO agreed to alert the hospital leadership team of the Level 4 lockdown. The interview showed that Staff #2 notified the hospital security officer of the authorized lockdown and informed security staff that only those needing to be seen were allowed to enter the hospital. Staff #2 stated that they had received a phone call from another facility (Hospital B) that 3 patients arrived at Hospital B stating that they were turned away from the Trios ED because the hospital was on lockdown. Staff #2 stated that the information was received at the end of their shift, so they documented the information received and forwarded it to hospital leadership, including the ED Director, the CEO, the CNO, and the Director of Quality. 5. On 07/08/25 at 11:28 AM, during an interview with the investigator, the interim ED Director (Staff #3) stated that they read the hospital supervisor’s report and received a phone call from Hospital B’s ED Director about patient’s being turned away from the ED on 06/08/25. Staff #3 stated they contacted the CNO and the Director of Quality about the EMTALA violation and recommended that the hospital self-report the incident to the Washington State Department of Health. 6. On 07/08/25 at 9:55 AM, during an interview with the investigator, the CNO (Staff #6) stated that the hospital reviewed the EMTALA incident but had not yet formalized a corrective action plan. Staff #6 stated that the hospital revised the lockdown policy within 2 weeks of the event, but staff had received no training regarding the new policy at the time of the investigation. 7. On 07/08/25 at 9:55 AM, during an interview with the investigator, the Director of Plant Services and Security (Staff #7) stated that they had spoken to all of the security guards individually about the lockdown event but had not kept any documentation of the items reviewed or attendance verification. 8. On 07/11/25 at 3:20 PM, the investigator contacted Hospital B by phone and email. Hospital B confirmed that 3 patients arrived in their ED on 06/08/25 after they were refused service at Trios Health during the lockdown (Patients #21, #22, and #23). .”