Capital 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: 27347 . Based on interview and document review, the hospital failed to ensure all patients seeking care in the emergency department (ED) receive an appropriate medical screening exam. Failure to ensure patients receive a comprehensive medical screening examination by a qualified medical professional and stabilizing treatment risks poor health outcomes, injury and death. Findings included: The hospital failed to provide a medical screening exam to 1 of 20 patients seeking care in the emergency department (Patient#1). Cross Reference Tag A2406 .”

“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: 27347 . Based on interview and document review, the hospital failed to implement its policy under Emergency Medical Treatment and Labor (EMTALA) to provide a medical screening exam to a patient in the emergency department (ED) for 1 of 20 patient records reviewed (Patient #1). Failure to complete a mental screening exam to rule out medical or psychiatric emergencies places patients at risk for serious physical or psychological harm including death. Findings included: 1. Document review of the hospital policy titled,”Emergency Medical Treatment and Labor Act (EMTALA),” revised 01/25, showed that persons presenting to the hospital emergency department (ED) will receive a medical screening exam (MSE). If the patient’s condition changes after being discharged and the patient was on the hospital property, they will be given another MSE. 2. Review of Patient #1’s medical record showed that: a) Patient #1 was brought to the ED on 07/20/25 by ambulance, for a complaint of hip and foot pain. The patient was provided a MSE. At the time of discharge the patient began yelling and cursing at staff for no apparent reason. The patient was discharged to the ED waiting room to wait for their ride home. b) The patient continued to yell and make threats toward staff while in the ED waiting room. The ED nurse called security to come talk to the patient. there was no documentation that the patient requested a MSE. 3. Review of the security log showed security staff responded to the ED lobby for multiple complaints from triage of a patient yelling and making inappropriate comments after the patient had been given their discharge instructions. The security department called the local police department to help with the situation. 4. On 08/01/25 at 11:00 AM, the investigator interviewed the local Police Crisis Response Officer that responded to the hospital call for assistance. the officer stated that hospital security requested police assistance to remove Patient #1 from hospital property. The officer stated that Patient #1 appeared to be having a mental health crisis, and the police called for an ambulance to take the patient to another local hospital for a mental health evaluation. 5. On 08/04/25 at 9:00 AM, the investigator interviewed the Security Officer (Staff #3)). Staff #3 stated that they responded to a call for assistance about a disruptive patient that had been discharged from the ED. Staff #3 was instructed by the nurse to remove the patient from the lobby. Staff #3 called the local police for help. The police crisis officer decided to send the patient to another hospital by ambulance for an evaluation. 6. On 08/04/25 at 10:00 AM, the investigator interviewed the ED Nurse Manager (Staff #5). Staff #5 stated that if a patient’s condition changed after discharge and the patient was still on hospital property, the patient should be provided another MSE to rule out a medical or psychiatric emergency. 7. On 08/04/25 at 12:30 PM, the investigator interviewed the ED Medical Director (Staff #10). Staff #10 who verified that patients that are discharged, but have a change in condition while on hospital property, should be provided another MSE by the medical provider to rule out a medical or psychiatric emergency.”

“GOVERNING BODY CFR(s): 482.12 There must be an effective governing body that is legally responsible for the conduct of the hospital. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body ... This Condition is not met as evidenced by: 38532 . Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations and Medicare Conditions of Participation for Hospital’s. Failure to provide effective oversight of services under contract or arrangement and staff can lead to dependence on another health care entity or service for compliance with federal regulations and put patients at risk of inconsistent care. Findings included: 1. The governing body failed to have an effective system in place to evaluate the quality of care provided by contracted services (formal contracts, joint ventures, informal agreements, shared services, or lease arrangements) for 6 of 6 shared services reviewed. Cross Reference: A084 2. The hospital failed to ensure the Hospital operated under one unified nursing service under the direction of one Registered Nurse who was responsible for the quality of care provided to hospital patients by hospital and non-hospital nursing staff. Cross Reference: A0385 Due to the scope and severity of deficiencies cited under 42 CFR 482.12, the Condition of Participation for Governing Body was NOT MET. .”

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 38532 . Based on observation, interview, and document review, the hospital failed to ensure the Hospital operated under one unified nursing service under the direction of one Registered Nurse who was responsible for the quality of care provided to hospital patients by hospital and non-hospital nursing staff. Failure to ensure that Nursing Services are provided under the direction of one hospital-wide nursing service under the direction of one Registered Nurse accountable for the quality of nursing care provided to its patient’s places patients at risk for inconsistent or inadequate care, adverse outcomes, and death. Findings included: 1. The hospital failed to ensure that MultiCare Capital Medical Center operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the quality of the patient care provided by nursing services. Cross Reference: A0386 2. The Hospital failed to ensure the Chief Nursing Officer or designated qualified hospital registered nurse conducted clinical evaluation activities of supplemental non-hospital nursing personnel who provided patient care. Cross Reference: A0398 Due to the scope and severity of deficiencies cited under 42 CFR 482.23, the Condition of Participation for Nursing Services was NOT MET. .”

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 38532 . Based on interview, document review, review of the hospital’s quality and performance improvement program, and review of Governing Body documents, the Governing Body failed to ensure that the hospital had an effective system in place to evaluate the quality of care provided by contracted services (formal contracts, joint ventures, informal agreements, shared services, or lease arrangements) for 6 of 6 shared services reviewed. Failure to ensure that patient care services, and all other services, provided under contract are subject to the same hospital-wide quality assessment and performance improvement (QAPI) evaluation as other services provided directly by the hospital risks ineffective and unsafe healthcare to patients. Findings included: 1. Document review of hospital policy titled, “Contract Management Policy”, PolicyStat ID 12679280, last revised 11/22, showed the following: a. For purposes of this policy, the term contract is used to discuss documented business relationships including providing or receiving goods or services or otherwise commit MultiCare Health System resources. b. Contract management services will ensure each clinical contract that involves direct patient care contains measurable quality metrics and those metrics are reviewed for compliance on a regular basis and as part of the quality review process. c. Responsible parties and executives will participate in the quality review process of internal and external services and present results at appropriate quality committee meetings. Document review of hospital document titled, “2023 Quality Assessment and Performance Improvement Plan (QAPIP)”, dated January 2023, showed the following: a. Purpose: To ensure that quality, safety and performance improvement activities of staff, medical staff and contractors result in continuous improvement of patient health outcomes. To Define a framework and integrated system that specifies requirements, approvals, key structures, and processes that satisfy the intent. b. The Quality Safety Steering Committee (QSSC) provides oversight of the quality and safety performance of the hospital and reviews data related to improving clinical outcomes and patient safety. c. Regulatory readiness, Quality and Program priorities include indicators related to facility embedded clinical services (e.g. Pharmacy, Lab, Imaging). Document review of hospital document titled, “2023 Quality Assessment and Performance Improvement Plan (QAPIP)”, dated January 2023, showed the following: a. Purpose: To ensure that quality, safety and performance improvement activities of staff, medical staff and contractors result in continuous improvement of patient health outcomes. To Define a framework and integrated system that specifies requirements, approvals, key structures, and processes that satisfy the intent. b. The Quality Safety Steering Committee (QSSC) provides oversight of the quality and safety performance of the hospital and reviews data related to improving clinical outcomes and patient safety. c. Regulatory readiness, Quality and Program priorities include indicators related to facility embedded clinical services (e.g. Pharmacy, Lab, Imaging). Document review of the hospital’s, “MultiCare Capital Medical 2023 Infection Prevention Program Risk Assessment and Plan,” no document number, approved 04/23, showed that the hospital’s Infection Prevention and Control program provides surveillance, prevention, and control strategies to reduce the occurrence of healthcare associated infection (HAI). 2. Document review of QSSC meeting minutes from January through November 2023, and the Capital Medical Center Dashboard for January through December 2023 showed that there were not any reports or data pertaining to the virtual constant observer service, the MultiCare System Nursing Float Pool, the Wound Center, or Radiation Oncology. 3. On 01/09/24 between 9:45 AM and 11:30 AM, Investigator #10, the Intensive Care, Progressive Care, and Medical/Surgical Unit Manager (Staff #1001), and the Medical/Surgical Assistant Nurse Manager (Staff #1002) inspected the Intensive Care Unit (ICU). Investigator #10 observed remote monitoring equipment and asked about its use. Staff #1001 explained that it was 1 of 4 cameras used for the virtual constant observer (VCO) program, in which patients at high risk for fall or injury can be remotely monitored for safety. Investigator #10 asked if the monitoring staff were employed by and located at the hospital. Staff #1001 stated that they were located at MultiCare Auburn hospital, and not employees of Capital Medical Center. 4. On 01/10/24 at 2:45 PM, the System Director, Accreditation (Staff #1008) provided a document showing contract reviews for 5 hospital services, including the VCO program. Staff #1008 stated that no contract was in place between Capital Medical Center and MultiCare Auburn for the VCO services, but that they were working on creating a memorandum of understanding at present. 5. On 01/11/24 between 2:30 PM and 3:50 PM, Investigator #5 and Investigator #6 met with the Infection Preventionist (Staff #604) and the Quality Manager & Patient Safety Officer (Staff #602) to discuss the hospital’s Infection Control Program. During the interview, Staff #602 stated that employee health data from the hospital is reported to a system level coordinator. The data is analyzed in aggregate with data from other facilities in the system and reported to the System Infection Prevention and Control Program. 6. Document review of the Infection Prevention Committee quarterly meeting minutes for 2023 showed that hospital specific employee health data was not listed separately from system level employee health reports. 7. On 01/11/24 at 5:00 PM, Investigator #5 and the Chief Nurse Executive/Chief Operating Officer (Staff #502) discussed MultiCare Capital Medical Center’s Organizational Chart, hospital versus system departments, and oversight of nursing services. At this time, Staff #502 verified that the hospital utilized the MultiCare Regional Nursing Float Pool for Nurse Staffing. Staff #502 stated that Quality data was not collected or reviewed through the hospital’s quality program as the MultiCare Nursing Float Pool was a Regional System Level Department. Staff #502 verified that VCO, Radiation Oncology, Respiratory Therapy, and the Wound Center reported through Regional System Level Departments. Staff #502 stated that there were no contracts or memorandum as they were all MultiCare Employees and quality improvement information would be collected and reviewed at the Regional Level. 8. On 01/12/24 at 10:30 AM, Investigator #10, Investigator #5, and Investigator #6 met with the Quality Manager & Patient Safety Officer (Staff #1006), the Quality Program Manager (Staff #1011), the Director of Nursing Operations (Staff #1009), and the Infection Preventionist (Staff #1012) to review the hospital’s quality plan and improvement processes. 9. Investigator #10 reviewed the QSSC meeting minutes from January through November 2023, and the Capital Medical Center Dashboard for January through December 2023. The review showed: a. The wound care clinic director was included in the list of QSSC members but was not marked as having attended meetings. b. There was no documentation of a report from the wound care clinic in any QSSC minutes. c. The Dashboard had a Program Measure under Goal #7 Regulatory Readiness titled “Advanced Wound Care Center of Distinction,” but there was no benchmark, data, or trendline for the measure. Investigator #10 found no evidence that any data from the hospital’s wound care service was collected, measured, assessed, and shared with QSSC. 10. At the time of the review, Staff #1006 confirmed the finding. .”

“ORGANIZATION OF NURSING SERVICES CFR(s): 482.23(a) The hospital must have a well-organized service with a plan of administrative authority and delineation of responsibilities for patient care. The director of the nursing service must be a licensed registered nurse. He or she is responsible for the operation of the service, including determining the types and numbers of nursing personnel and staff necessary to provide nursing care for all areas of the hospital. This Standard is not met as evidenced by: 38532 . Based on interview and document review, the hospital failed to ensure that MultiCare Capital Medical Center Hospital operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the quality of the patient care provided by nursing services. Failure to ensure that Nursing Services are provided under the direction of a hospital-wide nursing service under the direction of one Registered Nurse places patients at risk for suboptimal care, adverse outcomes, and death. Findings included: 1. Document review of the hospital’s organizational chart titled, “MultiCare Capital Medical Center-Functional Org Chart,” dated 08/01/23, did not include a line of reporting for the MultiCare System Virtual Constant Observer, the MultiCare Regional Nursing Float Pool, or MultiCare Employee Health. The document showed a dotted line of reporting for the Wound Care Center, Respiratory Therapy, PULSE Cardiac Cath Lab, and the Lacey Off Campus Emergency Department. The listed departments provide nursing services to patients receiving care at MultiCare Capital Medical Center Hospital. 2. On 01/11/24 at 5:00 PM, Investigator #5 and the Chief Nurse Executive/Chief Operating Officer (Staff #502) discussed MultiCare Capital Medical Center’s Organizational Chart, hospital versus system departments, and oversight of nursing services. The interview and document review showed the following: a. The Manager of the offsite Emergency Department in Lacey (Staff #511) reported to the MultiCare Regional Offsite Emergency Room Services (OSE) program. Staff #511 stated that the Off-Site Emergency Department is licensed under MultiCare Capital Medical Center but functionally all the MultiCare offsite Emergency Rooms are organized under one Regional Corporate System Department through which the managers report. He stated that the organizational chart showed a dotted line reporting to him. He stated that the Offsite ED Manager (Staff #511) manages the nursing staff for the Emergency Department but that he is involved and has weekly meetings. Staff #502 was unable to provide documentation to show oversite of the manager for her work evaluation but stated that he is in contact with the MultiCare Regional System Manager for the MultiCare Offsite Emergency Departments department as part of daily business. b. The Respiratory Therapy Department is a MultiCare Regional System Department and the department reports to a regional manager. c. The Wound Care Center is a MultiCare Health Systems Regional Department and is managed by the Wound Care Center Manager (Staff #508) who reports to the MultiCare Health System Regional Manager (Staff #512). d. The MultiCare Regional Corporate Nursing Float pool is a MultiCare Regional System Department and quality data collection and assessment is completed at the corporate level. He does not provide oversite for this department. Staff #502 verified that the hospital utilizes the system float pool for nursing staff and stated that all the staff are oriented to the hospital on their first day of work. Staff #502 stated there is no contract, memorandum of understanding, or any quality indicators as they are all MultiCare Health System Employees including the employees at this hospital. e. The Virtual Constant Observer Service is provided to the hospital by the MultiCare Health Regional System. Staff #502 stated there is no contract, memorandum of understanding, or any quality indicators as they are all MultiCare Health System Employees. .”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 38532 . Based on interview and document review, the hospital failed to ensure the Chief Nursing Officer or designated qualified hospital registered nurse conducted clinical evaluation activities of supplemental non-hospital nursing personnel who provided patient care. Failure to evaluate the nursing care provided by non-hospital personnel by a qualified hospital registered nurse risks patients receiving inconsistent or inadequate care. Findings included: 1. Document review of the hospital’s organizational chart titled, “MultiCare Capital Medical Center-Functional Org Chart,” dated 08/01/23, did not include a line of reporting for the MultiCare System Virtual Constant Observer, the MultiCare Regional Nursing Float Pool, or MultiCare Employee Health. The document showed a dotted line of reporting for the Wound Care Center, Respiratory Therapy, PULSE Cardiac Cath Lab, and the Lacey Off Campus Emergency Department. The listed departments provide nursing services to patients receiving care at MultiCare Capital Medical Center Hospital. 2. On 01/11/24 at 5:00 PM, Surveyor #5 and the Chief Nurse Executive/Chief Operating Officer (Staff #502) discussed MultiCare Capital Medical Center’s Organizational Chart, hospital versus system departments, and oversight of nursing services. The interview and document review showed the following: a. The Manager of the offsite Emergency Department in Lacey (Staff #511) reported to the MultiCare Regional Offsite Emergency Room Services (OSE) program. Staff #502 stated that the Off-Site Emergency Department is licensed under MultiCare Capital Medical Center but functionally all the MultiCare offsite Emergency Rooms are organized under one Regional Corporate System Department that the managers’ report up through. He stated that the organizational chart showed a dotted line reporting to him and that he is in contact with the MultiCare Regional System Manager for the MultiCare Offsite Emergency Departments department as part of daily business. Document review of the Performance Evaluation for the Nurse Manager (Staff #511) showed that the evaluation was completed by the MultiCare Regional System Offsite Emergency Department Manager (#513). b. The Respiratory Therapy Department is a MultiCare Regional System Department. Staff #502 verified the department manager reports to a System Regional manager. c. The Wound Care Center is a MultiCare Health Systems Regional Department and is managed by the Wound Care Center Manager (Staff #508) who reports to the MultiCare Health System Regional Manager (Staff #512). The hospital was unable to provide an employee evaluation for Staff #508. The hospital provided a job description for the position which showed that the Wound Care Center Manager reported to the Regional MultiCare System. The hospital provided Surveyor #5 with the annual evaluation for the Wound Care Center Assistant Manager (Staff #514). The document showed the evaluation was completed by the MultiCare Health System Regional Manager for Wound Care (Staff #512). d. The MultiCare Regional Corporate Nursing Float pool is a MultiCare Regional System Department. Staff #502 stated that oversite of the nursing staff is provided at the system level but that the staff do receive orientation. Surveyor #5 requested performance evaluations. The hospital was unable to provide the performance evaluations but did provide completed orientation for 2 Registered Nurses from the System Float Pool who provided care to Patients at the hospital (Staff #515 and #516). e. The Virtual Constant Observer Service is provided to the hospital by the MultiCare Health Regional System. Staff #502 stated that performance evaluations are completed at the System Level, but that they are all MultiCare Employees. f. The Radiation Therapy Department is a MultiCare Regional System Department and nursing staff report to the Regional Director (Staff #517) Document review of the annual performance evaluation for the Radiation Therapy Supervisor (Staff #509) showed that the review was completed by the Regional Director (Staff #517). .”