Braxton County Memorial Hospital, Inc.

“MAINTENANCE CFR(s): The CAH has housekeeping and preventive maintenance programs to ensure that-- (1) All essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition; This Standard is not met as evidenced by: 37324 Based on record review and staff interview it was determined the facility failed to ensure all essential mechanical and electrical equipment followed manufacturer-recommended maintenance activities and schedules. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 2. Findings include: Record review on 12/11/24 at approximately 11:24 a.m., revealed no documentation available for review during survey to show that all essential mechanical and electrical equipment was listed in an inventory, which includes a record of maintenance activities. Record review on 12/11/24 at approximately 11:32 a.m., revealed no documentation available for review during survey to show that preventative maintenance for all essential mechanical and electrical equipment followed manufacturer’s recommendations or an approved alternate equipment maintenance (AEM) program. Interview on 12/11/24 at approximately 11:34 a.m. with the Maintenance Supervisor verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 37324 Based on observation, record review, and staff interview it was determined the facility failed to comply with the Health Care Occupancy chapter requirements of NFPA (National Fire Protection Association) 101. This deficient practice could affect all patients, staff, and visitors in the areas referenced. Facility census 2. Findings include: In reference to Federal Life Safety Code (FLSC) citation K 345, the facility failed to ensure that the fire alarm system was properly tested and maintained. In reference to FLSC citation K 353, the facility failed to ensure that the sprinkler system was properly tested and maintained. In reference to FLSC citation K 521 the facility failed to ensure that fire and smoke dampers were properly tested and maintained. In reference to FLSC citation K 781 the facility failed to ensure that portable space heaters were properly used and tested. In reference to FLSC citation K 918 the facility failed to ensure that the emergency generator was properly tested and maintained. In reference to FLSC citation K 920 the facility failed to ensure that power strips were properly used. In reference to FLSC citation K 921 the facility failed to ensure that fixed and portable patient-care equipment was properly tested and maintained. Interview on 12/11/24 at approximately 10:32 a.m. with the Maintenance Supervisor verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 40269 Based on document reviews and interviews, it was determined the facility failed to ensure Medical Staff Bylaws, Rules and Regulations were reviewed and approved by the Governing Body every two (2) years. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: The “Medical Staff Bylaws,” were reviewed, last reviewed by the Governing Body on 07/16/21. No more recent reviews or approvals were listed. The “Medical Executive Committee Meeting” minutes were reviewed for 08/28/23 and state in part, “...Old Business: MS (Medical Staff) Bylaws/Rules & (and) Regs (Regulations)- Awaiting review by legal services. Action tabled until completion of review...” The “Medical Executive Committee Meeting” minutes were reviewed for 12/19/23 and state in part, “...Old Business: Review of MS Bylaws/Rules & Regs - Awaiting review by legal services. Action tabled until completion of review...” The “Medical Executive Committee Meeting” minutes were reviewed for 02/20/24 and state in part, “...Old Business: Review of MS Bylaws/Rules & Regs - Awaiting review by legal services. Action tabled until completion of review...” The “Medical Executive Committee Meeting” minutes were reviewed for 04/16/24 and state in part, “...Old Business: Review of MS Bylaws/Rules & Regs - Awaiting review by legal services. Action tabled until completion of review...” The “Medical Executive Committee Meeting” minutes were reviewed for 07/18/24 and state in part,”...New Business: Medical Staff Bylaws: The draft of proposed revisions to the Medical Staff Bylaws will be forwarded to [Staff #13], to review.” An interview was conducted with Staff #13 on 12/11/24 at 9:21 a.m. Staff #13 explained the updated proposals for the Medical Staff Bylaws information was sent to them for review on 07/18/24, but had not been reviewed yet. Staff #13 confirmed there were no further updates or reviews documented by the Governing Body since 07/16/21.”

“SNF SERVICES CFR(s): The CAH is substantially in compliance with the following SNF requirements contained in subpart B of part 483 of this chapter: §485.645(d)(1) Resident Rights (§483.10(b)(7), (c)(1), (c)(2)(iii), (c)(6), (d), (e)(2) and (4), (f)(4)(ii) and (iii), (g)(8) and (17), (g)(18) introductory text, (h) of this chapter). “ §483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident’s behalf. The court-appointed resident representative exercises the resident’s rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law. “ §483.10(c) Planning and implementing care. The resident has the right to be informed of, and participate in, his or her treatment, including: (1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. “ §483.10(c)(2)(iii) The right to be informed, in advance, of changes to the plan of care. “ §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. “ §483.10(d) Choice of attending physician. The resident has the right to choose his or her attending physician. (1) The physician must be licensed to practice, and (2) If the physician chosen by the resident refuses to or does not meet requirements specified in this part, the facility may seek alternate physician participation as specified in paragraphs (d)(4) and (5) of this section to assure provision of appropriate and adequate care and treatment. (3) The facility must ensure that each resident remains informed of the name, specialty, and way of contacting the physician and other primary care professionals responsible for his or her care. (4) The facility must inform the resident if the facility determines that the physician chosen by the resident is unable or unwilling to meet requirements specified in this part and the facility seeks alternate physician participation to assure provision of appropriate and adequate care and treatment. The facility must discuss the alternative physician participation with the resident and honor the resident’s preferences, if any, among options. (5) If the resident subsequently selects another attending physician who meets the requirements specified in this part, the facility must honor that choice. “ §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. “ §483.10(e)(4) The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement. “ §483.10(f)(4)(ii) The facility must provide immediate access to a resident by immediate family and other relatives of the resident, subject to the resident’s right to deny or withdraw consent at any time; “ §483.10(f)(4)(iii) The facility must provide immediate access to a resident by others who are visiting with the consent of the resident, subject to reasonable clinical and safety restrictions and the resident’s right to deny or withdraw consent at any time; “ §483.10(g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (ii) Access to stationery, postage, and writing implements at the resident’s own expense. “ §483.10(g)(17) The facility must- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. “ §483.10(g)(18)[introductory text only] The facility must inform each resident before, or at the time of admission, and periodically during the resident’s stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility’s per diem rate. “ §483.10(h) Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. (1) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. (3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident’s medical, social, and administrative records in accordance with State law. This Standard is not met as evidenced by: 40269 Based on document reviews and interviews, it was determined the facility failed to ensure the Patient Bill of Rights for Swing Beds was provided to all Swing bed patients. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A review was conducted of the admission folder presented to Swing bed patients upon admission. The folder included the “Patient Rights and Responsibilities,” last approved 06/14/23 and the “Patient Bill of Rights,” last approved 06/14/23. The documents did not include the following rights of swing bed patients: The resident has the right to choose his or her attending physician, The right to retain and use personal possessions, including furnishings, and clothing, as space permits, The right to share a room with his or her spouse when married residents live in the same facility and both spouses consent to the arrangement, and The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service. An interview was conducted with Staff #11 on 12/10/24 at 2:08 p.m. Staff #11 concurred there was no Swing Bed Patient Bill of Rights, which included the above Rights, provided to the Swing Bed patients.”

“Fire Alarm System - Testing and Maintenance CFR(s): NFPA 101 Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72 This Standard is not met as evidenced by: 37324 Based on record review and staff interview, the facility failed to ensure that the fire alarm system was tested and maintained in accordance with NFPA (National Fire Protection Association) 72. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Record review on 12/09/24 at approximately 1:43 p.m., revealed the documentation for smoke detector sensitivity testing did not include the manufacturers’ listed sensitivity range, the actual tested sensitivity, or a pass/fail for all smoke detectors located throughout the facility. Interview on 12/09/24 at approximately 1:44 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“Sprinkler System - Maintenance and Testing CFR(s): NFPA 101 Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25 This Standard is not met as evidenced by: 37324 Based on record review and staff interview, the facility failed to ensure that the automatic sprinkler system was tested and maintained in accordance with NFPA (National Fire Protection Association) 25. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Record review on 12/09/24 at approximately 1:18 p.m., revealed two (2) sprinkler gauges dated 10/01/19, which had not been calibrated or replaced in the previous five (5) years. Interview on 12/09/24 at approximately 1:19 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“HVAC CFR(s): NFPA 101 HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer’s specifications. 18.5.2.1, 19.5.2.1, 9.2 This Standard is not met as evidenced by: 37324 Based on record review and staff interview, the facility failed to ensure that fire and smoke dampers were installed and maintained in accordance with NFPA (National Fire Protection Association) 90A. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Record review on 12/09/24 at approximately 2:37 p.m., revealed the fire damper inspection report did not include the location of fire dampers located throughout the building. Interview on 12/09/24 at approximately 2:38 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“Portable Space Heaters CFR(s): NFPA 101 Portable Space Heaters Portable space heating devices shall be prohibited in all health care occupancies, except, unless used in nonsleeping staff and employee areas where the heating elements do not exceed 212 degrees Fahrenheit (100 degrees Celsius). 18.7.8, 19.7.8 This Standard is not met as evidenced by: 37324 Based on observation, record review, and staff interview, the facility failed to ensure that portable space heaters were used in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Observation on 12/10/24 at approximately 9:51 a.m., revealed a portable space heater in the Med Surge Shower Room, near the Short Hall. Observation on 12/10/24 at approximately 2:24 p.m., revealed a portable space heater in use in the Human Resources Office. No documentation was provided during survey to show that the elements in this space heater did not exceed 212 degrees Fahrenheit. Interview on 12/10/24 at approximately 2:25 p.m. with the Maintenance Supervisor verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“Electrical Systems - Essential Electric Syste CFR(s): NFPA 101 Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70) This Standard is not met as evidenced by: 37324 Based on record review and staff interview, the facility failed to ensure that the emergency generator was tested and maintained in accordance with NFPA (National Fire Protection Association) 110. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Record review on 12/09/24 at approximately 2:12 p.m., revealed no documentation available for review during survey to show that the emergency generator battery electrolyte fluid level had been checked weekly for the previous twelve (12) months. Interview on 12/09/24 at approximately 2:13 p.m. with the Maintenance Supervisor verified this finding. This finding was also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“Electrical Equipment - Power Cords and Extens CFR(s): NFPA 101 Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5 This Standard is not met as evidenced by: 37324 Based on observation and staff interview, the facility failed to ensure power strips were used in accordance with NFPA (National Fire Protection Association) 99. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Observation on 12/09/24 at approximately 11:31 a.m., revealed a refrigerator and a coffee pot plugged into a power strip in the Pharmacy. Observation on 12/10/24 at approximately 8:47 a.m., revealed a power strip in use in Operating Room 1, which appeared to be a residential style power strip and did not appear to meet UL 1363A or UL 60601-1. Observation on 12/10/24 at approximately 9:51 a.m., revealed a refrigerator, two (2) coffee pots, and a toaster plugged into a power strip in Cardiopulmonary. Observation on 12/10/24 at approximately 2:33 p.m., revealed a microwave, refrigerator, and a coffee pot plugged into a power strip in the Infection Control Office. Observation on 12/10/24 at approximately 2:45 p.m., revealed two (2) power strips, which were being used to power a microwave, refrigerator, two (2) coffee pots, and an ice maker in the Clinic Breakroom. Observation on 12/11/24 at approximately 8:45 a.m., revealed a microwave, refrigerator, and toaster plugged into a power strip in the Maintenance Supervisor’s Office. Observation on 12/11/24 at approximately 10:29 a.m., revealed a refrigerator, toaster, coffee pot, and a microwave plugged into a power strip in the Cashier’s Office. Interview on 12/11/24 at approximately 10:30 a.m. with the Maintenance Supervisor verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“Electrical Equipment - Testing and Maintenanc CFR(s): NFPA 101 Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility’s policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8 This Standard is not met as evidenced by: 37324 Based on record review and staff interview, the facility failed to maintain the testing and maintenance requirements for fixed and portable patient-care equipment in accordance with NFPA (National Fire Protection Association) 101. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 2. Findings include: Record review on 12/10/24 at approximately 8:32 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for an Olympus Video Connector, Olympus Endoscope Video Connector, or an Olympus Water Pump used on the Scope Tower in Operating Room 2 had been completed since March of 2023. Record review on 12/10/24 at approximately 8:35 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for two patient warmers (BC00084) and (SR000289) in use in Operating Room 2 had been completed in the previous twelve (12) months. Record review on 12/10/24 at approximately 8:38 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for a water pump (BC000033) in use in Operating Room 2 had been completed since March of 2023. Record review on 12/10/24 at approximately 8:55 a.m., reveled no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for a Sequential Compression Device in use in Operating Room 1 had been completed since September of 2022. Record review on 12/10/24 at approximately 9:20 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for a Buffalo Smoke Evacuation Filter in use in Operating Room 1 had been completed in the previous twelve (12) months. Record review on 12/10/24 at approximately 9:45 a.m., revealed no documentation available for review during survey to show that the testing of the physical integrity of the power cord assembly, electrical resistance, or touch/leakage current testing for an EKG Machine in use in the Cardiopulmonary Outpatient Testing Room had been completed since March of 2023. Interview on 12/11/24 at approximately 9:46 a.m., with the Vice President Of Operations verified these findings. These findings were also acknowledged by the Interim President/CEO at the exit interview on 12/11/24 at approximately 12:19 p.m.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 46199 Based on medical record review, document reviews and staff interviews, it was determined the facility failed to provide a medical screening in one (1) out of twenty-seven (27) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy review titled “Triage of Emergency Department Patients”, last reviewed 07/2024. The policy states ...”Any person presenting, or on whose behalf a request is made, for an examination or treatment of a medical condition shall be provided for a medical screening examination to determine whether a medical emergency does or does not exist. The hospital shall provide for an appropriate medical screening examination beyond initial triaging, within the capability of the hospital. (Triage is not equivalent to a medical examination). Acuity levels shall be assigned prior to registration procedures and approved protocols shall be instituted as appropriate. Any physician, Advanced Practice Provider, or ED RN may triage emergency or urgent patients and assign them an available bed”. Procedure ...Once arrived the triage RN will complete Triage/ Screening History in EMR. While the Adult/Pediatric Assessment can be completed by the triage RN, it is primarily the patient assigned nurses responsibility ...Emergency Severity Index (ESI): ....Level III-Urgent: Moderate risk situations which involve significant complications, disabilities of impairment of bodily functions (i.e. open fracture, acute abdominal pain, severe pain, etc.). Nurse predicts the use of one resource...Level IV-Stable: Conditions considered at low risk for complications (i.e. simple lacerations, cough, etc.) Nurses predict the use of one resource. A policy review titled “Emergency Medical Treatment and Labor Act (EMTALA)”, last reviewed 02/01/2023. The policy states “West Virginia University (WVUH) will comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA) by ensuring that when an individual comes by him or herself or with another person to WVUH or its premises and a request is made by the individual or on the individual behalf for medical examination or treatment, WVUH or a department thereof will provide for an appropriate Medical Screening Examination within the capability of the WVUH Emergency Department, including ancillary services routinely available to the Emergency Department, to determine whether or not an emergency medical condition exists or, with respect to a pregnant woman having contractions, whether the woman is in labor. If it is determined that the individual has an emergency medical condition, stabilizing treatment will be provided and they will be either admitted, discharged or transferred as appropriate...Medical Screening Examination....”if an individual arrives on WVUH property or its premises and is not technically in the Emergency Department but requests emergency care, he or she will receive a MSE within the capabilities and capacity of WVUH. Movement of the patient to the WVUH Emergency Department is usually necessary for screening. However, common sense and individual judgment shall prevail. Consideration should be given to: 1. Whether WVUH Emergency Department has the personnel and resources necessary to render adequate medical treatment to all existing patients in the Emergency Department and to adequately respond to new patient emergencies that could arrive at any moment”. A medical record review was conducted for Patient #1. The patient was transported to the Emergency Department (ED) via emergency medical services (EMS) ground ambulance following a motorcycle accident on 7/2/24. The record includes a section titled “Patient Event Tracking” which has the following entries: 7/2/24 3:55 p.m. Patient arrived in ED. 7/2/24 5:18p.m. Patient Triage Started. 7/2/24 5:20p.m. ED Provider First Contact. 7/2/24 6:56p.m. Registration Completed. The record includes an entry titled “ED Primary Provider Note” completed on 7/2/24 at 5:18 p.m. by Emp #5 which includes a section titled “History of Present Illness” which states, in part, “[Patient #1] presents for evaluation after a motorcycle crash. [Patient #1] states [Patient #1] lost control going around a corner, laid the bike down onto the left side. [Patient #1] estimates speed at the time was around twenty-five (25) miles per hour (mph). Patient was helmeted. [Patient #1] does report striking [Patient #1’s] head without associated loss of consciousness and presents with a minimal headache. Main complaint consists of left flank, chest, left upper quadrant abdominal pain. [Patient #1] has had no vomiting. [Patient #1] also complains of left ankle pain. Patient does not take anticoagulants, antiplatelet medications.” The record includes an entry titled “Triage Plan” completed on 7/2/24 at 5:28 by Emp #8 which states, in part, “Triage Plan Patient Acuity: 3”. The record contains a document titled “Clay County Ambulance Service’’, dated 7/2/24. An entry on this document states, “At receiving facility (At Rec.) 3:55 p.m., transfer care destination 5:34 p.m.” A section titled “Narrative” states, in part, “Patient remained in ambulance for a total of one (1) hour thirty (30) minutes while waiting to be let into facility.” An interview was conducted with Emp #9 on 7/08/24 at 3:05 p.m. Emp #9 was asked about the Emergency Department (ED) on 7/2/24. Emp #9 stated, “The provider at that shift has a lot to do with discharges. A lot of patients were waiting for about four (4) or five (5) hours.” A telephone interview was conducted with Emp #5 on 7/9/24 at 12:50p.m. Emp #5 was asked about their interaction with Patient #1. Emp #5 stated, “I wasn’t aware that the patient had arrived at the ambulance bay. There had been a string of horrible days in terms of waiting.” Emp #5 was asked if ambulances waiting was a common event. Emp #5 stated, “In the past, typically, we get them into the waiting room from the stretcher no matter how busy we are. We have five (5) minutes to move someone.” A telephone interview was conducted with Emp #7 on 7/9/24 at 1:55 p.m. Emp #7 was asked about the events of 7/2/24. Emp #7 stated, “[Facility] is the most unlikely place for this to happen. Usually, patients are brought in and placed in the hallway. I don’t know what happened but the volume at [Facility] is low.”