Banner Wyoming Medical Center

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 16146 Based on medical record review, staff and patient interviews, and review of incident reports, the facility failed to ensure nursing services was provided to meet the needs of patients. Specifically, the facility failed to ensure the physician was notified of a significant change in condition for 2 of 7 patients (#3, #4) and failed to follow physician orders related to wound care for 1 of 3 patients (#3). The findings were: Related to physician notification: 1. Review of an incident report for patient #4 showed on 8/7/25 the family noticed the patient had a swollen lip and was missing two teeth. The facility’s investigation showed the patient bit down on the endotracheal tube which caused a loose tooth which became dislodged. Further, “...When the physician rounded on the patient family asked if they had been notified and the physician stated that they had no knowledge of the incident.” Review of the medical record showed the patient was intubated upon arrival to the facility on 8/5/25 (was transferred from another hospital). Review of a nursing note dated 8/7/25 showed the nurse was informed at the beginning of the shift that overnight the patient had become agitated and bit down on the bit block which caused a front tooth to become loose. Upon assessment, no front tooth was noted and was not seen in the mouth. Review of nursing documentation showed on 8/7/25 a loose front tooth was documented at 3 AM and “missing teeth” was documented at 7:28 AM. Further, on 8/7/25 at 2:50 PM “blood in mouth from when pt bit lip overnight per NOC RN [night registered nurse]” was documented. Review of a chest xray dated 8/7/25 showed “...density projected over the distal esophagus, may represent swallowed metallic foreign body or object overlying the patient.” The following concerns were identified: a. Review of a progress note from the physician dated 8/8/25 showed when the physician walked into the patient’s room, the family was upset. The physician documented “...the patient’s daughters also brought to my attention that the patient’s 2 front teeth were missing, which was never brought to my attention until she had told me. Apparently, the patient had bit down on the endotracheal tube Wednesday night, at which point [his/her] teeth apparently had dislodged.” b. Review of the medical record showed no evidence the physician was notified of the missing teeth until the family brought it to their attention on 8/8/25. c. During an interview on 9/17/25 at 12:48 PM the director of nursing (DON) stated the patient needed the bite block because s/he was biting through the tube. She further stated the expectation was that the provider should have been notified of the missing teeth. 2. Review of the medical record showed patient #3 was admitted on 6/17/25 and discharged on 6/23/25 for bilateral pulmonary emboli. Review of nursing documentation showed on 6/22/25 and 6/23/25 the patient had “pink” urine. The following concerns were identified: a. Further review of the medical record showed no evidence the physician was notified of the pink urine, and no urinalysis was ordered. b. During an interview on 9/16/25 at 2:10 PM the patient stated she had normal urine at the beginning of his/her hospital stay, but then it turned “reddish.” The patient stated they found out after their discharge they had a urinary tract infection (UTI) when they went to another hospital. c. On 9/17/25 at 12:48 PM the DON confirmed there was no evidence the physician was notified of the pink urine. She stated her expectation was that the physician should have been notified. She further stated the facility did not have a specific policy on notification of the physician. Related to following physician orders: 1. Review of the medical record showed patient #3 was admitted on 6/17/25 and discharged on 6/23/25 for bilateral pulmonary emboli. Review of wound care consult dated 6/18/25 showed daily wound care for the right buttock was to start 6/19/25. Instructions were to clean with normal saline and gauze and “pt has been applying small amount of mupirodin ointment to wound and then cover with a mediplex.” Review of physician orders showed an order dated 6/18/25 (with a start date of 6/19/25) for “Daily, Buttock, Right, clean with NS and gauze. pt has been applying a small amount of mupirocin ointment to wound and then cover with a mediplex.” Nursing documentation dated 6/21/25 showed an “abrasion” to the right coccyx. The following concerns were identified: a. Review of the medical record showed no evidence the wound care was provided as ordered on 6/19/25 or 6/20/25. The first documented wound care was 6/21/25. b. On 9/16/25 at 2:10 PM the patient stated she requested a bandage change to the wound on her tailbone, but the nurse never returned to do it. c. During an interview on 9/17/25 at 12:48 PM the DON confirmed wound care was not charted on 6/19/25 or 6/20/25. She stated nurses should follow physician orders.”

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 16146 The facility failed to ensure blood transfusions were administered in accordance with facility policies for 1 of 3 transfusions reviewed (patient #2). The findings were: 1. Review of the facility’s policy “Blood and Blood Component Administration, Adult,” effective 10/15/24, showed “V. Procedural Documentation: A. Complete the Transfusion Record or Blood Transfusion Refusal Form. B. Document the amount of transfused volume in the medical record (if this was not documented in Bridge Transfusion)...D. Document details of the transfusion, including, but not limited to: * consent * Start and stop times * Vitals signs *IV solutions...” The following concerns were identified: a. Review of the medical record for patient #2 showed a consent form for a blood transfusion and a provider note that showed 1 unit of RBCs (red blood cells) was transfused on 8/20/25. Further review of the medical record showed no transfusion record form. Review of nursing documentation showed there was a start time for the transfusion documented, but not a stop time. b. On 9/17/25 at 9:08 AM the director of nursing (DON) confirmed the transfusion record was not in the medical record. She stated the nurse remembered all of the details and remembered completing it, but they were unable to locate the form. She stated the facility was changing their process for transfusion documentation and that would be happening on October 14th.”

“QAPI CFR(s): 482.21 The hospital must develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program. The hospital’s governing body must ensure that the program reflects the complexity of the hospital’s organization and services; involves all hospital departments and services (including those services furnished under contract or arrangement); and focuses on indicators related to improved health outcomes and the prevention and reduction of medical errors. The hospital must maintain and demonstrate evidence of its QAPI program for review by CMS. This Condition is not met as evidenced by: 37603 Based on record review, staff interviews, and policy and procedure review, it was determined that the hospital failed to develop, implement, and maintain an effective, ongoing, hospital-wide, data driven quality assessment and performance improvement program that involved all hospital departments and services. Refer to A-283 regarding the facility’s failure to appropriately investigate and implement systematic improvements after a neonatal septic shock (life-threatening condition in newborns where a severe infection causes the body’s circulatory system to fail) event and interviews with staff revealed they felt reporting incidents could lead to retaliation. The findings resulted in the inability of the facility to meet the Condition of Participation for Quality Assessment and Performance Improvement Program.”

“EMERGENCY SERVICES CFR(s): 482.55 The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice. This Condition is not met as evidenced by: 37603 Based on medical record review, staff interview, and policy review, the facility failed to meet the emergency needs of patients. Refer to A-1112 regarding the facility’s failure to effectively monitor patient status to ensure emergency care needs were met for 1 of 20 sample patients (#15). On 5/16/25 a finding of Immediate Jeopardy (IJ) (immediate threat to the health and safety of patients) was identified in the area of 482.55 Emergency Services. The hospital was notified verbally of this finding of immediate jeopardy on 5/16/25 at 11:35 AM. The hospital submitted an IJ removal plan and the plan was accepted. The hospital was notified at 9:53 AM on 5/21/25. An onsite visit was conducted on 5/21/25, and the surveyor determined that based on verification of a policy for monitoring neonates on vasopressors, staff education for all ED staff, verification of staff knowledge, and verification of adequate patient monitoring, the IJ was removed on 5/21/25. The hospital was notified of this finding at 3:15 PM on 5/21/25. The seriousness of the finding resulted in the inability of the facility to meet the Condition of Participation for Emergency Services. .”

“QUALITY IMPROVEMENT ACTIVITIES CFR(s): 482.21(b)(2)(ii), (c)(1), (c)(3) (b) Program Data (2) [The hospital must use the data collected to - .....] (ii) Identify opportunities for improvement and changes that will lead to improvement. (c) Program Activities (1) The hospital must set priorities for its performance improvement activities that-- (i) Focus on high-risk, high-volume, or problem-prone areas; (ii) Consider the incidence, prevalence, and severity of problems in those areas; and (iii) Affect health outcomes, patient safety, and quality of care. (3) The hospital must take actions aimed at performance improvement and, after implementing those actions, the hospital must measure its success, and track performance to ensure that improvements are sustained. This Standard is not met as evidenced by: 37603 Based on record review, staff interviews, and policy and procedure review, it was determined that the hospital failed to identify an adverse patient event and implement preventive actions that included education for all staff. Specifically, the facility failed to identify a reported lack of adequate monitoring for a neonatal patient (#15) as an adverse patient event. In addition, interviews with staff revealed they felt reporting incidents could lead to retaliation. The findings were: 1. On 3/12/25 a neonatal septic shock event was reported. The verge/incident was reported to the management related to patient safety, missing blood pressure (BP) while the patient was considered stable, and was on vasopressors without cardiac monitoring. The employee submitted the verge anonymously on 3/13/25 at 1:16 PM. Review of the incident report showed the dayshift RN was told by management not to “verge” this and “it will be handled internally.” Further, “Staff fears retaliation from management, so anonymous report being made on 3/13/25 at 1:19 PM.” “The event reached the patient without harm” was noted by the AD ED on 3/13/25 at 2:21 PM. Further review showed under the section titled “What normally happens” it was written “When staff bring forward concerns, I listen to them and look for teaching opportunities and opportunities for improvement. A verge is encouraged when a pattern of behavior or concern is noticed or a safety concern.” 2. Review of the medical record for patient #15 showed the patient was triaged as Emergency Severity Index (ESI) level 1 (Requires immediate life-saving interventions), “ESI 1 = Continuous observation and monitoring, with documented reassessments at a minimum of every 1 hour until hemodynamically stable, then minimally every 2 hours or per admitting unit guidelines of care.” The diagnosis showed septic bacterial meningitis (bacterial meningitis is inflammation of the membranes surrounding the brain and spinal cord caused by bacteria. Sepsis is a life-threatening reaction to an infection). The following concerns were identified: a. The facility failed to monitor the patient’s BP within a 3.5-hour block (from 10:47 PM until 2:15 AM). The patient’s BP during triage on 3/11/25 at 10:47 PM was 77/62 (normal neonate ranges are 60 to 70 systolic and 30 to 53 diastolic). There were no more documented BP readings until 2:15 AM on 3/12/25 when the BP was 40/22 (low). The BP at 3:14 AM was 76/56 when norepinephrine (constricts blood vessels to increase blood pressure. Used to treat severe, acute low blood pressure in emergency situations) was ordered. Review of vital signs showed over the next four hours (until transfer to another facility) the blood pressures were up and down (the blood pressures varied from 29/19 at 4:48 AM to 71/55 at 7:16 AM). Epinephrine (used to treat low blood pressure) and cefepime (antibiotic) had been ordered at 3:53 AM. b. Review of the medical record showed the physician ordered cardiac monitoring on the pediatric patient on 3/12/25 at 1:11 AM. Further review showed at the same time an order for “Discontinued: Cardiac Monitoring.” Review of the medical record showed no evidence the patient was on a cardiac monitor throughout the stay. The record showed the patient had an EKG (electrocardiogram) twice (on 3/12/25 from 1:38:06 AM until 1:38:53 AM and again from 1:44:18 AM until 1:44:32 AM) c. The medical records showed on 3/12/25 at 3:14 AM norepinephrine was ordered, and was discontinued at 3:46 AM. Then at 3:45 AM epinephrine (vasopressor) was ordered. There was no evidence cardiac monitoring was done on the patient while administering the vasopressors. 3. The following concerns were identified in interviews with staff: a. Interview on 4/15/25 at 2:45 PM with employee #2 revealed s/he was fearful of reporting concerns to management, due to retaliation and potential loss of their job, and they stated they needed his/her job. b. Interview on 5/22/25 at 11:39 AM with employee #4 revealed if s/he had said anything about the management retaliating, it would have painted a big “X” on his/her back and they need their job. S/he stated that the managers retaliated on employees that voiced concerns. 4. Interview with the AD ED on 5/15/25 at 11 AM revealed “I did tell the nurse not to file a verge. I wanted to use it as a learning opportunity, instead of something punitive.” Interview with the AD ED on 4/16/25 at 3:15 PM revealed the facility did not allow retaliation. She stated concerns could be reported on-line, in person or to human resources. She further stated there were employee representatives that staff could report a concern to without revealing themselves. She stated if staff felt they were retaliated against they could go to employee relations and the corporation would investigate. 5. Interview with quality assurance staff #1 on 5/15/25 at 11:35 AM revealed the case did not meet criteria for a risk assessment because they did not deviate from standard of care. 6. Review of the facility policy “Compliance: Reporting and Investigating Potential Compliance Issues” effective Date 12/2/21 included “ ...IV. Procedure/Interventions ...b. If not a Potential Compliance Issue, assign to the appropriate individual or department based on the type of issue ... ii. Human Resources: Human resources issues (e.g., hostile work environment, employee relations, and staffing/scheduling issues ... iii. Clinical Risk Management / Patient Relations Service Center: Clinical risk management issues (e.g., certain patient safety issues, clinical care concerns, and potential or actual litigation matters) ...D. Investigating Potential Compliance Issues (INVESTIGATOR(S)) a. Make a preliminary, good faith inquiry into the Potential Compliance Issue to determine whether further investigation is warranted ... 6. Provide a response, if appropriate, to the Covered Person who initially reported the Potential Compliance Issue ...” 7. Review of the facility’s policy “Event Reporting” effective date 3/29/25 included “ ...I. Purpose and Population: A. To promote a culture of safety that supports internal reporting of errors and near misses. B. To prevent/reduce potential recurrence of similar events by: 1. Identifying patient care processes, systems, policies/protocols, and services that have opportunities for performance improvement and/or risk reduction. 2. To provide timely response to patient events ... III. Policy: A. Any employee/medical staff member who becomes aware of a safety event is responsible for reporting it. B. Banner Health is committed to utilizing Just Culture for reporting, investigating, and analyzing safety event.””

“QUALIFIED EMERGENCY SERVICES PERSONNEL CFR(s): 482.55(b)(2) There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. This Standard is not met as evidenced by: 37603 Based on medical record review, staff interview, policy review, and professional standards review, the facility failed to effectively monitor patient status to ensure emergency care needs were met for 1 of 20 patients (#15). The findings were: 1. Review of the medical record showed patient #15 was a 1-day old neonate who was brought to the ED on 3/11/25 and was triaged as an ESI 1 (requires immediate life-saving intervention). Review of the physician’s ED report showed the initial vital signs at 10:47 PM included a temperature of 38.8 Celsius (102 Fahrenheit) (normal temperature for neonate is typically between 97.7 F and 99.5 F). Further review of the medical record showed during the ED stay, the patient’s blood pressure dropped critically low and they were started on vasopressors (medication to constrict blood vessels to increase blood pressure). In addition, testing of the patient’s cerebrospinal fluid (CSF) showed bacterial growth and antibiotics were started. The patient was transferred to a specialty children’s hospital by air. The following concerns were identified: Related to blood pressure monitoring: a. The facility failed to monitor the patient’s BP within a 3.5-hour block (from 10:47 PM until 2:15 AM). The patient’s BP during triage on 3/11/25 at 10:47 PM was 77/62. There were no more documented BP readings until 2:15 AM on 3/12/25 when the BP was 40/22 (normal neonate ranges are 60 to 70 systolic and 30 to 53 diastolic). b. According to Emergency Severity Index Handbook, Fifth Edition, provided by facility administration on 5/15/25 at 11 AM showed “ESI 1 = Continuous observation and monitoring, with documented reassessments at a minimum of every 1 hour until hemodynamically stable [vital signs are within normal range and stable], then minimally every 2 hours or per admitting unit guidelines of care.” Related to Cardiac monitoring: a. Review of the medical record showed the physician ordered cardiac monitoring on the pediatric patient on 3/12/25 at 1:11 AM. Further review showed at the same time an order for “Discontinued: Cardiac Monitoring.” b. Review of the medical record showed no evidence the patient was on a cardiac monitor throughout the stay. The record showed the patient had an EKG (electrocardiogram) twice (on 3/12/25 from 1:38:06 AM until 1:38:53 AM and again from 1:44:18 AM until 1:44:32 AM) c. The medical records showed on 3/12/25 at 3:14 AM norepinephrine (vasopressor; used to treat low blood pressure) was ordered and was discontinued at 3:46 AM. Then at 3:45 AM epinephrine (vasopressor; used to treat low blood pressure) was ordered. There was no evidence cardiac monitoring was done on the patient while administering the vasopressors. 2. Interview with the DON on 5/15/25 at 9:55 AM revealed the patient was triaged as an ESI 1. She stated there was no difference from the ESI level with vasoactive medication for pediatric patients. She stated vitals should be taken every 1 hour until hemodynamically stable. 3. Interview with the AD ED and ED Director on 5/14/25 at 4:30 PM revealed the ED orders were changed to the [hospital B] Clinical Pathway “Sepsis Pathway” during the patient stay as requested by the [hospital B] provider (they were unable to provide a time). Interview on 5/15/25 at 11 AM with the AD ED and ED Director revealed “we have no policy that states what the facility needs to monitor when a patient is on vasopressors. We follow the policy “ED patient Care” or physician’s orders. The physician did not order cardiac monitoring.” 4. Review of a written document from RN #5 dated 3/12/25 showed she had concerns regarding the neonatal patient because the patient was on two vasoactive drip medications (norepinephrine and epinephrine) to keep the patient alive. The nurse documented the patient had been in the emergency department for upwards for six hours without any cardiac monitoring and had not had a blood pressure taken in over two hours. Further, “these medications are required to have extremely close cardiac and blood pressure monitoring in order to ensure the safety of the patient and the efficacy of the medication.” 5. Interview with RN #1 on 4/15/25 at 5:52 PM revealed she was the nurse taking care of patient #15 on the night of 3/11/25. She stated she had the BP machine set to take BPs every 5 minutes. She stated the BP machine would sometimes take the reading and sometimes it would not. Further, she stated she did not put the patient on the heart monitor; she just did not think of it. 6. Interview on 4/16/25 at 2 PM with the ED physician who provided the patient’s care revealed the mother brought in the infant who had changes and “had popped a fever.” The physician stated “the patient just went down quick and we did not think of putting [him/her] in a warmer or the heart monitor. We were just trying to save the patient.” 7. Interview with RN #2 on 4/16/25 at 2:45 PM revealed she did have concerns with the turnover of care. She stated she had specialized training in pediatrics. When she took over care of the patient from the night nurse the baby was not on a warmer, the BP had not been done in over an hour, and the patient should have been on cardiac monitor since s/he was being given epinephrine. 8. Interview with pharmacist #2 on 5/16/25 at 10:40 AM revealed any patient on vasopressors should be put on a cardiac monitor and have blood pressure monitored. 9. Interview with the Assistant Director of OB and Nursery on 5/15/25 at 11:50 AM revealed the patient should have been on a cardiac monitor and vital signs including blood pressure, pulse respirations, and oxygen saturation taken every hour for that sick of a child. She further stated “We would have responded to the ED if called.” 10. Interview with the AD ED on 5/15/25 at 10:30 AM revealed on 3/12/25 at 9 AM RN #2 had voiced concerns with the not monitoring the BP and no cardiac monitor on the patient while given vasopressors. Review of the 4/4/25 case review showed the staff talked through the case starting with triage nurse moving to the primary nurse, the primary doctor and the consulting doctor. The determination was that all care was deemed appropriate and timely and assessments were correctly performed. However, the OFI (Opportunity for Improvement) showed that staff could consult the labor and delivery nurse for help, that pediatric EKG stickers were available, the children’s pathways were on-line, ensure vital signs transferred to the electric medical record and record vital signs more frequently. The AD ED stated they had not yet educated all staff and that the education would be provided during the May staff meetings. 11. Interview on 5/14/25 at 4 PM with quality control staff #1 revealed there was no root cause analysis done due to it not being considered a safety event. Further, on 5/15/25 at 11:35 PM she revealed “the case did not meet criteria for a risk assessment, because we did not deviate from standard of care.” 12. Review of the facility’s policy “Emergency Department Patient Care” last revised 1/27/25 included for ESI 1 “Requires immediate life-saving interventions ...Continuous observation and monitoring, with documented reassessments at a minimum of every 1 hour until hemodynamically stable, then minimally every 2 hours or per admitting unit guidelines of care...Vital Signs 1. To be completed at a minimum with every ED assessment/reassessment and within 60 minutes of patient disposition from ED. 2. Vital signs include: Heart Rate, Blood Pressure, Respiratory rate, Temperature, Oxygen Saturation, Pain, and Fetal Heart Tones (if applicable). “ 13. Review of the facility’s policy “Safe Administration of Selected IV Medications” last revision was 4/3/24 showed no mention of monitoring vitals. 14. Review of the facility’s policy “Neonates Presenting for Care in the Emergency Department effective 7/21/22 included “ ...Following NRP (Neonatal Resuscitation Program), 2. Perform physical assessment: Vital signs ...Systems, including respiratory rate, heart rate, rhythm, and blood pressure, etc. ... Further, it showed “provide intravenous access, fluids, and medications as ordered ...” 15. Review of the facility’s policy “Neonatal Patient Guidelines - NICU/CCN” effective 12/6/23 showed “ ... F. Monitor all NICU and CCN neonates via continuous cardiac and respiratory monitors unless otherwise ordered. Cardiac monitoring includes at least 3 electrodes and 1 ECG wave form. Neonates will have a 6 second rhythm strip printed, mounted and scanned into the medical record with significant arrhythmias ...” 16. Review of the “Adrenalin-epinephrine injection” package insert by Endo USA, Inc showed “ ...5.7 Cardiac Arrhythmias and Ischemia. Epinephrine may induce cardiac arrhythmias and myocardial ischemia in patients, especially patients suffering from coronary artery disease, or cardiomyopathy ...” 17. Review of the “Norepinephrine Bitartrate in Sodium Chloride- norepinephrine bitartrate injection, solution” package insert by WG Critical Care, LLC showed “5.3 Cardiac Arrhythmias. Norepinephrine Bitartrate in Sodium Chloride Injection elevates intracellular calcium concentrations and may cause arrhythmias, particularly in the setting of hypoxia or hypercarbia ...””

“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: 16146 Based on medical record review, staff interview, video review, review of police reports, Division of Criminal Investigation (DCI) reports, autopsy results, and policies and procedures, the facility failed to ensure an appropriate medical screening examination was completed for 1 of 20 sampled patients (#18) who presented to the emergency department. The findings were: 1. Refer to A-2406 for details on the facility’s failure to provide an appropriate medical screening examination to patient #18.”

“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: 16146 Based on medical record review, staff interview, video review, review of police reports, Division of Criminal Investigation (DCI) reports, autopsy results, and policies and procedures, the facility failed to ensure an appropriate medical screening examination was completed for 1 of 20 sample patients (#18) who presented to the emergency department (ED). The findings were: 1. Related to patient #18: a. Review of a police report showed on 3/8/23 at 7:36 AM patient #18 was involved in a motor vehicle accident. The report showed on 3/8/23 at approximately 8:22 AM an officer tested a substance the other police officers believed was methamphetamine (a central nervous system stimulant that is mainly used as a recreational or performance-enhancing drug). The substance yielded a presumptive positive result. Two police officers placed patient #18 into custody and placed him/her in the back of the patrol car and transported him/her to jail. b. Review of the Wyoming DCI investigation report showed on 3/8/23 police officers searched the bag and truck of patient #18 and found a syringe and pipe. Both tested presumptive positive for methamphetamine. They placed patient #18 under arrest and transported him/her to jail. At jail, one of the officers asked patient #18 if s/he was high right now, and s/he stated “I ate an eight ball.” One of the officers observed patient #18 to be shaking badly and moaning. The jail nurse came in and tried to ask the patient a few questions for the medical clearance form, “which [patient name] could not answer.” The nurse told the officers to take the patient to the hospital. The officers handcuffed the patient and walked him/her back to the patrol car. The patient “...moaned and shook all the way to Wyoming Medical Center (WMC).”The officers parked next to the hospital sally port (secure entryway) and walked the patient into the ED and put him/her in bed #8. A nurse asked one of the officers what was going on and the officer told the nurse the patient was under arrest, acted normal until booking, and then began shaking and moaning. The officer told the nurse the patient told them s/he “ate an eight ball,” but never told them what s/he ate an eight ball of. Shortly after, a doctor came and asked the officers questions, and they gave the same answers they gave to the nurse. The doctor went into the room and came out a short time later and told the officers that he was going to clear the patient for jail and said something about the movements that the patient was making were deliberate and intentional and that the patient had a case of “incarceritis.” Officers were given a printout of the clearance forms and believed they were at the hospital for maybe 20 minutes. c. On 4/10/25 at 9:30 AM video of the ED on 3/8/23 was reviewed. The time stamp showed at 8:16 AM the patient was seen with his/her hands handcuffed in front of the body. Two law enforcement officers were holding onto him/her on each side of him/her while the patient walked through the ambulance bay into the ED. The patient’s hands/arms were observed to be shaking up and down. There was no video footage once the patient was in an ED room. The patient was seen exiting the ED at 8:34 AM (18 minutes later). d. Review of the medical record showed patient #18 arrived to the ED on 3/8/23 at 9:19 AM and was discharged at 9:37 AM (18 minutes). The chief complaint was a medical clearance for local law enforcement. “..Per LE [law enforcement], pt suddenly became non-verbal with tremors on arrival to jail. Pt not currently answering questions.” The patient’s blood pressure at 9:27 AM was documented as 168/125 mmHg (elevated; normal is less than 120/80). The Glasgow coma scale (neurological scale used to assess level of consciousness) was 12 and under “verbal” it read “incomprehensible sounds.” Review of the ED report by physician #1 showed the patient was in the ED for evaluation. “[S/he] was on [his/her] way to jail with the police with no complaints however when [s/he] arrived at the jail [s/he] began to shake violently. Patient would not discuss anything with me the predominance that history is obtained from police and nursing staff.” The physical exam showed vitals including the blood pressure of 168/125 mmHg, “patient appears agitated,” “psych: unable to assess,” and “neuro: Patient will move [his/her] extremities and volitional appearing [done on purpose] [male/female] without rhythmic movements that would suggest seizure. The activities that are visualized would not be consistent with an excited delirium [characterized by extreme agitation, erratic behavior, and potential for sudden death].” The physician’s medical decision making was documented as “Differential diagnosis includes but is not limited to intoxication, malingering, low suspicion for traumatic injuries or significant electrolyte derangement [abnormal concentration of electrolytes in the body].” No laboratory tests were ordered or completed. The physician documented “...The examination and findings that I am visualizing appear to indicate that this would most likely be malingering...I have low suspicion for acute medical emergency we will discharge to jail.” e. Further review of the DCI report showed when the police got back to the jail from the ED, one of the officers got out and went to the caged portion of the vehicle and stated “I don’t think [s/he’s] doing good.” They tried a sternum rub with no response. The officer pulled him/her out of the cage and laid him/her on their back. Sheriff’s deputies came to assist and chest compressions were started in an attempt to resuscitate him/her. An AED (automated external defibrillator) was placed which advised “no shock.” A sergeant called for an ambulance and emergency medical services (EMS) took over life-saving procedures upon arrival. f. Review of the ambulance report showed the ambulance was dispatched to the jail on 3/8/23 at 9:48 AM for an unconscious person and law enforcement had started cardiopulmonary resuscitation (CPR). The ambulance arrived on scene at 9:54 AM. The report showed “sheriff’s on scene told me upon our arrival that the patient in question swallowed what looked like an 8-ball of drugs but is unsure what kind.” The report showed life saving measures were provided, including CPR and the administration of Narcan (medication used for opioid overdose) and Epinephrine (administered for cardiac arrest to stimulate the heart). Attempts were made to resuscitate the patient for 30 minutes; 10 minutes by law enforcement and 20 minutes by EMS/fire personnel. The time of death was called at 10:19 AM. g. Review of the autopsy report for patient #18 showed the history was “...reportedly ingested drugs and presented to the emergency room for evaluation. [S/he] was released and when [s/he] arrived at the jail [s/he] began to shake violently and became unresponsive.” The coroner examination showed the stomach contained multiple fragments of plastic bag. The toxicology results included 19000 nanograms per milliliter (ng/mL) of Methamphetamine. The final diagnosis was listed as “I. Methamphetamine toxicity: A. Plastic bag in the stomach. B. Pulmonary edema and congested lungs.” 2. Review of the facility’s policy “EMTALA- Medical Screening Examination and Stabilization Treatment,” effective 11/4/2020, showed “An appropriate MSE [medical screening examination] will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested, or, in the absence of such a request, whose appearance behavior would cause a prudent layperson observer to believe that such individuals need examination or treatment for a medical condition...An MSE will be conducted to determine whether the Patient has an EMC [emergency medical condition]. The Hospital will conduct a consistent MSE, in nondiscriminatory matter [sic], for all Patients with similar medical conditions.””

“PATIENT VISITATION RIGHTS CFR(s): 482.13(h)(1), (h)(2) [A hospital must have written policies and procedures regarding the visitation rights of patients, including those setting forth any clinically necessary or reasonable restriction or limitation that the hospital may need to place on such rights and the reasons for the clinical restriction or limitation.] A hospital must meet the following requirements: (1) Inform each patient (or support person, where appropriate) of his or her visitation rights, including any clinical restriction or limitation on such rights, when he or she is informed of his or her other rights under this section. (2) Inform each patient (or support person, where appropriate) of the right, subject to his or her consent, to receive the visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same-sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. This Standard is not met as evidenced by: 16146 Based on medical record review, staff interview and review of policies and patient rights information, the facility failed to ensure patients were fully informed of their visitation rights, including any restrictions or limitations, and the right to receive visitors whom s/he designates, including a spouse (including same-sex partner), another family member or friend for 6 of 6 sample patients reviewed (#11, #12, #13, #14, #15, #16). The findings were: 1. Review of the facility’s policy “Visitors,” revised 2/15/2023 showed “Banner Health (BH) will not restrict, limit, or otherwise deny visitation privileges on the basis or race, color, national origin, religion, language, socioeconomic status, sex, gender identity, sexual orientation, or disability...Patients shall be informed of their rights for visitation upon admission and prior to the start of care...Patients (or their Support Persons or legally authorized representatives in case of patient’s inability to do so) may provide consent for visitation or withdrawal of that consent at any time during the hospital stay. ..BH has the right to designate clinically appropriate and reasonable restrictions or limits to visitation...General visiting hours are 6 a.m. to 10 p.m...two visitors are permitted at a time...” In addition, the policy addressed restrictions/limitations based on disruptive conduct, infection prevention, age restrictions, when visitation may interfere with the care of other patients, and for the health and privacy and any patient sharing a room with another. 2. Review of the “Patient & Visitor Guide,” provided to patients, showed that patient rights included “...Have access to visitors and to communicate with persons outside the facility, except where restrictions are necessary because of patient safety/health concerns. If restrictions are necessary, they will be explained to you and your family.” The information did not fully inform the patient of the facility’s policy on visitation rights. 3. Review of the following patient records showed the patients indicated on the Condition of Admission and Treatment form they were given information on patient’s rights (Patient & Visitor Guide), which did not fully inform the patient of the facility’s policy on visitation rights: a. Patient #11 who was admitted on 7/7/24. b. Patient #12, who was admitted on 7/24/24. c. Patient #13, who was admitted on 9/8/24. d. Patient #14, who was admitted on 9/8/24. e. Patient #15, who was admitted on 9/10/24. f. Patient #16, who was admitted on 8/8/24. 4. During interviews on 9/11/24 at 1:34 PM and 2:14 PM the regulatory consultant stated patients signed the Condition of Admission and Treatment form once per year, which indicated they received the patient guide. They were given the patient guide on each visit. She stated there was no other documentation regarding visitation rights.”

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 16146 Based on medical record review, and staff and family interviews, the facility failed to ensure medications were administered in accordance with professional standards for 1 of 6 sample inpatients (#12). The findings were: 1. Review of the medical record showed patient #12 was admitted on 7/24/24 and discharged 7/29/24. Review of physician orders showed on 7/25/24 the physician ordered brimonidine 0.1%, 1 drop to both eyes, three times a day and dorzolamide 2%, 1 drop to both eyes, three times per day. Both orders stated “Patient own medication- Stored on floor for patient use. Please return to patient prior to discharge.” 2. Review of the medication administration record (MAR) for July 2024 showed the patient did not receive the eye drops at all during the hospitalization. Documentation showed the drops were not given for the following reasons: not appropriate at this time, patient sleeping, unable to give, and patient refused. There lacked further explanation for “not appropriate at this time” and “unable to give.” In addition, there lacked evidence the physician was notified that the medication was not given on multiple occasions. 2. During an interview on 9/12/24 at 9:10 AM the medical unit manager stated the family of the patient brought in eye drops for the patient to use during the hospitalization. When the patient was discharged, staff were unable to locate the eye drops. Eventually they were found in a personal belongings bag. She stated the patient had moved rooms, so she was not sure when the drops were placed in the personal belongings bag, but were definitely in the bag the entire time the patient was in room 550. She further stated the eye drops should have been locked in the medication room, but were not. 3. On 9/12/24 at 9:20 AM the medical unit manager, director of nursing (DON) and regulatory consultant stated the facility’s expectation is that the physician should have been notified of the inability to administer the medications. Further, they stated there was no evidence the physician was notified. 4. On 9/12/24 at 10:30 AM a family member for patient #12 stated they brought in eye drops for glaucoma the day after admission because the facility was unable to provide them. She stated when the patient was discharged, staff were unable to locate the eye drops. She stated they were eventually found in a personal belongings bag in a room the patient was previously in (the patient had moved rooms during the hospitalization). Further, she stated she didn’t think the patient received the eye drops during the stay because the facility did not know where the drops were.”

“SECURE STORAGE CFR(s): 482.25(b)(2)(i) §482.25(b)(2)(i) - All drugs and biologicals must be kept in a secure area, and locked when appropriate. This Standard is not met as evidenced by: 16146 Based on medical record review, staff and family interviews, and policy review, the facility failed to ensure medications were stored in a secure area for 1 of 6 sample inpatients (#12). The findings were: 1. Review of the medical record showed patient #12 was admitted on 7/24/24 and discharged 7/29/24. Review of physician orders showed on 7/25/24 the physician ordered brimonidine 0.1%, 1 drop to both eyes, three times a day and dorzolamide 2%, 1 drop to both eyes, three times per day. Both orders stated “Patient own medication- Stored on floor for patient use. Please return to patient prior to discharge.” 2. During an interview on 9/12/24 at 9:10 AM the medical unit manager stated the family of the patient brought in eye drops for the patient to use during the hospitalization. When the patient was discharged, staff were unable to locate the eye drops. Eventually they were found in a personal belongings bag. She stated the patient had moved rooms, so she was not sure when the drops were placed in the personal belongings bag, but were definitely in the bag the entire time the patient was in room 550. She further stated the eye drops should have been locked in the medication room, but were not. 3. On 9/12/24 at 10:30 AM a family member for patient #12 stated they brought in eye drops for glaucoma the day after admission because the facility was unable to provide them. She stated when the patient was discharged, staff were unable to locate the eye drops. She stated they were eventually found in a personal belongings bag in a room the patient was previously in (the patient had moved rooms during the hospitalization). 4. Review of the facility’s policy “Medications Brought in by the Patient,” reviewed/revised 7/5/2023, showed “...Medications brought into the hospital by a patient should be sent home with a family member or a person designated by the patient if the medication if not needed for facility administration. If not sent home, medications will be stored in the Pharmacy (or a designated, pharmacy-controlled secure medication storage area for non-24-hour pharmacies), segregated from hospital stock...Any medications that are needed for facility administration should not be placed into the tamper-resistant package but should be sent separately to Pharmacy for identification and subsequent temporary storage and dispensation.””

“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: 16146 Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#15) reviewed who had an emergency medical condition and was transferred to another facility. The findings were: Refer to A-2409 for details on the facility’s failure to ensure patient #15 was not transferred to another facility without the patient’s written request or a certification signed by the physician stating the benefits outweighed the risks.”

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 16146 Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#15) reviewed who had an emergency medical condition and was transferred to another facility. The findings were: 1. Review of the emergency room (ER) record showed patient #15 arrived on 5/18/24 at 6:43 PM and was triaged at 7:05 PM and seen by a physician at 7:11 PM. Review of the physician’s note (written by physician #1) dated 5/19/24 showed the patient presented to the ER for evaluation of suicidal ideation. The patient stated s/he was planning to shoot themselves with a friend’s gun. The medical screening exam showed the patient’s mood was depressed and “...active suicidal ideation.” Further review showed “...I believe [s/he] is medically cleared for psychiatric treatment. [S/he] is voluntary to go to [name of inpatient psychiatric hospital] for further management of acute is acute [sic] suicidal ideation. As [s/he] is voluntary and cooperative I do not think [s/he] requires legal hold at this time. We consulted with [name of psychiatric hospital] who accepted patient for transfer. [S/he] will be transferred by ambulance to [name of psychiatric hospital] for further management of acute depression and suicidal ideation...” Review of the disposition note showed the patient was transferred to the psychiatric facility on 5/19/24 at 12:15 AM via ambulance. The following concerns were identified: a. Further review of the ER record showed no evidence the patient requested the transfer in writing. Further, there was no certification by the physician stating the benefits outweighed the risks. In addition, there lacked documentation of the name of the person at the receiving hospital who agreed to accept the transfer. b. On 5/30/24 at 4:12 PM the regulatory consultant stated the facility was unable to find a physician certification for the transfer. c. During an interview on 5/31/24 at 9:40 AM physician #1 stated normally there was a form that was signed by the physician for transfers. When asked why there wasn’t a form for patient #15 he stated he did not know. He stated the nurses printed off forms for the physicians to sign. d. On 5/31/24 at 9:45 AM the ER Director confirmed there was not a transfer certification for patient #15. She stated there may have been some confusion because the patient was willing to go to the psychiatric facility voluntarily. 2. During an interview on 5/31/24 at 9:01 AM the quality assurance coordinator stated ensuring transfer certification forms were completed was not something that was currently being looked at in quality assurance because they didn’t realize there was a problem. 3. Review of the facility’s policy “EMTALA- Medical Screening Examination and Stabilization Treatment,” revised 3/28/24, showed “...Transfer of a Patient may be considered under the following circumstances: a. The Patient is Stable for Transfer; or b. The Patient or Patient’s Representative requests Transfer after being informed of the Hospital’s obligation to provide stabilizing care and the risks and benefits of transfer; or c. The Patient requires a higher level of care; or d. The Hospital lacks Capacity to treat the Patient.” Further, “...The Patient may be Transferred to another Hospital if: a. The physician in attendance or QMP determines that the Patient is Stable for Transfer; or b. The physician in attendance or QMP in consultation with the physician determines that the benefits of Transfer outweigh the risks; or c. The Hospital is unable to stabilize the Patient within its capacity; d. The Patient or his/her Representative requests Transfer after being advised of the Hospital’s obligation to provide care and the risks and benefits of Transfer...Transfer of the Patient who is not Stable for Transfer is accomplished as follows: a. The form “Request for Transfer/Consent to Transfer/Certification for Transfer” is required and fully completed for Patients. The Patient’s or Patient Representative’s written consent/request is documented on this form. b. There is an accepting facility with available space and qualified personnel and documentation noting the date and time of the transfer request and the name of the individual authorized to accept the Patient on behalf of the facility. c. The Transfer is affected through appropriate means consisting of the necessary qualified personnel and transportation equipment including the use of life support measures...””

“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: 16146 Based on medical record review, staff and witness interviews, policy and procedure review, and review of video, the facility failed to provide a medical screening exam (MSE) for 1 of 20 patients (#4) reviewed. The findings were: Refer to A-2406 for details concerning the facility’s failure to re-assess and provide a MSE for one patient (#4) who experienced worsening signs and symptoms while in the waiting room. The resident became unresponsive in the waiting room and staff started cardiopulmonary resuscitation (CPR). Staff discontinued CPR because the patient had do not resuscitate (DNR) directive, and the patient expired.”

“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: 16146 Based on medical record review, staff and witness interviews, policy and procedure review, and review of video, the facility failed to provide a medical screening exam (MSE) for 1 of 20 patients (#4) reviewed. Resident #4 presented to the emergency room (ER) and was initially triaged, but then experienced worsening signs and symptoms while in the waiting room. The patient was not reassessed nor re-triaged in order to determine the priority to be seen by a provider. The resident became unresponsive in the waiting room and staff started cardiopulmonary resuscitation (CPR). Staff discontinued CPR because the patient had do not resuscitate (DNR) directive, and the patient expired. The findings were: 1. Review of the medical record showed the following: a. The 82 year old patient arrived on 2/26/24 at 3:06 PM via a nursing home van. The patient’s spouse was present. b. The chief complaint was nausea and vomiting every day for one month. It happened after having COVID and the patient had not been to a GI specialist. c. Initial vitals taken by the technician (tech) at 3:13 PM were: temperature 36.5 degrees C, oxygen sats 97%, heart rate 121 and blood pressure 83/61. d. Another blood pressure of 100/62 was documented by the triage registered nurse (RN) at 3:15 PM. e. The triage RN triaged the patient at 3:17 PM. The Glasgow Coma score was 15 and no actual or suspected pain was documented. The tracking acuity was listed as: ESI 3. [Emergency Severity Index (ESI) is used for triage, from level 1 (most urgent) to level 5 (least urgent).] f. Review of the CPR form showed the event was recognized at 4:27 PM in the ER waiting room. The arrival time of the physician was 4:29 PM. Efforts were terminated at 4:30 PM due to the DNR form at the bedside. g. Review of the note by the physician showed the patient presented with approximately one month of nausea and vomiting and complaints of anterior abdominal discomfort. The note showed the patient was “unresponsive pulseless, apneic CPR was initiated immediately. We did identify a DNI DNR form and therefore terminated resuscitation efforts. Time of death 1630.” The physician’s note showed “...appears older than stated age and chronically poor health...oropharynx with dried blood and coffee-ground emesis.” h. A note dated 2/28/24 showed the chief executive officer (CEO) called the spouse and apologized that s/he had such a traumatic experience in the waiting room and told him/her the facility was going to do an investigation. The spouse stated several times s/he didn’t understand why they didn’t take [the patient] back to the ER despite the patient’s symptoms and him/her expressing concern to staff and other patients expressing concern. i. The cause of death listed on the death form was cardiac arrest. 2. On 2/29/24 at 1:02 PM a video of the incident on 2/26/24 was reviewed in the presence of the ER Director and the COO (and corporate staff who were on a computer call). The video showed the following: a. The patient was wheeled to the waiting room following triage at 3:21 PM. The patient was slumped over in the wheelchair (leaning forward with head almost in lap). b. At 3:32 PM the spouse went to the desk to talk to staff. c. At 3:34 PM the triage tech brought the patient an emesis bag, then walked away. d. At 3:35 PM the triage tech swapped out the blanket that was on the patient’s lap. e. At 3:48 PM the spouse talked to the triage tech, and then to a security officer. f. At 4:13 PM there is a substance on the ground under the resident that appears to be blood. (as the video progresses, the substance spreads out further on the ground). g. At 4:16 PM a woman from the waiting room goes the desk to talk to staff. At 4:17 PM the spouse and the woman are talking to each other. h. At 4:19 PM the spouse talked to the triage tech at the desk. i. About 4:20 PM there is no more movement observed from the patient; his/her arm appears to be limp. j. At 4:22 PM another woman from the waiting room goes up to the desk to talk to staff. k. At 4:24 PM a woman from the waiting room goes up the desk. l. At 4:25 PM a housekeeper comes in, goes over to the patient, and then leaves and talks to the triage tech. m. At 4:26 PM the triage tech goes to the patient, and then leaves and comes back with the triage RN. N. At 4:27 PM the triage RN positioned the patient upright and started chest compressions as the tech wheeled him/her back to the ER. 3. During an interview on 2/28/24 at 4:54 PM physician #1 stated the first time she saw the patient on 2/26/24 was after the code was called and she assisted with the resuscitation efforts until the DNR was presented and they stopped efforts. She stated that day in the ER was very busy. She stated she had not heard anything about vomiting or blood regarding that patient. 4. On 2/28/24 at 4:56 PM physician #2 stated nurses triage patients based on acuity from level 1 to 5 and that determines the priority to be seen by the provider. 5. During an interview on 2/29/24 at 9 AM RN #1 stated she was the triage nurse working on 2/26/24. She stated she saw the patient in the triage room and s/he complained of abdominal pain and intermittent vomiting for a month. She stated she re-took the blood pressure after she reviewed the tech’s vitals. She stated s/he was awake and coherent. She stated s/he vomited once in the triage room and it was “greenish.” She stated the patient was slumped over in the wheelchair and she asked about that, and the patient responded it was more comfortable that way. She stated she took the patient to the waiting room. She stated it was a very hectic day in the ER. She stated techs were supposed to do hourly vitals on everybody in the waiting room. She stated the tech came and got her when the patient was unresponsive. She stated she started CPR while the tech wheeled them back to room 4 in the ER. She further stated after the incident the tech told her the spouse had been bringing up concerns to her and the desk staff. The RN stated nobody had told her about the spouse’s concerns and she was not told about the patient vomiting in the waiting room. She stated during the incident in the waiting room she observed the vomit was black. 6. On 2/29/24 at 11:39 AM triage tech #1 stated she was the only triage tech working during that time on 2/26/24. She stated that day was very busy in the ER. She stated she took the initial vitals on the patient and then the RN triaged him/her. She stated techs have been instructed to do vitals about every hour on people in the waiting room. She stated on busy days it is closer to an hour and a half. She stated at one point the patient’s spouse approached her and told her the patient had vomited. She stated she gave him/her a new emesis bag and exchanged his/her blanket. She stated it was hard to see the vomit in the emesis bag, but the vomit on the blanket was “yellowish.” She stated the spouse came up to her again later and asked how long it would be because she felt the patient was getting worse. She stated she told the spouse she couldn’t give her an exact time. She stated a woman in the waiting room came up and told her the patient had thrown up on the floor so she called housekeeping. She stated another person from the waiting room came up and reported the patient had vomited and she told the person housekeeping had been called. She stated the housekeeper then showed up, and then shortly after asked her to look at the patient. She stated she observed the patient and saw blood on the ground. She nudged the patient and called his/her name but the patient was unresponsive. She got the triage nurse who came out and then started CPR. She stated it was a “pool of blood” under the patient, but she couldn’t see exactly where the blood was coming from (nose or mouth) because there was so much blood on his/her face. She further stated due to the ER census on 2/26/24 she was unable to complete vital signs on patients in the waiting room hourly and confirmed patient #4 did not have vital signs re-assessed prior to the incident. 7. During an interview on 2/29/24 at 12:20 PM housekeeper #1 stated he was called to clean up vomit in the ER waiting room on 2/26/24. He stated when he arrived he notice the patient was slumped over and it looked like there was blood on the floor. He stated he walked over to the triage tech and asked her to check on the patient. When the triage tech came over she tried to rouse the patient but s/he was unresponsive. She then got the nurse who then started CPR. He stated a woman and her son seemed upset and left the ED. He stated the patient’s spouse told him “I told them [s/he] needed to go back.” 8. On 2/29/24 at 2:25 PM the ED Director stated the facility followed their process for incidents after the 2/26/24 incident. She stated she was called at home that day and she immediately came in and they started an investigation. She stated she did an in-depth chart review as part of the investigation, staff were interviewed, and she viewed the video. She stated the triage nurse and tech were suspended pending the investigation. She stated she had a couple of concerns. She stated she felt the patient should have been triaged a level 2 and not a 3, based on nausea/vomiting for a month, 82 years old, increased heart rate and a lower blood pressure recorded from the tech. She stated after she watched the video of him in the waiting room, she would have triaged him/her a 1. She also had concerns that staff had not re-assessed the patient after the spouse and other patients in the waiting room brought up concerns. She stated techs were instructed to do hourly vitals on patients because they don’t under the ESI levels, but re-assessment should be done per the facility facility, which was based on the ESI levels. 9. During an interview on 2/29/24 at 4:18 PM witness #1 stated she was in the waiting room that day. She stated she observed a patient who was hunched over in the w/c and vomiting. She stated later she sat closer to the patient and noticed blood on the ground. She stated she got up and went to the desk to tell staff, but they cut her off saying they had already called housekeeping. She stated when the housekeeper came, he got staff, who then came over and started CPR right there in the waiting room. 10. Review of the facility’s policy “Emergency Department Patient Care,” revision date 1/26/22, showed re-assessments were based on the ESI levels. “...ESI 3= documented reassessments every 4 hours...ESI 2= Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care.” Further, “...An ESI score will be assigned based upon acuity and resources needed. Patients assigned ESI level 1 & 2 to be given placement priority. These priorities may be modified throughout the patient encounter as diagnostic testing/findings are made available and interventions/treatments are evaluated for effectiveness.” 11. Review of the facility’s policy “EMTALA- Medical Screening Examination and Stabilization,” revision date 11/4/20, showed “...4. Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE. 5. An MSE will be conducted to determine whether the Patient has an EMC...The MSE is an ongoing process requiring continuing monitoring based upon the Patient’s needs and must continue until the EMC is stabilized or the Patient is admitted or appropriately transferred.””

“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: 44506 Based on medical record review the facility failed to ensure an appropriate medical screening exam based on the individual’s presenting symptoms was incomplete for 1 of 22 sample patients (#7) who presented to the emergency room (ED). The findings were: Refer to A-2406 for details concerning the facility’s failure to perform an appropriate medical screening examination for one patient (#7) who presented to the ED with left eye swelling, pain and ear infection.”

“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: 44506 Based on medical record review the facility failed to ensure an appropriate medical screening exam based on the individual’s presenting symptoms was completed for 1 of 22 sample patients (#7) who presented to the emergency room (ED). The findings were: 1. Review of the ED record showed patient #7 arrived on 10/16/23 at 7:31 PM and the medical screening exam (MSE) was performed at 8:36 PM. There was no delay in the performance of the MSE, however there was only a limited physical exam performed. The following concerns were identified: a. The emergency medical condition identified was conjunctivitis, blepharitis and possible early cellulitis. b. The patient was provided ketorolac eye drops, pain medication (ibuprofen), continue antibiotic eye drops and oral antibiotic prescription by other providers, and outpatient follow-up if symptoms did not improve in 24-48 hours. c. The patient did not receive a visual acuity nor a full physical exam. 2. Review of the patient’s inpatient medical record showed the patient sought emergency services at another hospital 50 miles away on 10/18/23 and was sent back to Wyoming Medical Center and admitted as an inpatient from 10/18-10/23/23 for IV antibiotic therapy related to orbital cellulitis.”