Beacon Plainwell

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 29955 Based on observation and interview, the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signs in the emergency waiting room areas were conspicuous and likely to be noticed by all individuals that visit the Emergency Department resulting in the potential for all emergency patients to be uninformed of their rights. Findings include: On 3/4/2026 at 0950 during tour of the emergency waiting room areas, it was observed that a waiting room adjacent to the main lobby of the Emergency Room Waiting area failed to have EMTALA signage and failed to have line of sight to any EMTALA signage outside of the room. On 3/4/2026 at 1550 during tour of the emergency waiting room area with staff B, ED manager, staff B was queried about the absence of EMTALA signage. Staff B stated that the signs they had would not stay up on the walls and continued to fall down. She stated the signage would be put back on the walls. On 3/5/2026 at 0910 during a return tour of the ED waiting room area the signage remained missing. Staff B was queried about the missing signage. Staff B stated after checking there was no signage for the walls and it would have to be ordered.”

“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: 36887 Based on interview and record review, the facility failed to complete an appropriate medical screening exam for 1 (P-1) of 21 patients reviewed for EMTALA (Emergency Medical Treatment and Labor Act) requirements and failed to provide required documentation for appropriate transfer for 1 (P-18) of 6 patients reviewed for transfer, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. See Specific Tags: A-2406 Failure to provide an appropriate medical screening exam A-2409 Failure to provide required documentation for transfer”

“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: 36887 Based on interview and record review, the facility failed to ensure an appropriate medical screening exam was conducted for 1 (P-1) of 21 patients reviewed resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-1 revealed she was a 71-year-old female who presented to the ED 9/3/2025 at 1533 via ambulance with a chief complaint of “chronic left hip pain.” P-1 had a past medical history of rheumatoid arthritis, osteoarthritis, fibromyalgia, and osteoporosis. Review of the ambulance run sheet revealed arrival to the facility at 1500 and a chief complaint of “Back pain unable to walk.” Narrative documentation stated the patient had been “having back and hip pain for several days with no relief (sic) she has made ER (emergency room) visits for the pain again with no relief.” Pain was not assessed. P-1 was “assisted to stair chair...Patient is moved from stair chair to cot arm knee method...” Triage occurred at 1534. Pain was assessed at 9/10 on the numeric pain scale, and she was assigned an acuity of 4 (semi-urgent or non-urgent). The nursing assessment stated “Musculoskeletal... chronic left hip pain.” The psychosocial assessment stated, “tearful angry chronic left hip pain with eval prev.” No other assessment was documented of the left hip/leg by nursing. Physician Staff G saw P-1 at 1536. Review of physician documentation dated 9/3/2025 at 1539 (3 minutes after being assigned to see the patient) revealed in the physical exam for musculoskeletal, “Extremities atraumatic. No edema, no calf tenderness to palpitation...Neurologic...Gait is within normal limits...” It stated pain management options were offered including “ibuprofen (non-steroidal anti-inflammatory-NSAID), comatalinol (unknown medication), and a lidocaine patch”; however, the patient refused those meds. “Care plan and follow-up discussed in detail.” It was also documented that home care or rehabilitation therapy was offered and the patient refused. No labs or further x-rays/imaging were ordered. There was no documentation of a targeted left hip assessment found including palpation, inward or outward rotation of the leg, color, presence of pulses, stability of the joint, or description of the type and quality of her pain. There was no documentation of offering a transfer of the patient back to Facility B, or any other acute care hospital of choice, for further work-up. During interview on 11/20/2025 at 0951, Physician Staff G was queried as to his evaluation of P-1. He stated he could clearly recall the patient and there was no abnormality on exam and no neurological deficits. When queried as to where that was documented within the medical record, he stated the documentation was “very broad” regarding the physical exam. He stated he offered multiple medications for pain control which were all declined. He wanted to transfer her back to Facility B for further work-up, but she declined that as well. Staff G was queried as to if he had visualized P-1 ambulating. He stated he couldn’t recall that specifically and referred back to his documentation in the medical record. The entry from the ambulance run sheet was relayed to Staff G regarding the patient being unable to walk and he was queried how P-1 could go from being unable to ambulate, requiring assistance, and then being carried to the cot to walking with a normal gait all within 40 minutes while having 9/10 pain. Staff G stated she “must have been able to stand and/or transfer and take a few steps.” Staff G was queried as to if a second visit for the same issue would be a cause for concern that perhaps something else could be going on that would require further evaluation. He stated a return within 48-72 hours was a cause of concern; however, in this case there was nothing more to be done. P-1 was discharged home at 1608. She was in the ED for a total of 34 minutes. During interview with Confidential Informant #1 on 11/18/2025 at 1533, the informant stated the physician did not ask any questions of P-1 including her pain. “We were told, ‘We can’t do anything for you’ and ‘We can send you for physical therapy or to the nursing home.’ I was flabbergasted.” Review of the medical record from the receiving facility revealed P-1 had been experiencing pain for over a week and had been trying to alleviate her pain with Tylenol and Motrin at home without success. Physician notes dated 9/3/2025 at 2235 revealed under physical exam, “Significant tenderness palpation about the left hip with range of motion preserved, especially passively... The pain has gotten significantly worse since Monday morning... She describes the pain as sharp, achy, constant and it has affected her mobility.” An MRI of the pelvis, which was read on 9/4/2025, had the following findings: “No acute fracture. Partial tendon tear of the left gluteus and minimus insertions (points of attachment to the femur). Mild bilateral hip osteoarthrosis.” Orthopedic surgery evaluated P-1 and recommended weight bearing as tolerated on the left side along with Toradol and other NSAIDS for pain control. She was also evaluated by physical and occupational therapy who recommended discharge to home. P-1 was discharged home 9/5/2025 at 1218 with home health services, a prescription for Meloxicam (NSAID medication) for pain, with instructions to follow up with her primary physician in 3-5 days. Facility policy #16882221 titled “Ascension Michigan Emergency Medical Treatment & Active Labor Act (EMTALA) Policy” effective 11/13/2024 states, “Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: 1. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or the unborn child) in serious jeopardy; 2. Serious impairment to bodily functions; 3. Serious dysfunction of any bodily organ or part... Medical Screening Examination (MSE) - The process required to reach with reasonable clinical confidence the point at which it can be determined whether an Emergency Medical Condition exists. The Medical Screening Examination must be the same Medical Screening Examination that the Hospital Would perform on any individual coming to the Hospital’s emergency department with those signs and symptoms, regardless of the individual’s ability to pay for medical care... The patient’s medical record should reflect documentation related to the Medical Screening Examination and Stabilizing Treatment provided.” Facility policy #12391583 titled “Pain Management” effective 1/22/2024 states, “Patients have a right to appropriate assessment and management of pain. This includes completing regular assessments of pain, providing pharmacological and non-pharmacological therapies as appropriate and educating the patient/family/and significant other on the pain management plan... Effective pain medication dosage: the amount of medicine that results in maximal pain relief with minimum side effects. Pain intensity as indicated in numerical pain assessment is defined as: A. Mild Pain = 1-3 B. Moderate Pain = 4-6 C. Severe Pain = 7-10... Upon admission, assess for age-specific presence, absence, and history of pain. Include both the patient and/or or (sic) patient advocate in the pain management process. B. Assess these pain factors as appropriate: 1. Description/character of pain 2. Onset and duration 3. Intensity numeric, or picture pain scale... 4. Location 5. Aggravating and alleviating factors 6. Associated signs and symptoms 7. Impact on functional ability, physical, emotional or spiritual 8. Spiritual or mental distress 9. Methods of pain management that have been helpful and/or unhelpful in the past 10. Patient’s personal goal for pain relief... 11. Cultural/language barriers to reporting pain, using analgesics and/or to learning about pain management...””

“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: 36887 Based on interview and record review, the facility failed to provide appropriate transfer for 1 (P-18) of 6 patients reviewed for transfer, resulting in the potential for unrecognized, unmet patient needs and poor patient outcomes. Findings include: Review of the medical record for P-18 revealed she was a 15-year-old female that presented to the ED 10/23/2025 at 0239 for suicidal ideation after taking 3000 mg (milligrams) of Tylenol. Review of physician notes does not address patient stability. Physician documentation stated, “There is a high probability of imminent or life threatening deterioration in the patient’s condition.” P-18 was transferred by her mother via private vehicle to a nearby psychiatric facility. No transfer documentation was present in the medical record to indicate patient stability, risks/benefits of transfer, equipment/personnel needed for transfer, accepting physician, or documentation provided to the receiving facility. On 11/20/2025 at 1125, Staff B stated the transfer form should be completed for each patient requiring transfer to another facility. Facility policy #17330373 titled “Transfer and Discharge of Patients” effective 2/2025 states, “Transfer to a level of care equal to or higher than that provided by (facility name) may occur and be planned or unplanned. 1. A Physician working with a Registered Nurse and Health Unit Coordinator must ensure that there is a receiving facility, receiving physician, and a bed ready for patient transfers. 2. Transfer record must be completed along with any ambulance necessity forms. 3. Depart process section of the Electronic Medical Record should be completed by nursing. 4. Physician should complete transfer medication reconciliation report with copy to receiving facility... 5. Registered Nurse must call report to receiving Registered Nurse per Hand Off communication policy.””