Memorial Hospital of Converse County

“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: 37603 Based on medical record review, staff, patient and family interviews, and review of policies and procedures and the emergency department (ED) log, the facility failed to provide a medical screening examination (MSE) for 1 of 20 patients (#20) who came to the dedicated ED. The findings were: 1. Refer to C-2406 for details on the facility’s failure to provide a MSE to patient #20, who presented to the dedicated ED on 1/4/25.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 37603 Based on review of the emergency department (ED) log, and patient, family and staff interviews, the facility failed to ensure 1 of 20 patients (#20) who came to the ED seeking emergency medical care, was included on the ED log. The findings were: 1. Interview with family member #1 on 1/29/25 at 10:21 AM revealed their family member (patient #20) had been sick for 2 weeks. On 1/4/25 in the afternoon patient #20 went to the ED and asked for swabs to test for influenza. The admission clerk told the patient it would cost thousands of dollars to be seen since the patient did not have insurance. The admission clerk did not do any paperwork to admit the patient to the ED. The family member stated the facility did nothing, just sent patient #20 away. 2. Interview with patient #20 on 6/24/25 at 3 PM revealed s/he went to the window at the ED on 1/4/25. The patient stated s/he told the person working at the window “I wanted to be tested for influenza A. We had an outbreak in the care center.”The patient stated s/he was told they would need to check in to get into the ED. The patient stated s/he did not have insurance at that time, and was told it would be a lot of money out of pocket without insurance. The staff person went back to the ED, and came back out and told the patient the nurse said to try Nyquil, Tylenol and Ibuprofen, and the patient left. 3. Interview on 1/29/25 at 1 PM with admission clerk #1 revealed she did tell the patient it was not about money; it was about taking care of him/her, however the patient left without being seen. 4. Review of the ED log showed the patient was not noted on the log. 5. Interview with the director of nursing on 1/28/25 at 4:30 PM confirmed the patient was not on the ED log. 6. A policy for the ED log was requested but was not provided by the 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: 37603 Based on medical record review, staff, patient and family interviews, and review of policies and procedures and the emergency department (ED) log, the facility failed to provide a medical screening examination (MSE) for 1 of 20 patients (#20) who came to the dedicated emergency department (ED) for emergency care. The findings were: 1. Interview with family member #1 on 1/29/25 at 10:21 AM revealed their family member (patient #20) had been sick for 2 weeks. On 1/4/25 in the afternoon patient #20 went to the ED and asked for swabs to test for influenza. The admission clerk told the patient it would cost thousands of dollars to be seen since the patient did not have insurance. The admission clerk did no paperwork related to the patient’s presentation to the ED in order for the patient to be seen. The family member stated the facility did nothing, just sent patient #20 away. Patient #20 was sick and crying. Patient #20 went to a clinic 2 days later and was provided a prescription for a Z-pak (antibiotics) and cough syrup. 2. Interview with patient #20 on 6/24/25 at 3:00 PM revealed s/he went to the window at the ED on 1/4/25. The patient stated s/he told the person working at the window “I wanted to be tested for influenza A. We had an outbreak in the care center (that the patient worked at).” The patient stated s/he was told they would need to check in to get into the ED. The patient stated s/he did not have insurance at that time and was told it would be a lot of money out of pocket without insurance. The staff person went back to the ED, and came back out and told the patient the nurse said to try Nyquil, Tylenol and Ibuprofen. The patient further stated s/he followed up with their private physician, and was prescribed antibiotics. The patient stated s/he did not ask to be seen after s/he was told what to take; s/he just left. 3. Interview on 1/29/25 at 1 PM with admission clerk #1 revealed she did tell the patient it was not about money; it was about taking care of him/her, however the patient left without being seen. 4. Interview on 1/29/25 at 12:30 PM with the registered nurse (RN) on duty that day (RN #1) revealed she did not see the patient. 5. Interview on 1/29/25 at 1:41 PM with the physician on duty that day (physician #1) revealed he did not evaluate the patient, nor did he see him/her as a patient in the ED. 6. Review of the ED log showed the patient was not noted on the log. Continued review showed no evidence of patient #20 having a hospital or ED medical record. There lacked evidence the patient was educated on the risks of not having a MSE nor evidence the facility attempted to have the patient sign a form indicating s/he did not want a MSE. 7. Review of the outpatient “Office Physician Progress Note” dated 1/8/25 showed the patient reported having a cough and congestion for 7 - 8 days and felt the symptoms were worsening. The patient stated s/he had not been able to sleep because the cough kept them up all night. The exam showed the ears had abnormal fluid behind the tympanic membrane bilaterally. The assessment and plan showed upper respiratory tract infection, and acute cough. The physician ordered azithromycin (antibiotic) and promethazine-codeine (Antihistamine, Narcotic, and Cold medication). 8. Interview on 1/29/25 at 8:55 AM with quality assurance (QA) staff #1 and #2 revealed if a patient came to the ED they would go through admissions first. They stated admissions cannot refuse patient services, and the clerk was supposed to call the ED staff right away to come and triage the patient. 9. Review of the facility’s policy “Emergency Services,” revised 12/2022 showed “1. On receiving a patient for emergency service, the ED reception and triage documentation will be completed in the Electronic Medical Record...” 10. Review of the facility’s policy “Triage of E.R. Patients,” effective 12/2022 showed “Triage Process: 1. As soon as a patient enters the admission area, the admission clerk will call immediately back to the ED with a patient admission. At this point they are to speak with a nurse/paramedic ONLY. The nurse/paramedic is responsible for that patient from this point forward to include timely initial assessment for patient classification ...””