Holy Family Memorial

“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: 52395 Based on record review and interview the facility failed to immediately report an allegation of caregiver abuse/misconduct in 1 of 1 caregiver misconduct allegations reviewed (Patient #1) in a total sample of 1 caregiver misconduct allegations reviewed. Findings include: Review of policy entitled “Compliance Reporting, Hotline, Non-Retaliation Policy” last reviewed on 09/30/2026 reveals “...IV. Policy A. System Standard 1. Team Members...are obligated and have a duty to immediately report any knowledge or reasonable suspicion of wrongdoing, misconduct or any other form of non-compliance...includes but it not limited to...d. Any violation of laws, regulations, standards or policies including the Code of Conduct. E. Any situation that may put Patients, Residents, Team Members, Workforce Members, Providers and/or the Organization at risk...” Review of policy entitled “HR Caregiver Misconduct and Injury of Unknown Source Investigation and Reporting Policy” last reviewed on 02/24/2026 reveals”...B. Every Workforce Member must report any alleged, known, or suspected Caregiver Misconduct or Injury of Unknown Source to their leader...” Per medical record review, Patient #1 was a 65-year-old male admitted to facility on 01/21/2026-01/23/2026 after a scheduled surgical revision of L3-L4-L5 laminectomy (surgical procedure that removes the back part of a vertebra to relieve pressure on the spinal cord/nerves). A safety event entered on 1/29/2026 at 12:39 PM by RT (Respiratory Therapist) C revealed that a security event was called on Pt. #1 because he was being “belligerent, spitting, hitting and biting staff.” RT C reported RN B was upset during the event and put a pillow over Pt. #1’s face, called Pt. #1 names and wrapped her hands around Pt. #1’s throat and pushed him down on the bed. RT C reported concerns of abuse to RT Lead I on the morning of 01/23/2026. RT Lead I told RT C to submit an online safety event and to send an email to leadership. RT Lead I did not report the allegation to leadership or verify a safety event was placed. Leadership was not notified of the allegation until 01/29/2026. Leadership initiated an investigation on 01/29/2026.”

“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: 47413 Based on record review, observation and interview facility staff failed to ensure all patients who present on hospital property requesting treatment were documented on the Emergency Department (ED) central log for 3 of 20 patients (Patients #1, 2, 3), and failed to complete a Medical Screening Exam for 3 of 20 patients (Patients #1, 2, 3) who presented on hospital property requesting treatment in a total sample of 20 medical records reviewed. Findings Include: The facility staff failed to ensure patients who presented on hospital property requesting treatment were documented on the ED central log. See Tag A-2405. The facility staff failed to provide a Medical Screening Exam for patients who presented on hospital property requesting treatment. See Tag A-2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 47413 Based on record review and interview facility staff failed to ensure all patients who present on hospital property requesting treatment were documented on the Emergency Department (ED) central log for 3 of 20 patients (Patients #1, 2, 3) in a total sample of 20 medical records reviewed. Findings Include: A review of Hospital A’s policy titled, “FHFMH Case Management EMTALA (Emergency Medical Treatment and Labor Act) and Inter-Hospital Patient Transfer Policy” last reviewed 03/20/2025 revealed, “... A. Upon arrival to ED all patients seeking care in the ED are registered as an ED patient ...” Observation of Hospital A’s ED security footage on 06/04/2025 revealed: 06/04/2025 at 5:09 PM: Driver I (accompanied by Patients #1, 2, 3) pulls up via car to ED entrance (leaving Patients #1, 2, 3 in the car) and enters the ED and speaks to Registrar G (no audio). 06/04/2025 at 5:10 PM: Driver I goes back to car outside, Registrar G leaves desk and goes back into the ED. Driver I comes back into ED entrance and sits in ED waiting room. 06/04/2025 at 5:12 PM: Driver I and Registrar G have a conversation (no audio) at ED registration desk. 06/04/2025 at 5:14 PM: Driver I drives away from ED entrance with Patients #1, 2, 3 in the car. A review of Hospital A’s ED patient log revealed Patients #1, 2, 3 were not registered as ED patients at Hospital A on 06/04/2025. During an interview on 07/22/2025 at 1:41 PM with CNO (Chief Nursing Officer) E, when asked about the ED patient log on 06/04/2025, CNO E confirmed that Patients #1, 2, 3 were not on the log and were not registered as ED patients. During an interview on 07/22/2025 at 2:45 PM with Registrar G, when asked about Patients #1, 2, 3 and Driver I on 06/04/2025, Registrar G stated that Driver I came to the registration desk stating that he had 3 patients in the car outside that had possible carbon monoxide poisoning. Registrar G stated that she went back to the ED to ask the nurse and doctor what they wanted to do with these patients and Registrar G stated that they told her that Hospital A does not have a hyperbaric chamber (a specialized room or enclosure where the atmospheric pressure is increased, and the patient breathes 100% oxygen) but that they are happy to see the patients, or they can go to Hospital B for treatment. Registrar G stated that she relayed the information to Driver I and gave Driver I directions and the phone number for Hospital B, and Driver I left the ED.”

“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: 47413 Based on record review, observation and interview facility staff failed to complete a Medical Screening Exam for 3 of 20 patients (Patients #1, 2, 3) who presented on hospital property requesting treatment a total sample of 20 medical records reviewed. Findings Include: A review of Hospital A’s policy titled, “FHFMH Case Management EMTALA (Emergency Medical Treatment and Labor Act) and Inter-Hospital Patient Transfer Policy” last reviewed 03/20/2025 revealed, “... B. Hospital Campus: ... The physical area immediately adjacent to the provider’s main buildings... but are located within 250 yards of the main buildings... to be part of the provider’s campus... A. An appropriate Medical Screening Exam (MSE) is provided to individuals of any age who present to the Emergency Department or other hospital property requesting or requiring an examination of treatment for a medical condition ...” Observation of Hospital A’s ED security footage on 06/04/2025 revealed: 06/04/2025 at 5:09 PM: Driver I (accompanied by Patients #1, 2, 3) pulls up via car to ED entrance (leaving Patients #1, 2, 3 in the car) and enters the ED and speaks to Registrar G (no audio). 06/04/2025 at 5:10 PM: Driver I goes back to car outside, Registrar G leaves desk and goes back to the ED. Driver I comes back into ED entrance and sits in ED waiting room. 06/04/2025 at 5:12 PM: Driver I and Registrar G have a conversation (no audio) at ED registration desk. 06/04/2025 at 5:14 PM: Driver I drives away from ED entrance. Record review of Patient #1, 2, 3’s ED medical record from Hospital B revealed Patients #1, 2, and 3 presented to Hospital B’s ED on 06/04/2025 at approximately 5:25 PM (10 minutes later), received treatment for their symptoms, and were all discharged home at approximately 8:30 PM. During an interview on 07/22/2025 at 2:45 PM with Registrar G, when asked about Patients #1, 2, 3 and Driver I on 06/04/2025, Registrar G stated that Driver I came to the registration desk stating that he had 3 patients in the car outside that had possible carbon monoxide poisoning. Registrar G stated that she went back to the ED to ask the nurse and doctor what they wanted to do with these patients and Registrar G stated that they told her that Hospital A does not have a hyperbaric chamber (a specialized room or enclosure where the atmospheric pressure is increased, and the patient breathes 100% oxygen) but that they are happy to see the patients, or they can go to Hospital B for treatment. Registrar G stated that she relayed the information to Driver I and gave Driver I directions and the phone number for Hospital B, and Driver I left the ED.”