Thedacare Regional Medical Center - Appleton Inc.

“MEDICAL STAFF CFR(s): 482.22 The hospital must have an organized medical staff that operates under bylaws approved by the governing body, and which is responsible for the quality of medical care provided to patients by the hospital. This Condition is not met as evidenced by: 53566 Based on record review and interview, the facility failed to ensure medical staff accountability for the quality of medical care provided by the medical staff in 1 (Patient #1) of 3 patients requiring a transfer to the intensive care unit (ICU) in a total of 10 medical records reviewed. Findings include: Medical staff failed to consult the Hospitalist for a medically complex patient with needs beyond the clinical capabilities of the attending provider; failed to respond to communication from nursing staff regarding changes in patient condition; and failed to round daily on a hospitalized patient. See tag A-0347.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 53566 Based on record review and interview, the facility failed to obtain informed consent from a patient’s legal representative prior to a medical procedure in 1 (Patient #7) of 8 patients requiring informed consent prior to medical procedures in a total universe of 10 medical records reviewed. Findings: A review of facility policy titled “Informed Consent Policy” last revised 8/6/2025 revealed, “...C. Signatures. 1. The following individuals must participate in an informed consent (IC) discussion and sign the IC form: a. Adult Patients with capacity and competency...c. Legal Representative, when applicable. 2. The signer of the IC form must have the capacity to grant permission for the intended procedure...E. Legal Representatives. 1. In situations where there is a Legal Representative who cannot be available in person, a telephone authorization may be sought. The telephone call will be placed to the authorized party and conversation monitored by a witness...conversation will be documented on the appropriate form and signed by both the caller and the witness...” A review of facility policy titled “Advance Directives Policy” last revised 12/17/2025 revealed, “...Power of Attorney for Health Care (POAHC): A document that appoints a person to be a Patient’s or Resident’s ‘agent’ to make their health care decisions for them in the event they lose the ability to do so for themselves...C. Incapacity Procedure with a POAHC. 1...an individual’s POAHC takes effect upon a finding of Incapacity by two physicians...who both personally examine the individual and sign a statement that the individual has Incapacity...” A review of Patient #7’s medical record revealed she was a 95-year-old female with a diagnosis of moderate cognitive impairment. The “advance care planning” section of Patient #7’s medical record identified Legal Representative W as Patient #7’s activated POAHC. A review of “Statement of Incapacity” dated 11/27/2025 revealed that both Hospitalists X and Y examined Patient #7 and found her to have “’incapacity’ as defined in Wisconsin Statute 155.01(8)*...Definition: Incapacity means the inability to receive and evaluate information effectively or to communicate decisions to such an extent that the patient lacks the capacity to manage his/her health care decisions...” A review of “Informed Consent for Surgery or Designated Procedure(s)” dated 6/22/2026 revealed, “I hereby authorize and direct [Vascular Surgeon Z]...to perform...Technical Description: Bilateral lower extremity andiogram [sic], possible stent or balloon...Patient Description: (left blank)...[Vascular Surgeon Z] has informed me...how it may help me (benefits)...how it may harm me (risks)...MY SIGNATURE BELOW CONSTITUTES MY ACKNOWLEDGEMENT THAT: 1. I have the right to consent to or to refuse the proposed operation or special procedure...” The signature field contained Patient #7’s name in a cursive font e-signature, witnessed by Cath Lab RN AA using a handwritten signature. Telephone signature consent fields (2) were left blank. Vascular Surgeon Z signed the physician attestation that risks and benefits were explained to Patient #7. A review of “Operative Report” by Vascular Surgeon Z written 6/22/2026 at 2:49 PM revealed that Patient #7’s angiogram was started and subsequently terminated. “Findings” section of the note revealed, “...I perseverated about intervention...I did not think she was a reasonable endovascular candidate...I strongly believe pursuing a more palliative/hospice course is in her best interest. I terminated the procedure and will discuss all this further with her family...” During an interview on 6/24/2026 at 9:42 AM, Director of Nursing (DON) R stated cath lab (cardiac catheterization laboratory) leadership confirmed that Patient #7 signed the informed consent for her angiogram. DON R stated that Patient #7’s POAHC, Legal Representative W, was not present for the risk/benefit discussion with Vascular Surgeon Z, nor was Legal Representative W contacted to obtain his telephone consent for Patient #7’s procedure.”

“MEDICAL STAFF ORGANIZATION & ACCOUNTABILITY CFR(s): 482.22(b)(1), (2), (3) The medical staff must be well organized and accountable to the governing body for the quality of the medical care provided to the patients. (1) The medical staff must be organized in a manner approved by the governing body. (2) If the medical staff has an executive committee, a majority of the members of the committee must be doctors of medicine or osteopathy. (3) The responsibility for organization and conduct of the medical staff must be assigned only to one of the following: (i) An individual doctor of medicine or osteopathy. (ii) A doctor of dental surgery or dental medicine, when permitted by State law of the State in which the hospital is located. (iii) A doctor of podiatric medicine, when permitted by State law of the State in which the hospital is located. This Standard is not met as evidenced by: 53566 Based on record review and interview, medical staff failed to consult the Hospitalist for a medically complex patient with needs beyond the clinical capabilities of the attending provider; failed to respond to communication from nursing staff regarding changes in patient condition; and failed to round daily on a hospitalized patient in 1 (Patient #1) of 3 patients requiring a transfer to the intensive care unit (ICU) in a total of 10 medical records reviewed. Findings include: A review of facility policy titled “Medical Staff Bylaws” last revised 5/14/2026 revealed, “...2.6 Practitioner Responsibilities...2.6.1. Each Practitioner must provide for appropriate, timely, and continuous care of their patients at the level of quality and efficiency generally recognized as appropriate by medical professionals in the same or similar circumstances. This includes alternate coverage by a Practitioner in the same Department with similar Privileges at this Hospital that can care for the Practitioner’s patients when the Practitioner is absent..2.6.5. Each Practitioner with Privileges must abide by the Medical Staff Bylaws and any other rules, regulations, policies, procedures, and standards of the Medical Staff and Hospital...” A review of “Rules and Regulations” last revised 9/13/2022 revealed, “...3.7 PROGRESS NOTES. The attending physician, or privileged designee, will see the patient and record a progress note each day, and for each significant patient encounter, on all hospitalized patients...ARTICLE IV. STANDARDS OF PRACTICE. 4.1 ADMITTING, ATTENDING, AND DISCHARGING PHYSICIAN. 4.1.1 Responsibilities...The attending physician will be responsible for:...b. the medical care and treatment of each patient in the Hospital; c. making daily rounds; d. ordering consultations, if appropriate; e. the prompt, complete, and accurate preparation of the medical record...4.2 COVERAGE AND CALL SCHEDULES. Each practitioner shall provide a list of designated Medical Staff ...who shall be responsible for the care of their patients in the Hospital when the practitioner is not available...4.3 RESPONDING TO CALLS AND PAGES. a. Telephonic Response: Practitioners are expected to respond within fifteen (15) minutes to calls from the ED and thirty (30) minutes to calls from elsewhere in the hospital telephonically...b. Physical Response: Practitioners are expected to respond within a timeframe as specified in the communication with the requesting party. If needed urgently, the physician should be able to respond within thirty (30) minutes after the telephonic contact at acute care hospitals...4.5 CONSULTATION. a. Consultation is to be considered in the following situations:...iv. When expertise is needed which is beyond the clinical capabilities of the attending provider...b...The attending physician will provide written authorization in the EMR (electronic medical record) requesting the consultation, permitting the consulting practitioner to attend or examine their patient. This request shall specify: i. the reason for the consultation, ii. the urgency of the consultation (urgent or emergent - in a timeframe determine by conversation between the referring physician and the consultant which is documented; (routine - within 24 hours)...” A review of Patient #1’s medical record revealed she was an 81-year-old female status post removal of an infected right ankle implant on 3/11/2026. She was admitted to the Medical/Surgical floor for recovery, where she later developed hypotension (low blood pressure) and abdominal pain. On 3/16/2026, Patient #1 was transferred to the intensive care unit (ICU) for worsening hypotension, respiratory distress, and severe abdominal pain. Her condition rapidly deteriorated and on 3/16/2026 at 6:22 PM, Patient #1 was pronounced deceased. Failure to consult Hospitalist: A review of “Orders” revealed that on 3/11/2026 at 4:17 PM, Orthopedic Surgeon B ordered “Consult to Hospitalist. Reason for Consult? S/P (status post) right ankle replacemnt [sic] removal with antibiotic spacer placement, significant medical comorbidities, mgmt (management) input requested. Consulting provider or office contacted? No.” A review of “Flowsheets: Notification” revealed: -3/12/2026 at 12:00 PM: “Reason for Communication: Evaluate. Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat. Response: Waiting for response. Additional documentation when notifying:...Hospitalist was consulted last night, however they have been unable to get someone to see them today. Direct is saying we should get a new consult placed. Could you do that?” -3/15/2026 at 6:31 PM: “Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat...Additional documentation when notifying:...did you complete the Hospitalist consult last night because I tried to get a hold of whoever was on call for your service and neither the midlevel (APNP) or MD called me back and they were both paged 4 times so I am going to need a better option to get a hold of someone for tonight if there are any issues.” During an interview on 6/23/2026 at 3:20 PM, Med/Surg RN K stated that on 3/15/2026 during morning rounds, she asked Orthopedic Surgeon B to speak directly to a Hospitalist to complete the Hospitalist consultation process for Patient #1. During an interview on 6/23/2026 at 3:53 PM, Med/Surg RN L stated that on the morning of 3/15/2026, she sent a Secure Chat to Orthopedic Surgeon B, asking him to complete the ordered hospitalist consultation by speaking directly to a Hospitalist. During an interview on 6/24/2026 at 8:35 AM, Hospitalist S stated that placing a consultation to the Hospitalist group is a two-part process in which the referring physician must first place the consultation order in Epic and then speak to a Hospitalist personally, giving the Hospitalist the opportunity to ask questions and accept the referral. Hospitalist S stated that a Hospitalist would see a non-Hospitalist service patient without a consultation order only if the patient needed urgent/emergent treatment or stabilization and would contact the patient’s primary provider prior to placing any non-urgent orders. Failure to respond to communication from nursing staff regarding changes in patient condition: A review of “Flowsheets: Notification” revealed: -3/15/2026 at 2:02 AM: “Reason for Communication: Evaluate. Provider Name: [Orthopedic APNP V]...Method of Communication: Page. Response: Waiting for response. Additional documentation when notifying: [Patient #1] having chest pain.” -3/15/2026 at 2:23 AM: “Reason for Communication: Evaluate. Provider Name: [Orthopedic APNP V]...Method of Communication: Page. Response: Waiting for response. Additional documentation when notifying: sent a 2nd page as a [sic] never received a call back from the 1st page I sent about [Patient #1] having chest pain.” -3/15/2026 at 6:31 PM: “Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat...Additional documentation when notifying:...did you complete the hospitalist consult last night because I tried to get a hold of whoever was on call for your service and neither the midlevel (APNP) or MD called me back and they were both paged 4 times so I am going to need a better option to get a hold of someone for tonight if there are any issues.” -3/16/2026 at 8:15 AM: “Reason for Communication: Change in status. Provider Name: [Orthopedic Surgeon B]...Method of Communication: Page. Response: Other (comment): Unable to get there in timely manner, divert to Hospitalist team to evaluate. Additional documentation when notifying: Change in [Patient #1’s] status, increased SOB (shortness of breath) on 5L (5 liters of oxygen), slurred speech, called RT (respiratory therapy) to evaluate O2 (oxygen) status. Unable to obtain BP, working on manual (BP). Should come to see [Patient #1] asap.” A review of “Flowsheets: Shift Event” on 3/16/2026 at 8:15 AM revealed, “Called RRT (Rapid Response Team) for change in [Patient #1’s] status (SOB, slurred speech). [Patient #1’s] primary provider too far away and needed emergent attention.” During an interview on 6/23/2026 at 3:20 PM, Med/Surg RN K stated that on the morning of 3/15/2026, she was concerned about Patient #1’s abdominal pain and tried to contact Orthopedic Surgeon B but did not receive a response. Med/Surg RN K stated that when she contacted Orthopedic Surgeon B on 3/16/2026 at 8:15 AM to discuss Patient #1’s symptoms, including slurred speech, Orthopedic Surgeon B stated, “Is there someone from neuro (neurology) you can ask [about Patient #1’s symptoms] instead?” During a telephone interview on 6/23/2026 at 3:53 PM, Med/Surg RN L stated that on 3/15/2026 around 2:00 AM, she became concerned about Patient #1’s low blood pressure, abdominal pain, and chest pain. Med/Surg stated she tried to page both Orthopedic Surgeon B and his midlevel provider, Orthopedic APNP V, but received no response. Med/Surg RN L stated she then contacted Hospitalist E to evaluate Patient #1’s immediate symptoms and followed up with Orthopedic Surgeon B later that morning, asking Orthopedic Surgeon B to complete the ordered Hospitalist consultation by speaking directly to a Hospitalist. During an interview on 6/24/2026 at 8:35 AM, Hospitalist S stated that attending providers are expected to be responsive to pages in timeframes outlined in the medical staff bylaws, and if the attending physician cannot return a page or come to the hospital in a timely manner, he/she should assign a partner to cover patient care duties. During an interview on 6/24/2026 at 7:35 AM, Quality Director J stated that all physicians and midlevel providers with privileges at the facility have access to and are expected to follow the “Medical Staff Bylaws” and all other hospital rules, regulations, and policies. Failure to round daily on a hospitalized patient: A review of “Progress Notes” from 3/12/2026 to 3/16/2026 revealed progress notes from Orthopedic Surgeon B on 3/12/2026 at 12:21 PM, 3/13/2026 at 9:22 AM, 3/15/2026 at 2:19 PM, and 3/16/2026 at 12:15 PM. There is no evidence of a progress note from Orthopedic Surgeon B on 3/14/2026. During an interview on 6/23/2026 at 12:34 PM, DON R reviewed Patient #1’s medical record and stated there is no progress note from Orthopedic Surgeon B on 3/14/2026. DON R stated there is no evidence of Patient #1 being seen by a provider between 3/13/2026 at 12:21 PM and 3/15/2026 at 3:09 AM, when Hospitalist E evaluated Patient #1 on an urgent basis for symptoms of chest pain at the request of nursing staff. During an interview on 6/24/2026 at 7:35 AM, Quality Director J stated that all physicians and midlevel providers with privileges at the facility have access to and are expected to follow the “Medical Staff Bylaws” and all other hospital rules, regulations, and policies. During an interview on 6/24/2026 at 8:35 AM, Hospitalist S stated that attending providers and active consultants are expected to round daily on hospitalized inpatients and write a progress note about each visit. She stated that if an attending patient is unable to round on his/her own patients, that provider is responsible for designating a covering partner from his/her own speciality group to cover rounding responsbilities.”

“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: 53566 Based on record review and interview, facility staff failed to follow the facility policy for communicating with medical staff regarding changes in patient condition or patient updates requiring a provider response in 1 (Patient #1) of 5 patients with a change in condition or update requiring a provider response, in a total universe of 10 medical records reviewed. Findings: A review of facility policy titled “Epic (electronic medical record system) Secure Chat Instant Messaging Policy” last revised 10/2025 revealed, “I. SCOPE. The Epic Secure Chat Instant Messaging Policy...establishes the standards and processes for using instant messaging...and applies to all Team Members and Medical Staff within all entities, departments, divisions, facilities, and service lines...IV. POLICY...1. Epic Secure Chat may be used to communicate brief, non-critical Patient or workflow information between health care Team Members and Providers...3...Epic Secure Chat must not be used to communicate any of the following: a. For emergent or urgent Patient care situations, critical Patient care updates, or communication of any critical results...c. For conveying any Patient updates that require a Provider response...” A review of Patient #1’s medical record revealed she was an 81-year-old female status post removal of an infected right ankle implant on 3/11/2026. She was admitted to the Medical/Surgical floor for recovery, where she later developed hypotension (low blood pressure) and abdominal pain. On 3/16/2026, Patient #1 was transferred to the intensive care unit (ICU) for worsening hypotension, respiratory distress, and severe abdominal pain. Her condition rapidly deteriorated and on 3/16/2026 at 6:22 PM, Patient #1 was pronounced deceased. A review of “Flowsheets: Notification” revealed the following: -3/12/2026 at 12:00 PM: “Reason for Communication: Evaluate. Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat...Additional documentation when notifying:...Hospitalist was consulted last night, however they have been unable to get someone to see them today. Direct (hospital system that coordinates patient transfers and consultations) is saying we should get a new consult (consultation order) placed. Could you do that? Also wanted to let you know BPs (blood pressures) are stable but have been softer, low 100s. I tried pushing out metoprolol, spironolactone and losartan but BP persists low 100s. [Patient #1] is asymptomatic.” -3/15/2026 at 6:30 PM: “Reason for Communication: Evaluate. Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat...Additional information when notifying: FYI [Patient #1’s] BP is 99/58.” -3/15/2026 at 6:31 PM: “Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat ...Additional documentation when notifying:...did you complete the hospitalist consult last night because I tried to get a hold of whoever was on call for your service and neither the midlevel (APNP) or MD called me back and they were both paged 4 times so I am going to need a better option to get a hold of someone for tonight if there are any issues.” -3/15/2026 at 7:09 PM: “Reason for Communication: Evaluate. Provider Name: [Orthopedic Surgeon B]...Method of Communication: Secure Chat...Additional documentation when notifying: [Patient #1’s] BP is now 91/60. Do you want a little bolus or anything?” During an interview on 6/23/2026 at 9:49 AM, Med/Surg RN K stated any change in a patient’s condition requires a telephone page to notify medical staff. During an interview on 6/24/2026 at 8:35 AM, Hospitalist S stated any serious or emergent patient updates should be communicated by paging the attending physician or calling an RRT.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 50644 Based on record review and interview, facility staff failed to complete prompt resolution of a patient grievance per their policy for 1 out of 3 (Patient #1) patient grievances reviewed. Findings Include: A review of facility policy #18171556 titled, “Patient Complaints and Grievances Policy” last approved 05/2025 revealed, “...With Grievances, contact the Patient and/or their Legal Representative and inform them of the process and their rights, and prepare an Initial Acknowledgment Letter within seven (7) business days of the receipt of the Grievance...The Area Manager or other designated leader from where the Grievance originated, will prepare a Grievance Resolution Letter within thirty (30) calendar days of the date the Grievance was received...” A review of Patient #1’s grievance to the facility revealed that Patient #1 submitted a grievance on 8/4/2025. On 8/9/2025 an initial letter was sent to Patient #1 stating they would receive a response within 30 days. On 8/13/2025, Patient #1 called and submitted more complaint details to the facility. On 8/27/2025 (23 days after initial receipt of the Grievance and 14 days after additional details were submitted), ED Manager B called Patient #1 to discuss the complaint further and Patient #1 needed to reschedule the phone call to 8/29/2025. On 8/29/2025, Manager B was able to discuss the complaint with Patient #1 in detail. A final Grievance Resolution Letter was sent to Patient #1 on 9/23/2025 (50 days after initial receipt of the Grievance). During an interview on 12/17/2025 at 1:21 PM Patient Safety Officer L was asked what the process was for following up with a Grievance. Patient Safety Officer L stated that the policy states to complete an initial response within 7 days and complete the investigation and send a final letter within 30 days.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50644 Based on record review and interview, facility staff failed to complete discharge vital signs within 30 minutes prior to ED (Emergency Department) discharge per Emergency Nurses Association (ENA) Guidelines for 5 out of 10 Patients (Patient #1, #3, #5, #7 and #8) medical records reviewed. Findings Include: A review of facility policy #19236424 titled, “Nursing Patient Assessment Policy” last revised 11/4/2025 revealed, “Vital signs include: Blood Pressure (B/P), Pulse (P), Respirations (R), Temperature (T) and Oxygen Saturation (O2 sat)...The depth and frequency of the physical examination and function pattern assessment is individualized according to the Standard of Care for the Patient’s population, the Patient’s needs, the Patients plan of care, nursing judgment, and Provider orders...Emergency Departments:...Assessment: See Emergency Nurses Association (ENA) Standards of Care.” A review of “Emergency Nurses Association Guidelines” (no date) revealed, “ENA emphasized that final vital signs should be completed very close to discharge, ideally within 30 minutes of the patient leaving the facility, as part of a comprehensive reassessment to ensure stability...” A review of Patient #1’s ED medical record revealed that Patient #1 arrived at the ED on 7/17/2025 at 11:54 PM with complaint of hip pain. Patient #1 was discharged on 7/18/2025 at 7:31 AM. Last recorded vital signs were completed on 7/18/2025 at 6:00 AM (1 hour and 31 minutes prior to discharge). A review of Patient #3’s ED medical record revealed that Patient #3 arrived at the ED on 9/14/2025 at 3:57 AM with complaint of leg swelling. Patient #3 was discharged on 9/14/2025 at 7:44 AM. Last recorded vital signs were completed on 9/14/2025 at 6:15 AM (1 hour and 29 minutes prior to discharge). A review of Patient #5’s ED medical record revealed that Patient #5 arrived at the ED on 9/14/2025 at 8:54 PM with complaint of abscess. Patient #5 was discharged on 9/15/2025 at 1:34 AM. Last recorded vital signs were completed on 9/15/2025 at 12:08 AM (1 hour and 26 minutes prior to discharge). A review of Patient #7’s ED medical record revealed that Patient #7 arrived at the ED on 10/12/2025 at 8:47 AM with complaint of leg pain. Patient #7 was discharged on 10/12/2025 at 10:07 AM. Last and only set of vital signs were completed on 10/12/2025 at 8:51 AM (1 hour and 16 minutes prior to discharge). A review of Patient #8’s ED medical record revealed that Patient #8 arrived at the ED on 10/18/2025 at 5:25 PM with complaint of leg pain. Patient #8 was discharged on 10/18/2025 at 6:43 PM. Last and only set of vital signs were completed on 10/18/2025 at 5:31 PM (1 hour and 12 minutes prior to discharge). During an interview on 12/17/2025 at 9:02 AM, ED Manager B stated that every patient gets an initial set of vital signs (VS) at the time of ED triage, temperature, pulse, respiratory rate, blood pressure (BP), oxygen saturation, and pain. When asked about frequency of VS after the initial set, ED Manager B responded, “We don’t have a predetermined timeframe and are looking to standardize this.” When asked about a time period for a final set of VS prior to a patient’s discharge from the ED, ED Manager B stated a full set of VS should be done 30 minutes to 1 hour before discharge, but this is currently an “unwritten rule.” During an interview on 12/17/2025, ED RN E described the discharge vital sign routine as BP, pulse, oxygen saturation, and respiratory rate 30 minutes prior to discharge. “Temp only if they came in for a temperature problem or had a fever on admission.” During an interview on 12/17/2025 at 1:26 PM, ED Nurse Educator C stated that nurses in the ED follow discharge guidelines from ENA (Emergency Nurses Association), which includes “vital signs 30 minutes prior to discharge.””

“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: 43037 Based on record review and interview, facility staff failed to provide an emergency medical screening exam sufficient to rule out an emergency medical condition for 1 of 20 patients reviewed (Patient #1), in a total sample of 20 patients. Findings include: The facility staff failed to complete a full medical screening exam for 1 of 20 patients (Patient #1) who presented to the Emergency Department. See Tag A-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: 43037 Based on record review and interview, facility staff failed to provide an emergency medical screening exam sufficient to rule out an emergency medical condition for 1 of 20 patients reviewed (Patient #1), in a total sample of 20 patients. Findings include: Review of Patient #1’s medical record revealed Patient #1 presented to the Emergency Department (ED) on 10/13/2024 at 6:59 PM with complaints of lower abdominal pain. Patient #1’s ED Narrator event log (timeline) pre-arrival documentation dated 10/13/2023 at 7:02 PM reveals, “Triage information...Patient arrives with c/o (complaint of) lower abdominal pain that started last night accompanied by nausea and multiple vomiting ...Other Complaints/Symptoms: Denies chest pain, diff (difficulty) breathing, urinary symptoms and blood in stools or urine.” Patient #1’s event log dated 10/13/2023 at 7:05 PM, reveals, “Pain score: 7 (on 0-10 scale with 10 being highest); Pain Type: Acute Pain; Pain Location: Abdomen; Pain Descriptors: Aching; Pain Frequency: Continuous; Associative Factors ...Nausea, Vomiting.” Per the “ED Provider Note” authored by ED Physician Assistant J and dated 10/13/2023 at 7:31 PM, “...reports starting yesterday evening, began developing concerns of lower abdominal discomfort. ...uncertain if she may have pulled something in her abdominal wall. ...states in the middle of the night she started with new onset nausea and vomiting and estimates ...about 9 episodes of vomiting activity. ...states her abdomen was not causing her any significant pain immediately however, the more activity she began to do the more her pain returned. ...continues to report nausea but has not had recurrent vomiting. ...did not have a bowel movement today but did have diarrhea yesterday. Denies any dysuria (pain with urination) or hematuria (bloody urine) symptoms. Denies a prior history of abdominal surgeries. (Patient #1) did not take anything for pain today. No obvious recent fevers. No other concerns...” Patient #1’s medical records indicates that a urine specimen was collected 10/13/2023 with results indicating, “...Specimen...Clean catch urine: Epithelial (surface cells from skin, blood vessels, urinary tract or organs) cells: 3-5! (Reference range 0-2/HPF (high powered field)), Urine WBCs (white blood cells): Too numerous to count! (Reference range 0-2/HPF), Urine Bacteria 2+! (Reference range None seen/HPF) ...Laboratory results for “WBC (white blood cell) count (an indicator for infection) 10.0 (Reference range 4.0-11.0) ...’Positive’ for Nitrites, ‘Moderate’ for Leukocytes and ‘Trace’ for Urine Blood. Normal results for these values are “Negative.” Review of Patient #1’s ED Summary and Plan revealed, “...Differential diagnoses considered today include diverticulitis (inflammation of a diverticulum, especially in the colon), viral gastroenteritis (stomach flu), cystitis (inflammation of the bladder), dehydration, electrolyte disturbance (necessary minerals in blood), ureterolithiasis (kidney stone stuck in the ureter), less worried for but possible appendicitis (inflammation of the appendix)...Urinalysis appeared concerning for infection with positive nitrites (sign of possible urinary tract infection), moderate leukocyte esterase (sign of infection or inflammation in the urinary tract), many WBCs and 2+ bacteria. Urine was sent for culture. Medical chart review demonstrates (Patient #1) has not had a prior urine culture completed. Based on (Patient #1’s) allergy list, will place (Patient #1) on Macrobid (antibiotic) for treatment of urinary tract infection. Recommend pushing fluids. (Patient #1) was given a prescription for Zofran to help with nausea symptoms. Follow-up instructions discussed. Instructions provided...” There is no documented re-assessment of pain, nausea or vomiting after the triage note at 7:05 PM. There is no documentation in the medical record of the provider having assessed the patient for clinical signs and symptoms of a urinary tract infection after the urinalysis results. There is no documentation of reassessment for resolution of patient #1’s presenting symptoms prior to discharge on 10/13/2023. The medical screening examination was not sufficient to exclude additional emergency medical conditions contributing to the patient’s presentation of abdominal pain, nausea and vomiting. A review of Patient #1’s medical record for ED visit of 10/14/2023 revealed Patient #1 was readmitted to the ED on 10/14/2023 at 5:34 PM with complaints of vomiting, nausea and worsening abdominal pain. A CT (computed tomography) scan of the abdomen was ordered revealing small bowel obstruction with umbilical herniation. Patient #1 was admitted as an inpatient per surgical consult recommendation.”