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Based on record review, policy review, and interview, the facility failed to comply with the conditions of participation outlined in §489.24: The facility failed to report to CMS or the State survey agency (within 72 hours of the occurrence) any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital for one patient (#22). The facility failed to maintain a central log on each individual who comes to the emergency department, 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 for one patient (#22). The facility failed to perform a medical examination for patients when they arrived at the facility for one patient (#21); the facility failed to conduct vaginal examinations for 2 (#11 and #16); and the facility failed to provide proper treatment for a patient who was diagnosed with a femoral head fracture for 1 (#24) of 24 sampled residents. This failure caused harm to patient #21 who experienced severe anxiety; and harm to patient #24 who endured intolerable pain prior to her death.

Findings include:

1. Record review of facility documents showed Patient #22 was transferred to the facility via Emergent ambulance services on 05/12/21. The patient was received by the facility and documented as an unapproved, unstable, emergency transfer. Review of facility documents and interviews with facility staff showed the facility failed to report to CMS or the State Agency that another hospital had transferred an unapproved, unstable patient. Refer to C-2401.

2. Record review of facility documents showed patient #22 was transferred to the facility via emergent ambulance services on 05/12/21. The patient was received by the facility in the emergency department. Record review of facility documents and interviews with facility staff showed the patient was never entered onto the ED log. Refer to C-2405.

3. An Immediate Jeopardy was called for the failure of a medical screening exam and/or treatment for patients #21, #16, #11, and #24). The facility developed a plan for the removal of the immediacy and the immediacy was removed on 10/13/21 at 8:30 a.m. Refer to C-2406.

Based on interview and record review, the facility failed to report within 72 hours to CMS or the State Agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital for 1 (#22) of 24 sampled patients.

Findings include:

Record review of patient #22's EMS report, dated 05/12/21 showed, "Upon arrival pts nurse reported pt had been admitted inpatient ward after experiencing acute pancreatitis, pt needed blood transfusion at marias medical center .... The patient was transported to Marias Care Center Emergent (Immediate Response) ...The use of lights and sirens from the scene was Emergent (Immediate Response)."

During an interview on 10/04/21 at 3:39 p.m., staff member C stated patient #22 was from IHS and needed blood. She stated the patient was transferred via ambulance and was given treatment. Staff member C stated blood transfusions are not a service that is provided in Browning. She stated, "No one called from Browning to let us know that they were transferring the patient, and there was no provider to provider contact to notify that the patient was being transferred." Staff member C stated, "I am now aware that the unstable transfer needed to be reported. I became aware of the reporting requirements today."

During an interview on 10/05/21 at 12:35 p.m., staff member I stated she was present at the Medical Staff Meeting on June 10, 2021. She stated she was working on the day patient #22 arrived at the ED via ambulance services. She stated, "(Patient #22) arrived from Browning for a blood transfusion. She had very low hemoglobin." Staff member I stated, "(Patient #22) was transferred without our consent. She was not stable. Her hemoglobin was less." Staff member I stated, "This incident did get brought up in Med Staff. I remember that day. Everyone in Med Staff identified the incident as an unauthorized, unstable transfer." Staff member I stated the incident should have been reported to CMS or State Agency, and stated, "I am aware that it was never reported." She stated, "(Staff member D) stated, "Whoa I knew nothing about this!", when the patient arrived at the ED.

During an interview on 10/05/21 at 2:56 p.m., staff member L stated he was present at the Medical Staff Meeting on June 10, 2021. He stated he was aware of the unstable transfer that was received at the ED. He stated he did not know that the unstable transfer was not reported to CMS or the State Agency and stated he did not know that it was an EMTALA requirement.

Record review of facility 2021 training, "EMTALA" showed, "What is an Appropriate Transfer ...a transfer in which transferring hospital provides medical treatment within its capacity which minimizes risk to the individual's health ...receiving facility has available space and qualified personnel for treatment, Has agreed to accept transfer and to provide appropriate medical treatment".

Record review of facility policy, "Employee Education", effective date 04/17/19 showed, "Required Education: For clinical and other designated employees, Annual Required Education will also include classroom and/or computer knowledge/skills review of high priority topics as driven by healthcare regulations, standard of care, high risk needs and outcome data."

During an interview on 10/06/21 at 6:59 a.m., staff member C stated there was no documentation on file for the facility showing staff member A or staff member D had completed EMTALA training during their employment with the facility.

Based on interview and record review, the facility failed to maintain a central log on each individual who comes to the emergency department, 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 for 1 (#22) of 24 sampled patients.

Finding include:

Record review of patient #22's EMS report, dated 05/12/21 showed, "Upon arrival pts nurse reported pt had been admitted inpatient ward after experiencing acute pancreatitis, pt needed blood transfusion at marias medical center .... The patient was transported to Marias Care Center Emergent (Immediate Response) ...The use of lights and sirens from the scene was Emergent (Immediate Response)."

Review of the facility ED log on 10/04/21 at 1:15 p.m. showed there was no record of patient #22 arriving at the facility ED.

During an interview on 10/04/21 at 3:39 p.m., staff member C stated patient #22 was from IHS and needed blood. She stated the patient was transferred via ambulance and was given treatment. Staff member C stated blood transfusions are not a service that is provided in Browning. She stated, "No one called from Browning to let us know that they were transferring the patient, and there was no provider to provider contact to notify that the patient was being transferred."

During an interview on 10/05/21 at 12:35 p.m., staff member I stated she was working on the day patient #22 arrived at the ED via ambulance services. She stated, "(Patient #22) arrived from Browning for a blood transfusion. She had very low hemoglobin." Staff member I stated, "(Patient #22) was transferred without consent. She was not stable."

During an interview on 10/05/21 at 2:56 p.m., staff member L stated he was aware of the unstable transfer that was received at the ED.

During an interview on 10/06/21 at 12:35 p.m., staff member T stated he did not remember if he was working on the day of the unstable transfer from HIS for

During an interview on 10/05/21 at 6:41 p.m., staff member E stated she was aware of one unstable transfer received in the ED from Browning. She stated, "The ambulance showed up, the patient presented for a blood transfusion." Staff member E stated, "The person is on the ED log because they came via ambulance. She had a GI bleed and needed a transfusion, or she would have died."

Based on interview and record review, the facility failed to perform a medical examination for a patient when the patient arrived at the facility for 1 (#21) of 24 sampled patients; the facility failed to conduct vaginal examinations for 2 (#11 and #16) of 24 sampled patients; the facility failed to provide proper treatment for a patient who was diagnosed with a femoral head fracture for 1 (#24) of 24 sampled patients. This failure caused: harm to patient # 21 who experienced severe anxiety, and harm to patient #24 who endured intolerable pain prior to her death.

IMMEDIATE JEOPARDY

On 10/06/21 at 2:56 p.m., the Chief Executive Officer was notified that an Immediate Jeopardy existed in the area of C-2406 (§489.24(a); §489.24(c)) Appropriate Medical Screening Examination.

1) Patient #21 presented at the ED on 01/05/21 @ 3:41 a.m. with a chief complaint of severe vaginal bleeding from a miscarriage. The doctor on-call arrived at the ED on 01/05/21 at 04:33. The doctor did not speak to the patient, and he did not perform a medical assessment on the patient.

2) Patient #16 was admitted to the ED on 07/2/21 at 8:41 a.m. with a presenting diagnosis of active labor. The patient was in her third trimester and was full-term. The provider did not perform a vaginal examination of the patient while the patient was in the ED. The provider arranged for a transfer of the patient to Great Falls (82 miles away) via ambulance.

3) Patient #11 was admitted to the ED on 09/26/21 at 9:35 p.m. with a presenting diagnosis of severe vaginal bleeding. The patient reported having massive blood clots that appeared to be worsening. The provider did not perform a vaginal examination of the patient while the patient was in the ED. The provider arranged for a transfer of the patient (via the patient's personal vehicle) to Great Falls (82 miles away).

4) Record review of the facility's EMTALA training for dedicated ED staff showed one of the ED providers had not received EMTALA training during his employment with the facility. There was also no documentation of the ED's Administrator receiving EMTALA training at any time during his employment.

The facility submitted an acceptable plan to remove the immediacy on 10/12/21 at 10:25 a.m.

The removal of the immediacy was verified on 10/13/21 at 8:30 a.m.

PLAN TO REMOVE IMMEDIACY

A summary of the facility's plan to remove the immediacy was as follows:

Marias Medical Center Removal of Immediacy Plan
October 12, 2021

Logan Health - Shelby, formerly known as Marias Medical Center, ("the hospital") takes quality and compliance very seriously. The Hospital's Board Chair was notified of the complaint survey on 10/6/2021, and that a report would be issued.

Upon notification of the Immediate Jeopardy situation, the Hospital created a response team comprised of individuals from across the Logan Health System. The team was comprised of the CEO, Compliance Officers, Quality Director, Risk Advisors, Nursing and Provider Executive Directors and HIT. The team immediately began coordination and implementation of the plan. The following responds to the template provided to the hospital on 10/6/21:

All patients will receive a complete and timely Medical Screening Examinations (MSE) for presenting chief complaints and to provide within the capabilities of the staff and facilities available at the hospital treatment as required to stabilize the medical condition or for transfer of the individual to another medical facility or for discharge.

Upon receiving notification of this Immediate Jeopardy, the facility removed the provider associated with incidents identified from the Emergency Department schedule on 10/7/2021.

The Hospital Administrator, was removed from that position on 10/11/2021. The Chief Nursing Officer was placed on administrative suspension on 10/11/12 pending final outcome of investigation of non-compliance with incident complaint process.

An electronic submission and tracking process for Incident Reports and Complaints has been developed. This electronic process will ensure that Incident Reports are routed through the investigation process, includes reviewers and outcomes to ensure that the documents are tracked at all times. Training will be provided to all impacted staff and an overview for all staff by 10/15/2021 or prior to the start of their next shift.

EDUCATION for all Logan Health - Shelby employees and providers on the following specific topics:
-EMTALA
-Timely and Complete MSE for presenting chief complaints
-Definition of stabilized
-Reporting requirements for anti-dumping
-Ongoing annual training for all staff and providers including attestations on policy
-Incident Reports/Complaints

Process for submission and investigation of events and complaints. Training will be provided to ED Providers and All Staff by 10/15/2021, prior to the start of their next shift.

All Emergency Room patient encounters undergo a chart audit, effective 10/12/2021.
-These audits will be completed by Logan Health Medical Center Quality department
-Findings will be reviewed by the Chief of Medical Staff for Logan Health - Shelby with authority to implement remedial measures and discipline when appropriate.
-Findings will be communicated to Logan Health - Shelby and Logan Health Medical Center Compliance, Risk and Quality.

Review of all submitted Incident Reports and Complaints will be completed by Compliance, Risk and Quality. Investigations of submitted items will be conducted and appropriate corrective action will be identified and taken.

Monthly findings will be reported to the Logan Health - Shelby QAPI committee. Reports will include findings of Chart Auditing and information on Incident Report and Complaints submitted.

EMTALA violations will be reported to the Board during semi-annual Compliance reports.

Education on EMTALA and Incident Reports/Complaints will be provided to staff and providers by 10/15/2021.
100% Emergency Department encounter Chart auditing effective 10/12/2021.

Findings include:

1. During an interview on 10/6/21 at 7:52 a.m., patient # 21 stated her husband and mother-in-law took her to the Emergency Room on 01/05/21 because she was severely hemorrhaging due to a miscarriage. She stated prior to arriving to the ED, her mother-in-law had called the facility and was instructed to take her to Great Falls because the facility does not handle OB cases. Patient #21 stated that while on the way to Great Falls, she began bleeding so much that she felt like she was going to pass out. She stated her mother-in-law turned the car around and took her to the ED because she did not think she would be able to get her all the way to Great Falls safely. Patient #21 stated once she arrived at the facility, she had to wait over twenty minutes for the doctor (staff member D) to arrive. Patient #21 stated staff member D never spoke to her during her entire stay at the facility, and he never crossed the threshold of the doorway leading to her ED room. She stated staff member D never provided her with a medical examination. Patient #21 stated her experience with staff member D was, "Awful." She stated it was her first pregnancy and first miscarriage, and she was extremely scared and nervous. Patient #21 stated staff member D had her transferred to Great Falls via ambulance, where she underwent an emergency D&C.

During an interview on 10/6/21 at 7:59 a.m., family member #1 stated prior to patient #21's 01/05/21 admission to the facility, she contacted the ED department to inform them of patient #21's condition. Family member #1 stated the staff at the ED advised her to transport the patient to Great Falls (82 miles away) because the ED does not have a designated OB department. Family member #1 stated she began driving patient #21 to Great Falls. She stated, "Within five minutes of the drive, (patient #21) began experiencing severe hemorrhaging, and began feeling faint. She was losing so much blood. I decided to turn around and take her to the ED." Family member #1 stated staff member D was the doctor on-call at the ED. She stated, "(Staff member D) never came within ten feet of (patient #21). He never even talked to her." Family member #1 stated patient #21's nurse asked staff member D if he wanted to examine patient #21 and he stated, "No." Family member #1 stated, "I know they can't treat her here, but (staff member D) could have approached her and made her feel better." She stated patient #21 was shaking and very scared.

Record review of patient #21's ED chart showed, patient #21 presented at the ED and was admitted on 01/05/21 @ 3:41 a.m. with a chief complaint of severe vaginal bleeding from a miscarriage. Patient #21 was admitted to the ED with an admitting diagnosis of, "Bleeding after miscarriage."

Record review of the patient #21's triage nursing note, dated 01/05/21 at 04:07 a.m. stated, "Pt having miscarriage yesterday per Great Falls. Pt headed back there this am, became worried about loss of blood and turned around, arriving at 0352. Pt Shaky, c/o cold, covered with a warm blanket ...Call to (staff member D)."

Record review of patient #21's medical chart showed, staff member D arrived at the ED on 01/05/21 at 04:33 a.m.

Record review of patient #21's Transfer Sheet showed, staff member D obtained transfer acceptance from the receiving hospital at 04:30 a.m. on 01/05/21.

Record review of patient #21's ED medical chart, "Notice: Emergency Services/Physician Availability" showed, "The on-call providers will respond to emergency medical needs within 20 minutes. You will receive a medical screening examination and stabilizing treatment within the capabilities of this hospital and pursuant to the requirements of EMTALA and applicable federal regulations. If a transfer to another facility is necessary to provide appropriate medical care, the hospital will provide medical treatment within its capacity to minimize risks to you and subsequently provide medically appropriate transportation to a facility which has the ability to meet your medical needs."

Record review of the patient #21's medical chart showed staff member D did not arrive at the facility within twenty minutes of receiving notification of patient #21's admission to the ED, and he obtained verbal consent for transfer from another hospital for patient #21 prior to his arrival at the facility. In addition, staff member D did not perform a necessary medical screening examination for patient #21.

Record review of facility policy, "Employee Education", effective date 04/17/19 showed, "Required Education: For clinical and other designated employees, Annual Required Education will also include classroom and/or computer knowledge/skills review of high priority topics as driven by healthcare regulations, standard of care, high risk needs and outcome data."

During an interview on 10/06/21 at 6:59 a.m., staff member C stated there was no documentation on file for the facility showing staff member D had completed EMTALA training during his employment with the facility.

2. Record review of patient #16's ED medical chart showed, the patient was admitted to the ED on 07/2/21 at 8:41 a.m. with a presenting diagnosis of active labor. Patient #16 was in her third trimester and was full-term.

During an interview on 10/05/21 at 12:35 p.m., staff member I stated patient #16, "Was extremely concerned that (staff member D) never performed a vaginal exam." She stated, "(Staff member D) said he was not going to do an exam because he was just going to transfer the patient."

During an interview on 10/06/21 at 9:21 a.m., staff member E stated she was the nurse who attended to patient #16 on 07/02/21. She stated staff member D did not perform a vaginal examination of patient #16 while the patient was in the ED. Staff member E stated staff member D arranged for a transfer of patient #16 to Great Falls (82 miles away) via ambulance.

During an interview on 10/05/21 at 2:56 p.m., staff member L stated, "Pregnant females who are in active labor, depending on how symptoms are presenting and where its at, I would think they would have a vaginal examination. If presenting in third trimester, prior to transfer, I would complete a vaginal examination. From a patient, husband, or individual standpoint, I would think I would want that checked."

Record review of patient #16's Transfer Sheet showed, staff member D obtained transfer acceptance from the receiving hospital at 09:24 a.m. on 07/20/21. Patient #16 departed the facility via ambulance at 10:40 a.m.

Record review of patient #16's ED medical chart, "Notice: Emergency Services/Physician Availability" showed, "You will receive a medical screening examination and stabilizing treatment within the capabilities of this hospital and pursuant to the requirements of EMTALA and applicable federal regulations. If a transfer to another facility is necessary to provide appropriate medical care, the hospital will provide medical treatment within its capacity to minimize risks to you and subsequently provide medically appropriate transportation to a facility which has the ability to meet your medical needs."

Record review of facility policy, "Employee Education", effective date 04/17/19 showed, "Required Education: For clinical and other designated employees, Annual Required Education will also include classroom and/or computer knowledge/skills review of high priority topics as driven by healthcare regulations, standard of care, high risk needs and outcome data."

During an interview on 10/06/21 at 6:59 a.m., staff member C stated there was no documentation on file for the facility showing staff member D had completed EMTALA training during his employment with the facility.

3. Record review of patient #11's ED medical chart showed, patient #11 was admitted to the ED on 09/26/21 at 9:35 p.m. with a presenting diagnosis of severe vaginal bleeding. Patient #11 reported having massive blood clots that appeared to be worsening.

During an interview on 10/05/21 @ 7:45 p.m., staff member R stated she was the nurse assigned to patient #11 on 09/26/21. She stated she asked staff member D to perform a vaginal examination of patient #11, and staff member D stated, "There is no need, I am just going to transfer her."

During an interview on 10/05/21 @ 3:55 p.m., staff member D stated he did not complete a vaginal exam on patient #11 prior to her transfer. He stated, "(Patient #11) had clots the size of a hard baseball. I would not have been able to see anything."

Record review of patient #21's Transfer Sheet showed, staff member D obtained transfer acceptance from the receiving hospital at 22:50 on 09/26/21.

Record review of patient #11's ED medical chart, "Notice: Emergency Services/Physician Availability" showed, "You will receive a medical screening examination and stabilizing treatment within the capabilities of this hospital and pursuant to the requirements of EMTALA and applicable federal regulations. If a transfer to another facility is necessary to provide appropriate medical care, the hospital will provide medical treatment within its capacity to minimize risks to you and subsequently provide medically appropriate transportation to a facility which has the ability to meet your medical needs."

Record review of facility policy, "Employee Education", effective date 04/17/19 showed, "Required Education: For clinical and other designated employees, Annual Required Education will also include classroom and/or computer knowledge/skills review of high priority topics as driven by healthcare regulations, standard of care, high risk needs and outcome data."

During an interview on 10/06/21 at 6:59 a.m., staff member C stated there was no documentation on file for the facility showing staff member D had completed EMTALA training during his employment with the facility.

4. Record review of patient #24's ED medical chart, dated 04/10/21 showed patient #24 presented to the ED on 04/10/21 via ambulance with a chief complaint of left lumbar and left femur pain with walking.

Record review of patient #24's Emergency Department Report, signed by staff member D, showed, "Pt went to sit down on a swiveling chair. She sat on the edge and slipped off, landing on the floor. She didn't have any pain until she started to walk. Then she noted pain in her left mid femur and her left lumbar area."

Record review of patient #24's Radiology Report, dated 04/10/21 showed, "RADIOGRAPH: LUMBAR SPINE, TWO OR THREE VIEWS ...No visualized displaced fracture. In the setting of diffuse osseous demineralization, if there is a clinical concern for nondisplaced hip fracture or the patient is unable to bear weight, a rapid protocol pelvis MR may be obtained for further evaluation."

Record review of patient #24's ED discharge instructions, dated 04/10/21, signed by staff member D read, "Drink plenty of fluids, Use Tylenol, as needed for pain. Pain killers would put you at a high risk of more falls and constipation. Return if worse or new symptoms develop."

Record review of patient #24's ED medical chart, dated 04/16/21 showed patient #24 presented to the ED on 04/16/21 via ambulance with a chief complaint of, "left side throbbing pain 10/10 that came on rapidly; pt denies any injury."

Record review of patient #24's Emergency Department Report, signed by staff member D, showed, "Pt fell last week. She sat on the edge of a swivel chair, then slid to the floor. X rays were done and no fractures seen. The aides at the Heritage have been helping her get up. She feels like she may have twisted her back during that process. No further injuries. Pain is in left lower ribs and upper left abdomen., but without tenderness."

Record review of patient #24's Radiology Report, dated 04/16/21 showed, "After secondary review the left femoral neck is fractured, impacted with mild proximal migration. No dislocation. The addendum was called to the referring provider at 22:25 on 4/16/2021."

Record review of patient #24's ED discharge instructions, dated 04/16/21, signed by staff member D read, "Bacterial UTI, rib pain on left side ...Take your antibiotic twice a day for 5 days. Drink plenty of fluids ...Chew each bite of food at least 20 times, before swallowing. Follow up with gastroenterologist about the food bolus that was seen today (your food is not emptying into your stomach properly). Return if worse or new symptoms develop."

Record review of patient #24's ED medical chart, dated 04/22/21 showed patient #24 presented to the ED on 04/22/21 via ambulance with a chief complaint of, "recent fall, intractable pain."

Record review of patient #24's ED medical chart, dated 04/22/21, "Assessment and plan" showed patient #24 was, "Admitted for intractable pain of the left hip, and failure to thrive due to that pain. Will treat pain with IV and oral pain meds and get PT/OT to help ...She was not eating or drinking well due to the severity of her pain. With better pain control we should see an improvement in her appetite."

Record review of patient #24's medical chart showed patient #24 expired on 04/26/21 at 1:45 a.m.

Record review of facility "Emergency Room Survey", dated March 12, 2021, submitted by the family of patient #24 showed, "They misread the CAT scan and later discovered mom had a broken hip. This was AFTER they tried to do physical therapy on her leg, which made the break WORSE ...(Staff member D) told us a strained muscle & she went nearly 2 wks with a broken hip in Chronic Pain & passed away!"

Based on record review, Patient #24's chief presenting complaint was not addressed during the time of her ED visit on 04/16/21. Staff member D did not follow up after receiving a call from the Radiologist, indicating that patient #24 did if fact have a femoral head fracture.

On 10/6/21 at 6:49 a.m., a request was made for the facility to provide the surveyor with investigations for complaints received by the facility from patient #24's family.

During an interview on 10/06/21 at 12:09 p.m., staff member C stated she was unable to find any investigations for the requested patient. She stated she checked staff member A and staff member E's offices but was unable to find any of the requested documentation.