South Big Horn County Hospital

“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, review of mental health evaluations, agreements and policies and procedures, and outside agency staff interview, the facility failed to ensure the hospital provided an appropriate medical screening examination for 1 of 20 sample patients (#5). In addition, the facility failed to ensure the hospital provided stabilizing treatment for an emergency medical condition and failed to ensure an appropriate transfer for 1 of 10 sample patients (#5) who were transferred to another healthcare facility. The findings were: 1. Refer to C-2406 for details on the facility’s failure to ensure patient #5 was provided an appropriate medical screening examination. 2. Refer to C-2407 for details on the facility’s failure to ensure patient #5 was provided stabilizing treatment for a psychiatric emergency condition. 3. Refer to C-2409 for details on the facility’s failure to ensure patient #5 was appropriately transferred to another healthcare facility.”

“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: 16146 Based on medical record review, staff interview, review of mental health evaluations, agreements and policies and procedures, and outside agency staff interview, the facility failed to ensure the hospital provided an appropriate medical screening examination (MSE) for 1 of 20 sample patients (#5). The findings were: 1. Review of the medical record showed patient #5 arrived to the emergency department (ED) on 2/12/25 at 6 PM with a chief complaint of suicidal ideations. Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) documented on 2/12/25 at 6:07 PM showed the patient was high risk. The ED report showed provider #1 evaluated the patient in the ED. The provider did a physical exam and obtained labs. The provider documented the patient reported s/he had been dealing with suicidal ideation for quite some time but it was worse. The patient stated s/he had a plan to kill himself/herself by hanging. The provider documented the patient had been evaluated by [name of evaluator at mental health agency] and found to need inpatient mental health care. The provider further documented the Department of Family Services (DFS) case worker was working on placement, but [name of psychiatric hospital] did not currently have beds and the patient was unable to go to [name of city in another state] because the patient was a ward of the state. The following concerns were identified: a. Further review of the medical record on 4/1/25 showed no evidence the mental health evaluation was in the chart, nor evidence the provider directly reviewed the evaluation. In addition, the examination completed in the ED by provider #1 did not include a thorough psychiatric history and physical. b. During an interview on 4/1/25 at 5 PM the director of nursing (DON) stated the patient was evaluated by [mental health agency] prior to admission to the ED, therefore the evaluation was not available in the chart. The DON stated the normal process for patients with psychiatric symptoms was for the provider to do a MSE to look for medical reasons and then [mental health agency] did a psychiatric evaluation via telehealth and discussed the results with the provider. c. Review of the evaluation (faxed to the facility on 4/2/25 after requested) by mental health evaluator #1 from [mental health agency] dated 2/12/25 and timed 5:30 PM showed patient #5 was evaluated in a group home. The evaluation showed the patient made suicidal statements to his/her case worker. The evaluator assessed the patient as high risk. The plan was for the patient to be taken to the ED for labs and the evaluator was contacting the psychiatric hospital. d. During an interview on 4/2/25 at 2:30 PM provider #1 stated the patient had been evaluated by [mental health agency] prior to arrival in the ED. She stated the normal process for patients with thoughts of self-harm was for the provider to talk to them and find out if they had a plan. At that point they called for a crisis evaluation. She stated since patient #5 already had one, she didn’t call for another one. However, she stated she did not personally speak to the evaluator, but got her information from the DFS case worker. She stated the DFS case worker told her the evaluator felt inpatient care was needed. e. Review of the ED disposition form dated 2/12/25 and timed 9:47 PM showed the patient was being discharged. “DFS case worker and group home personnel will take patient via POV [personal vehicle] to [hospital A] for further eval, not a direct transfer from ED...” f. Review of the medical record from hospital A showed the patient admitted to the ED on 2/12/25 at 10:51 PM. The ED progress note showed the patient’s chief complaint was suicidal ideations. Review of nursing notes showed on 2/12/25 the evaluator from [mental health agency] was contacted about her assessment of the patient at Three Rivers Health [the facility, South Big Horn County CAH]. The evaluator stated she had intended to place a hold on the patient but stated the attorney in Big Horn County would not place a hold on pediatric patients. She stated while she was trying to find out information on a DFS hold, she received a call stating the patient was going to be discharged and brought to [hospital A]. Another progress note showed the evaluator re-evaluated the patient on 2/12/25 at 11:23 PM. A note on 2/13/25 at 12:06 AM showed the evaluator placed a hold on the patient. Review of a discharge summary showed the patient remained in hospital A until 3/6/25 when a bed opened up at [psychiatric hospital] and the patient was transferred. g. Review of the re-evaluation by evaluator #1 from [mental health agency] on 2/12/25 at 11:20 PM showed the patient remained high risk and the patient was “titled” [placed on psychiatric hold]. h. Review of the emergency detention form [3-81, psychiatric hold] showed the patient was put on a hold on 2/12/25 at 11:30 PM due to “client reported suicidal ideation, method, and plan. Client reported an attempt a few days ago. Client has history of SI [suicidal ideation] and a previous attempt in Oct. 24” i. During an interview on 4/2/25 at 4:42 PM the chief of staff stated that when a patient presented to the ED with psychiatric symptoms the provider would do a medical screening exam to rule out medical reasons. He stated the Columbia suicide scale was also used. Then a telehealth psychiatric evaluation by [mental health agency] would be done. He stated the mental health evaluator would give their expert opinion and the provider would also use their clinical judgement. j. During an interview on 4/3/25 at 8:15 AM mental health evaluator #1 from [mental health agency] stated she evaluated the patient on 2/12/25 prior to him/her going to the ED. She assessed him/her as high suicide risk and felt s/he needed inpatient care. She stated she started the process for possible admission to [psychiatric hospital]. When asked if she placed the patient on a hold, she stated Big Horn County did not allow them to place children on a hold. She stated the patient was brought to the facility’s ED because it was the closest hospital. She stated she did not have any conversations with the ED provider at the facility. She stated the patient was not safe to go back to the group home. She further stated when the patient went to hospital A she reevaluated him/her and placed the patient on a hold. k. On 4/8/25 at 11:06 AM DFS case worker #1 stated the patient had suicidal ideation and stated s/he had attempted suicide in the past. [Mental health agency] evaluated him/her and they recommended a higher level of care. The evaluator told the DFS case worker the patient needed [psychiatric hospital] and to take him/her to the ED. She stated they wanted a hold on the patient, but Big Horn County would not allow holds on minors. 2. Review of the facility’s policy “ED-3500-4 Emergency Medical Treatment and Labor Act (EMTALA)” showed “...G. Medical Screening Exam (MSE): the process required to reach, within reasonable clinical confidence, a determination about whether a medical or psychiatric emergency exists or does not exist...South Big Horn County Hospital District will provide an appropriate medical screening examination (MSE) to any individual who comes to the emergency department and requests examination or treatment. If the MSE reveals an emergency medical condition exists, SBHCHD will provide appropriate stabilizing treatment and/or transfer to an appropriate medical facility to meet the medical needs of the patient.” 3. Review of the memo of understanding (MOU) between [mental health agency] and the facility, dated 1/1/24, showed the mental health agency provided telehealth availability of a counselor 24 hours per day, 7 days per week to answer any requests by the facility for the primary purpose of providing risk assessments and consultations.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 16146 Based on medical record review, staff interview, review of mental health evaluations and policies and procedures, and outside agency staff interview, the facility failed to ensure the hospital provided stabilizing treatment for an emergency medical condition for 1 of 10 sample patients (#5) who were transferred. The findings were: 1. Review of the medical record showed patient #5 arrived to the emergency department (ED) on 2/12/25 at 6 PM with a chief complaint of suicidal ideations. The ED report showed provider #1 evaluated the patient in the ED. The provider documented the patient reported s/he had been dealing with suicidal ideation for quite some time but it was worse. The patient stated s/he had a plan to kill himself/herself by hanging. The provider documented the patient had been evaluated by [name of evaluator at mental health agency] and found to need inpatient mental health care. The provider further documented the Department of Family Services (DFS) case worker was working on placement, but [name of psychiatric hospital] did not currently have beds and the patient was unable to go to [name of city in another state] because the patient was a ward of the state. In addition, “Due to staffing issues, [name of mental health agency], requested that the patient be transferred to [a critical access hospital, hospital A], [name of mental health agency] can not provide a sitter at this time.” The provider contacted hospital A but was told the patient could not be transferred because patients on a “hold” [involuntary hold for psychiatric reasons] could not be transferred out of the county. The provider documented she didn’t believe the patient was technically on a hold, but relayed the information to the DFS case worker. The DFS worker requested the patient be discharged from this facility and that they would seek further medical care for the patient. The provider documented the patient denied any thoughts of harming himself/herself now but would not rule out the possibility of harming himself/herself in the near future. The following concerns were identified: a. Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) documented on 2/12/25 at 6:07 PM showed the patient was high risk. b. Further review of the provider’s notes showed the provider discharged the patient and documented “...while [s/he] needs ongoing psychiatric care the patients crisis worker states that they will get this” and “...They have two people monitoring [him/her] on discharge and report that [s/he] will be taken to a facility for further care.” The documented assessment/plan was “Suicidal ideation. Requires psychiatric care and [name of mental health agency] and DFS report that [s/he] will be getting that.” c. Review of the ED disposition form dated 2/12/25 and timed 9:47 PM showed the patient was being discharged. “DFS case worker and group home personnel will take patient via POV [personal vehicle] to [hospital A] for further eval, not a direct transfer from ED...” d. Review of the evaluation by mental health evaluator #1 from [name of mental health agency] dated 2/12/25 and timed 5:30 PM showed patient #5 was evaluated in the group home. The evaluation showed the patient made suicidal statements to his/her case worker. The evaluator assessed the patient as high risk. The plan was for the patient to be taken to the ED for labs and the evaluator was contacting the psychiatric hospital. e. Further review of the ED medical record showed no documented interventions such as a 1:1 sitter or a suicide-safe environment. f. Review of the medical record from hospital A showed the patient admitted to the ED on 2/12/25 at 10:51 PM. The ED progress note showed the patient’s chief complaint was suicidal ideations. The provider documented the patient was seen at Three Rivers Health [the facility, South Big Horn County CAH] for these symptoms and was evaluated by [mental health agency]. “Apparently they did not have the capability of monitoring [him/her] at 3 Rivers Health in Basin and [s/he] was sent to [hospital A] ED with DFS case worker.” The plan was for the patient to be monitored in the ED until placement could be obtained. Review of nursing notes showed on 2/12/25 the evaluator from [mental health agency] was contacted about her assessment of the patient at Three Rivers Health. The evaluator stated she had intended to place a hold on the patient but stated the attorney in Big Horn County would not place a title on pediatric patients. She stated while she was trying to find out information on a DFS hold, she received a call stating the patient was going to be discharged and brought to [hospital A]. Another progress note showed the evaluator re-evaluated the patient on 2/12/25 at 11:23 PM. A note on 2/13/25 at 12:06 AM showed the evaluator placed a hold on the patient. Review of a discharge summary showed the patient remained in hospital A until 3/6/25 when a bed opened up at [psychiatric hospital] and the patient was transferred. g. Review of the re-evaluation by evaluator #1 at [mental health agency] on 2/12/25 at 11:20 PM showed the patient remained high risk and the patient was “titled” [placed on psychiatric hold]. The evaluator wrote that the patient had been transported to hospital A from Three Rivers Health where the patient could stay under supervision until there was an opening at a mental health facility. h. Review of the emergency detention form [3-81, psychiatric hold] showed the patient was put on a hold on 2/12/25 at 11:30 PM due to “client reported suicidal ideation, method, and plan. Client reported an attempt a few days ago. Client has history of SI [suicidal/ideation] and a previous attempt in Oct. 24” i. During an interview on 4/2/25 at 2:30 PM provider #1 stated the patient had been evaluated by [mental health agency] prior to arrival in the ED. She stated she did not personally speak to the evaluator, but got her information from the DFS case worker. She stated the DFS case worker told her the evaluator felt inpatient care was needed. When asked about her documentation that stated it was [mental health agency] who requested discharge, she stated that was a mistake. She stated it was actually DFS staff that she had been talking to. She stated it was the facility’s practice that if the patient was a minor, a responsible person had to accompany the patient; some type of guardian. She stated the DFS worker told her they did not have the staffing to provide a sitter. The provider stated DFS then requested discharge. She stated they had looked at a transfer to hospital A, but hospital A didn’t have the capacity. The provider stated she spoke to the patient who didn’t express any plans to harm himself/herself that day and DFS stated they would continue to seek placement for him/her. She suspected they were going to take the patient to hospital A. The provider further stated the county used to provide sitters, but since then the facility would need to assign staff if a sitter was needed. j. On 4/2/25 at 4:18 PM the director of nursing (DON) stated the facility did not have a specific policy on psychiatric patients. He also stated the facility did not have a policy to address minor patients or the practice of requesting an adult to stay with a minor patient. k. During an interview on 4/3/25 at 8:15 AM mental health evaluator #1 from [mental health agency] stated she evaluated the patient on 2/12/25 prior to [him/her] going to the ED. She assessed him/her as high suicide risk and felt s/he needed inpatient care. She stated she started the process for possible admission to [psychiatric hospital]. When asked if she placed the patient on a hold, she stated Big Horn County did not allow them to place children on a hold. She stated the patient was brought to the facility’s ED because it was the closest hospital. She stated in the past, the facility would hold onto a patient for a few days while waiting for placement, but stated usually parents were involved in those cases. She stated she did not have any conversations with the ED provider at the facility. She stated the patient was not safe to go back to the group home. She further stated when the patient went to hospital A she reevaluated him/her and placed the patient on a hold. l. On 4/8/25 at 11:06 AM DFS case worker #1 stated the patient had suicidal ideation and stated s/he had attempted suicide in the past. [Mental health agency] evaluated him/her and they recommended a higher level of care. The evaluator told the DFS case worker the patient needed [psychiatric hospital] and to take him to the ED. She stated they wanted a hold on the patient, but Big Horn County would not allow holds on minors. When asked why DFS asked to have the patient discharged, she stated the facility told her they did not have the staff to monitor him/her. She stated she was told DFS would have to provide staff to sit with him/her, but DFS did not have the staff available. Therefore, in order to get him/her to a higher level of care [mental health agency] recommended, they decided to have him/her discharged and they took the patient to hospital A. When asked why hospital A, she stated they knew that hospital had staff available to sit with the patient. She stated they would have been fine leaving the patient at the facility if there was staff available to sit with him/her while waiting for a bed at [psychiatric hospital]. 2. Review of the facility’s policy “ED-3500-4 Emergency Medical Treatment and Labor Act (EMTALA)” showed “...South Big Horn County Hospital District will provide an appropriate medical screening examination (MSE) to any individual who comes to the emergency department and requests examination or treatment. If the MSE reveals an emergency medical condition exists, SBHCHD will provide appropriate stabilizing treatment and/or transfer to an appropriate medical facility to meet the medical needs of the patient...If it is determined through a medical screening examination that an emergency medical condition exists or that a woman is in active labor, emergency personnel shall: a) Treat the patient within the facilities capabilities and stabilize the individual utilizing appropriate ancillary services; or b) Admit the patient as an impatient [sic], or c) Provide for appropriate transfer to another facility.””

“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, review of mental health evaluations and policies and procedures, and outside agency staff interview, the facility failed to ensure an appropriate transfer to another healthcare facility for 1 of 10 sample patients (#5) who were transferred. Patient #5 had an emergency medical condition and an appropriate transfer was not initiated. Instead, the patient was discharged with staff knowledge that the patient would be going to another healthcare facility in a personal vehicle to seek further treatment. The findings were: 1. Review of the medical record showed patient #5 arrived to the emergency department (ED) on 2/12/25 at 6 PM with a chief complaint of suicidal ideations. The ED report showed provider #1 evaluated the patient in the ED. The provider documented the patient reported s/he had been dealing with suicidal ideation for quite some time but it was worse. The patient stated s/he had a plan to kill himself/herself by hanging. The provider documented the patient had been evaluated by a mental health agency and was found to need inpatient mental health care. The provider further documented the Department of Family Services (DFS) case worker was working on placement, but the psychiatric hospital did not currently have beds. The provider contacted hospital A (a critical access hospital that did not offer psychiatric services) but the transfer was declined. The DFS worker requested the patient be discharged from this facility and that they would seek further medical care for the patient. The provider documented the patient denied any thoughts of harming himself/herself now but would not rule out the possibility of harming himself/herself in the near future. Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) documented on 2/12/25 at 6:07 PM showed the patient was high risk. Further review of the provider’s notes showed the provider discharged the patient and documented “...while [s/he] needs ongoing psychiatric care the patient’s crisis worker states that they will get this” and “...They have two people monitoring [him/her] on discharge and report that [s/he] will be taken to a facility for further care.” The documented assessment/plan was “Suicidal ideation. Requires psychiatric care and [name of mental health agency] and DFS report that [s/he] will be getting that.” Review of the ED disposition form dated 2/12/25 and timed 9:47 PM showed the patient was being discharged. “DFS case worker and group home personnel will take patient via POV [personal vehicle] to [hospital A] for further eval, not a direct transfer from ED...” The following concerns were identified: a. Further review of the ED record showed no evidence of an appropriate transfer. The provider contacted hospital A who did not have any specialty capabilities for psychiatric care and who refused the transfer. The ED disposition documented the patient was going to go to hospital A via private car. The record showed that DFS requested the discharge so the patient could be taken to hospital A via personal vehicle, but the record lacked evidence they were educated about the risks. In addition, there lacked evidence that medical records were provided to hospital A or the DFS caseworker. Furthermore, the patient was discharged into the non-medical care of a caseworker for transportation via a personal vehicle. b. During an interview on 4/2/25 at 2:30 PM provider #1 stated the patient had been evaluated by a mental health agency prior to arrival in the ED and the evaluator felt inpatient care was needed. She stated it was the facility’s practice that if the patient was a minor, a responsible person had to accompany the patient; some type of guardian. She stated the DFS worker told her they did not have the staffing to provide a sitter. The provider stated DFS then requested discharge. She stated they had looked at a transfer to hospital A, but hospital A didn’t have the capacity. The provider stated she spoke to the patient who didn’t express any plans to harm himself/herself that day and DFS stated they would continue to seek placement for him/her. She suspected they were going to take the patient to hospital A. c. During an interview on 4/3/25 at 8:15 AM mental health evaluator #1 from [mental health agency] stated she evaluated the patient on 2/12/25 prior to [him/her] going to the ED. She assessed him/her as high suicide risk and felt s/he needed inpatient care. She stated she started the process for possible admission to [psychiatric hospital]. She stated the patient was brought to the facility’s ED because it was the closest hospital. She stated in the past, the facility would hold onto a patient for a few days while waiting for placement, but stated usually parents were involved in those cases. She stated the patient was not safe to go back to the group home. She further stated when the patient went to hospital A she reevaluated him/her and placed the patient on a hold. d. On 4/8/25 at 11:06 AM DFS case worker #1 stated the patient had suicidal ideation and stated s/he had attempted suicide in the past. [Mental health agency] evaluated him/her and they recommended a higher level of care. The evaluator told the DFS case worker the patient needed [psychiatric hospital] and to take him to the ED. She stated they wanted a hold on the patient, but Big Horn County would not allow holds on minors. When asked why DFS asked to have the patient discharged, she stated the facility told her they did not have the staff to monitor him/her. She stated she was told DFS would have to provide staff to sit with him/her, but DFS did not have the staff available. Therefore, in order to get him/her to a higher level of care, they decided to have him/her discharged and they took the patient to hospital A. When asked why hospital A, she stated they knew that hospital had staff available to sit with the patient. She stated they would have been fine leaving the patient at the facility if there was staff available to sit with him/her while waiting for a bed at [psychiatric hospital]. e. Review of the medical record from hospital A showed the patient admitted to the ED on 2/12/25 at 10:51 PM. The ED progress note showed the patient’s chief complaint was suicidal ideations. The provider documented the patient was seen at Three Rivers Health [the facility, South Big Horn County CAH] for these symptoms and was evaluated by [mental health agency]. “Apparently they did not have the capability of monitoring [him/her] at 3 Rivers Health in Basin and [s/he] was sent to [hospital A] ED with DFS case worker.” The plan was for the patient to be monitored in the ED until placement could be obtained. Review of nursing notes showed on 2/12/25 the evaluator from [mental health agency] was contacted about her assessment of the patient at Three Rivers Health. The evaluator stated she had intended to place a hold on the patient but stated the attorney in Big Horn County would not place a title on pediatric patients. She stated while she was trying to find out information on a DFS hold, she received a call stating the patient was going to be discharged and brought to [hospital A]. Another progress note showed the evaluator re-evaluated the patient on 2/12/25 at 11:23 PM. A note on 2/13/25 at 12:06 AM showed the evaluator placed a hold on the patient. Review of a discharge summary showed the patient remained in hospital A until 3/6/25 when a bed opened up at [psychiatric hospital] and the patient was transferred. f. Review of the re-evaluation by evaluator #1 at [mental health agency] on 2/12/25 at 11:20 PM showed the patient remained high risk and the patient was “titled” [placed on psychiatric hold]. The evaluator wrote that the patient had been transported to hospital A from Three Rivers Health where the patient could stay under supervision until there was an opening at a mental health facility. g. Review of the emergency detention form [3-81, psychiatric hold] showed the patient was put on a hold on 2/12/25 at 11:30 PM due to “client reported suicidal ideation, method, and plan. Client reported an attempt a few days ago. Client has history of SI [suicidal/ideation] and a previous attempt in Oct. 24” 2. Review of the facility’s policy “ED-3500-4 Emergency Medical Treatment and Labor Act (EMTALA)” showed “...South Big Horn County Hospital District will provide an appropriate medical screening examination (MSE) to any individual who comes to the emergency department and requests examination or treatment. If the MSE reveals an emergency medical condition exists, SBHCHD will provide appropriate stabilizing treatment and/or transfer to an appropriate medical facility to meet the medical needs of the patient...If it is determined through a medical screening examination that an emergency medical condition exists or that a woman is in active labor, emergency personnel shall: a) Treat the patient within the facilities capabilities and stabilize the individual utilizing appropriate ancillary services; or b) Admit the patient as an impatient [sic], or c) Provide for appropriate transfer to another facility ...2. Transfer Prior to Stabilizing an Individual with an EMC or a Woman in Labor occurs under the following circumstances: 1) The individual, or a legally responsible person acting on his/her behalf, requests the transfer after being informed of the Hospital’s obligations under this policy and of the risks of transfer (a written request to transfer shall be obtained); or 2) The QMP evaluates the individual and determines transfer benefits outweigh the risks and transfer is in the best medical interest of the patient. The QMP is to certify in the medical record 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 ...4. Appropriate transport: a) The QMP will use their best judgement regarding the condition of the patient when determining the timing of the transfer, mode of transportation, level of care provided during the transfer, and destination of the patient. b) The closest, most appropriate mode should always be contacted first. “Most appropriate” is defined as the carrier that has the appropriate qualified trained staff and equipment to adequately care for the patient’s medical needs enroute, as required, including the use of necessary and medically appropriate life support measures during the transfer.””

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 44506 Based on review of the facility’s grievance log, patient interview, staff interview, and policy review, the facility failed to follow its written policy for responding to a grievance for 1 of 1 patient grievance received in the last six months (#9). The findings were: 1. Review of the facility’s grievance log showed one grievance in the last six months dated 10/23/23 for patient #9. The following concerns were identified: a. Interview with patient #9 on 1/30/24 at 1:59 PM revealed the patient had filed a written grievance with the facility regarding a care issue at the facility on October 9th, 2023 and as of the date of survey had not been contacted by the facility to address the grievance. b. Interview with the human resources director on 1/30/24 at 12:30 PM confirmed the facility had received a written grievance from patient #9 and it had been entered into the “Yes System” as required and assigned to the director of nursing (DON) for investigation. c. Interview with the DON on 1/30/24 at 3 PM revealed she was aware of the grievance from patient #9 and confirmed the patient had not been contacted to seek a resolution. 2. Review of the facility policy “Patient Complaints and Grievances”, no date, showed the purpose of the policy was “B. To provide an organized mechanism for identification, analysis, correction, and documentation of complaints or grievances...b. The Director of Quality and Risk will conduct or oversee the investigation of the Grievance...” The procedure described written grievances were “sent to the Director of Quality and Risk. The director will enter the issue in the YES System and coordinate an investigation...A grievance requires a written response to the patient or patient representative within seven business days...If a grievance cannot be resolved with seven business days (the hospital) shall inform the patient or patient’s representative that the facility is still working to resolve the grievance and will follow up with a written response within thirty days.””

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 44506 Based on medical record review, patient interview, staff interview, and review of personnel files, the facility failed to meet the nursing needs for 1 of 12 sampled patients (#9). The findings were: 1. Review of the medical record for patient #9 showed an outpatient chest computed tomography (CT) scan with contrast ordered at the facility on 10/9/23. Further review showed an order on the same date to access the patient’s “port-a-cath for CT scan.” The following concerns were identified: a. A nursing note in the patient’s medical record dated 10/9/23 at 12:29 PM showed the director of nursing (DON) accessed the “implanted port” at approximately 10:40 AM to draw blood and prepare the site for CT contrast. At approximately 11:30 AM the nurse was called to the radiology department for “swelling around the implanted port. Site was swollen, soft, warm, and dry to touch.” The procedure was stopped by patient request. b. Review of the CT report dated 10/9/23 showed the scan was completed without contrast. Further review showed “Moderate amount of extravasated contrast surrounding the port reservoir in the upper right chest.” 2. Interview with the patient on 1/30/24 at 2PM revealed the facility did not have anyone trained to access the port but two failed venipuncture attempts made the port the only option for blood work and contrast. The patient stated the DON came to access the port and the patient had concerns about the competency of the nurse from the beginning. The patient described the lack of aseptic technique, lack of appropriate supplies, and the pain and pressure experienced with the needle insertion. After being moved into the CT and the contrast was infused the patient immediately felt “extreme pain” and yelled, “stop this machine!” 3. Interview with radiology tech #1 on 1/29/24 at 10:47 AM revealed the tech remembered patient #9 and remembered the patient wanted the port accessed for the contrast. She verified that accessing a port was out of their scope of practice so nursing was called in to perform the procedure. 4. Interview with the radiology manager on 1/29/24 at 11:22 AM revealed she remembered patient #9. She reported the emergency room nurse tried twice to establish a peripheral IV and was unsuccessful. She verified the facility stocked the needles and appropriate supplies in the radiology department for the nursing staff to access implanted ports. 5. Interview with the DON on 1/30/24 at 3:10 PM confirmed she had accessed the port for patient #9 on 10/9/23 because she “was the only RN on that day.” She verified it had been some time since she had performed the procedure (not since her employment with this hospital) and she had not reviewed a skills checklist or video refresher prior to the procedure. 6. Review of the personnel file for the DON showed a contract hire date of 12/20/22. The file showed a current and valid registered nurse license but no evaluation related to performance, training or competency related to nursing skills, including accessing an implanted port.”