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Based on observation, interview and record review, the facility failed to ensure nursing staff implemented fall prevention interventions for 3 (P-2, P-18, and P-25) of 8 patients reviewed for fall risk, resulting in harm to 1 patient (P-2) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include:

See Specific Tag: A-0392 Failure to implement fall prevention interventions

Based on observation, interview and record review, the facility failed to ensure nursing staff implemented fall prevention interventions for 3 (P-2, P-18, and P-25) of 8 patients reviewed for fall risk, resulting in harm to 1 patient (P-2) and the potential for harm for all patients served by the facility who are at risk for falls. Findings include:

P-2
On 3/31/2025 at 1540 a record review occurred of P-2's medical record. According to P-2's medical record P-2 was sent to the Emergency Room for evaluation for an "unwitnessed fall" at the long-term care facility (nursing home) and becoming somnolent since the fall. The medical record also noted, "is normally confused but alert and conversative." P-2 arrived at the Emergency Room at 1312 on 1/12/2025.

On 1/12/2025 at 1322 under the subtitle "Neuro Assessment," P-2's level of consciousness documented, "reactive; lethargic," orientation documented as other with notation "uta; unable to answer questions," cognition/behavior, "confused", and communication, "delayed responses." On 1/12/2025 at 1543 P-2's level of consciousness documented, "alert," orientation documented as "confused; pt able to recall name, unable to recall anything else, including birthday," cognition/behavior, "poor," attention/concentration; short term memory loss; long term memory loss; poor safety awareness; confused; impulsive; poor judgement," and communication, "delayed responses...."

P-2 underwent a CT (computed tomography) scan on 1/12/2025 at 1322. P-2 CT scan results were the following: "Multicompartmental acute intracranial hemorrhage including a right temporal lobe hemorrhagic contusion, mixed density right subdural hematoma, layering intraventricular hemorrhage, and subarachnoid hemorrhage in the left parietal lobe. There is mild local mass effect related to the right temporal lobe hemorrhagic contusion, but no midline shift or evidence of herniation." The DPOA (durable power of attorney) was contacted and the decision was made by the DPOA to make the patient comfort measures only.

According to documentation P-2 sustained a fall on 1/12/2025 between 1517 and 1520 in the Emergency Room.

On 1/12/2025 at 1520 staff Z, ED RN documented, "sudden interruption in cardiac rhythm with consecutive failures of all cardiac leads alarming "asystole". RN to room to assess; pt found supine in room with head underneath overhang of sink in room feet towards the entryway with significant amounts of blood to face and pooling around head and upper torso on underlying floor...."

On 3/31/2025 at 1600 an interview was conducted with staff W, Registered Nurse for P-2 on 1/12/2025. Staff W was queried if he remembered P-2. Staff W stated he did remember P-2 related to the incident of the fall. Staff W was asked if he could describe P-2. Staff W stated that when P-2 arrived at the ED on 1/12/2025 that P-2 was obtunded and was quiet. Staff W continues that P-2 would mumble but didn't interact much during his assessment. Staff W was then queried if there were any concerns with P-2 being a fall risk. Staff W stated, "No, not really. He was very despondent." Staff W was asked if he knew why P-2 was brought to the ED. Staff W responded that P-2 had a change in interaction with the staff at the long-term care facility that he resided at since his fall a few days prior. Staff W was queried if P-2 was in a direct line of sight from the nurse's station. Staff W stated, "No. He was in room 13 ...patients go where there is an open bed, as much as we try to put them near a nurse's station if they're confused it is not guaranteed ...and he was obtunded."

On 4/1/2025 at 1045 a tour of the ED was conducted. Room 13 was observed to be located on the right side of a short hallway and not in a direct line of view from the nurse's station. The nurse's station was also noted to be behind frosted glass obscuring view of any rooms on the other side of the glass. Staff B, ED Manager confirmed that the frosted glass did not allow for visualization of any rooms in front of the nurse's station.

On 4/1/2025 at 1215 a review occurred of the policy titled, "Fall/Injury Prevention, NUR-30," PolicyStat ID #12721065, revision date 01/2023. The attachment named "Morse Fall Risk Assessment Scale," NUR-30 Attachment A was not utilized in P-2's medical assessment. However, according to the scale P-2 met the following criteria according to P-2's medical record: History of Falls - Yes - 25 (P-2 fell two days prior to ER visit), Secondary Diagnosis - Yes - 15 (P-2's secondary diagnoses included anxiety disorder, peripheral vascular disease, dysphagia, muscle weakness, hyperlipidemia, alcohol abuse (uncomplicated), other seizures ....per medical record from transferring facility). Ambulatory Aid - bedrest - 0, IV/Saline lock - Yes - 20, Gait/Transferring Bed Rest - 0, Mental Status - Forgets Limitations - 15. Total Score - 75. According to the Morse Fall Scale P-2 score would have been considered at high risk for falls.

On 4/1/2025 at 1310 a review occurred of attachment B "Safety Interventions." The attachment indicates the following to be used with "high" fall risk patients. High Fall Risk Interventions include but not limited to: 5. Consider moving the patient to a room with best visual access from the nursing station, 6. Consider the use of bed alarms or a personal alarm, 7. Consider the use of a patient observer (family or patient companion).

The facility failed to provide a fall risk evaluation for P-2 and failed to implement high fall risk interventions.

P-18
On 3/31/2025 at 1025 during a tour of the Emergency Room P-18 was located in trauma bay #1. During the tour of the ER the curtains to trauma bay #1 were closed. Trauma bay #1 was observed to be clean. P-18 was alert and oriented to person, time, place, and situation. P-18 was brought to the ER for a broken hip due to a fall on the morning of 3/31/2025. P-18 was asked if he could show a call light to use in case he needed assistance. P-18 was unable to locate a call light. Staff B, ER manager was queried where P-18's call light was located. Staff B located P-18's call light on the wall out of reach of P-18.

P-25
On 4/1/2025 at 0935 during the tour of the Emergency Room P-25 was located in room #8. During the tour of the ER the door for room #8 was closed. An interview was conducted with P-25 and P-25's family members that were bedside. P-25 was brought to the ER via ambulance on the morning of 4/1/2025 for signs and symptoms of stroke. P-25 was alert and oriented at the time of interview. The call light was viewed on the wall out of reach. Staff B, ER manager was queried where P-25's call light was located. Staff B located P-25's call light on the wall out of reach of P-25.

According to the attachment, NUR-30 Attachment B, under the subtitle, Safety Interventions, it revealed the following for all patients as a fall safety intervention: "Low and Moderate Fall Risk Prevention Interventions: 1. Create a safe patient room environment by conducting rounding for outcomes including: a. Placing the call light within reach..."

Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to maintain a complete central log with arrival times for patients arriving through the emergency department lobby, failure to provide a timely medical screening exam for 2 (P-1 and P-3) of 25 patients reviewed, and failed to provide an appropriate transfer for 3 (P-8, P-9, P-15) of 4 transfers reviewed resulting in the potential for delayed treatment, unrecognized and unmet patient needs and poor patient outcomes for all emergency patients served by the facility. Findings include:

See Specific Tags:

A-2405 Incomplete central log
A-2406 Delay in medical screening exam
A-2409 Incomplete transfer documentation

Based on observation, interview, and record review, the facility failed to have a complete central log for the ED which included an accurate arrival time of the patients, resulting in the failure to identify all patients who left prior to evaluation by a provider and the failure to capture an accurate time all patients coming through the ED lobby were waiting to be seen by the nurse and/or provider. Findings include:

On 4/1/2025 at 0945, surveyors, ED Manager Staff B, and Accreditation Coordinator Staff C went to the ED lobby to observe the triage area. Upon entrance, it was noted there were 12 patients seated in the waiting room and there was a line of 4 patients/families that were waiting. At the head of the line was a sign indicating patients needed to wait in line there to be triaged. The first three patients were in wheelchairs and the fourth was standing leaning against a wall. The triage desk was busy with a patient at the desk. It was noted the man in the third wheelchair back was visibly short of breath. It was unknown how long he had been waiting in line to be seen. Approximately two minutes after the surveyor's arrival to the area, the ED technician approached the man in the third wheelchair and obtained vital signs. She went back and spoke to the triage nurse. Upon the nurse finishing the triage with the patient at the desk, the ED technician came and got the man who was short of breath and took him ahead of the others to the triage desk for assessment. The woman who was in the wheelchair first in line got up and walked out the door accompanied by a man who was with her. They did not return. Observations continued with more patients entering, some with a security officer giving direction, and standing in the growing line waiting for triage.

After observing for approximately 10 minutes, ED Manager Staff B was asked to relieve the triage nurse so she could be interviewed. During interview, Triage Nurse Staff N was queried as to if she was aware the female patient had left, and she said she was. She was then queried as to the patient's name and the reason she was there to be seen. Staff N stated she didn't know because she hadn't triaged her yet. When asked how long the patient had been waiting prior to leaving, Staff N responded she thought the patient had been there approximately five minutes. Staff N was queried as to why the arrival times were not tracked and the triage nurse clicked the arrival time at the same time as the triage time. Her response was that was what they had been instructed to do as the encounter was created at the time of triage. A name would have to be present to note an arrival time and names of patients were not known until they were at the desk for triage. No quick registration system was in place in triage. All patients were registered in the main ED at bedside.

During review of medical records on 3/31/2025 and 4/1/2025, patients who came in through the ED lobby had the following arrival and triage times:

P-1 Arrival: 1249 Triage 1249
P-4 Arrival 1013 Triage 1013
P-5 Arrival 0207 Triage 0208
P-6 Arrival 1837 Triage 1837
P-8 Arrival 1027 Triage 1027
P-10 Arrival 1449 Triage 1449
P-12 Arrival 0849 Triage 0849
P-13 Arrival 1449 Triage 1449
P-14 Arrival 2237 Triage 2237
P-16 Arrival 1040 Triage 1040
P-17 Arrival 0301 Triage 0301

Review of facility policies for EMTALA (Emergency Medical Treatment and Labor Act) and Triage did not address capture of the arrival times vs. triage time.

Based on interview and record review, the facility failed to a timely medical screening exam for 2 (P-1, P-3) of 25 patients resulting in the potential for poor patient outcomes. Findings include:

Review of the medical record for P-1 revealed he was a 47-year-old male who presented to the Emergency Department (ED) via private vehicle on 11/4/2024 at 1249 with a chief complaint of abdominal pain. Triage documentation with the chief complaint has in parenthesis, "Pt reports ' Extreme abdominal pain. Hx (history) of hiatal hernia. PLEASE HELP ME IM IN SO MUCH PAIN ' . Family reports 'He had a big meal last night. Nausea, no vomiting. ULQ (upper left quadrant) pain. Sharp. Started after eating oatmeal.'" The triage assessment further indicated there was no radiation of the pain.

Initial vital signs at 1251 were as follows: Temperature (T)-98.6, Pulse (P)-85, Respirations (R)-16, Blood Pressure (BP)-167/105, and Oxygen Saturation (SpO2)-98% on room air. Pain was 10/10. Triage documentation indicated P-1 was irritable and boisterous; however, was not threatening. P-1 was listed as an acuity 3 (The emergency severity index {ESI} level three indicates a patient that requires prompt attention but can wait up to 30 minutes for assessment and treatment).

On 11/4/2024 at 1303, Triage Nurse Staff L documented the family was requesting a robe and stating P-1 was hot. He noted P-1 was "pacing in triage."

P-1 was roomed on 11/4/2024 at 1347 (58 minutes later) and ED Physician Staff M saw the patient immediately. Physician notes dated 11/4/2024 by the resident indicated P-1 was in "obvious pain", having abdominal pain with radiation to his shoulder. By the end of the exam, P-1 was reporting pain in both shoulders. An EKG (electrocardiogram) and labs were obtained at 1357 (1 hour, 8 minutes from time of triage). The resident documented, "My personal interpretation of the EKG was ST elevation in leads II, III and aVF and ST depressions in lead V2 consistent with an inferior STEMI (ST elevated myocardial infarction-heart attack). (Physician Staff M) was notified by the nurse of the EKG findings as well. At this point, the STEMI protocol was activated. The patient continued to be nauseated and continued having "intense abdominal pain, left-sided and back pain with left arm numbness." Pain medications and blood thinners were given, and P-1 was emergently transferred from the ED to the catheterization lab at 1423. He was admitted to the hospital following his heart catheterization.

During interview on 4/1/2025 at 0913, Triage Nurse Staff L stated he did recall P-1 coming in with "abdominal pain that worsened after eating." He stated he asked P-1 "if he was having chest pain and he said no." Staff L recalled P-1 was pacing, and, at some point, was taking off his shirt. Staff L asked P-1 to keep his shirt on. When queried as to if a patient stating pain was 10/10, and the patient was pacing, and did not appear to be able to get comfortable would be a cause for concern, Staff L stated pain was "very subjective but taken note of." When asked if a patient or family member interrupted him while with another patient to say symptoms were worse or were asking for help what he would do, Staff L stated he would direct them to "get back into (the triage) line" so they could be reassessed. During the course of survey, it was discovered the facility did not have a quick registration process in place and all patients were registered at bedside. Patients were first seen by the triage nurse and the triage nurse would document the patient's time of arrival the same as the time of triage. When queried, Staff L was unable to recall how long P-1 waited from his actual time of arrival to the time of triage.


Review of the medical record for P-3 from the receiving facility (Facility B) revealed he was a 75-year-old male who was being sent by a nursing home facility for evaluation of hematuria (blood in the urine). In the medical record was a copy of the ambulance run sheet which was also reviewed. The ambulance run sheet was dated 2/4/2025 and the call was initialed at 0220. They were on scene with the patient at 0239. It was noted the nursing home that the patient resided in was on the same road as the subject facility (Facility A). In the narrative portion of the ambulance run sheet, it was stated, "Initially Patient was taken to (Facility A) and when EMS (emergency medical services) arrived with the patient facility staff turned EMS away stating they were on diversion and were not taking any patients by EMS at this time so EMS asked patient and they requested to be taken to (Facility B)."

Review of the Diversion Log for the past 12 months revealed Facility A had been on diversion four times including the time frame from 2/3/2025 at 1958-2/4/2025 at 1347 (17 hours, 49 minutes).

Review of the EM Track (Emergency Track-radio communication system between hospitals and ambulances) Log revealed an entry dated 2/4/2025 at 0245 for a 75-year-old male with "hematuria x1 day, (catheter) replaced last week." It noted it was a "Bravo" call (low priority level) and which ambulance service was calling. Estimated time of arrival was 2/4/2025 at 0307. The "status" column stated "Received." On 4/1/2025 at 1150, Director of ED Staff A stated that "received" indicated the call was received from the ambulance.

In a general interview with Charge Nurse Staff E on 3/31/2025 at 1050, she was queried about diversion and stated she was aware of only 1 time being on diversion in the past year. That one time was the beginning of this year (2025) and was because there were too many patients being boarded (waiting for inpatient bed or to be transferred) in the ED and it was decided they "couldn ' t adequately care for all of the patients." When queried as to what she would do if a patient arrived via ambulance while they were on diversion, she said, "If the patient is on hospital grounds, we do take them unless we are on diversion."

On 4/1/2025 at 1342, Staff E was re-interviewed upon discovery she had been the charge nurse on 2/4/2025 during the early morning hours. She stated she had just come on shift on 2/4/2025 at 0300 and knew the facility was still on diversion. An alert went off from the EM Track for ambulance communication. Staff E stated she hit the "divert" button which sends a tone to the ambulance alerting them the facility was on diversion. She did not answer the call. Staff E then instructed the unit secretary to call the ambulance company office and inform them the facility was still on diversion. Staff E stated she performed a small, quick task, then walked back up the hallway and saw the patient and EMS crew standing in front of the charge nurse desk when she rounded the corner. "I asked them what was going on and told them I hit the divert button and the office had been called. They said, ' Oh, we must have missed it. ' They then asked the patient where else he would like to go, and they left." Staff E admitted she did not try to stop them from leaving.

On 4/1/2025 at 1615, Paramedic Staff Q stated he worked a 1800-0630 shift on 2/3 into the early morning hours of 2/4 and was aware the facility had been on diversion earlier in the night. At 0300, he thought the diversionary status had lifted as "generally they do not last that long." Upon arrival to the facility, he and EMT Staff P took the patient into the building. They were met by the charge nurse who asked what they were doing and informed them the facility was on diversion, and she had hit the divert tone when the call had come in. "I told her we must have missed it. I then asked the patient where he would like to go... and we left." Staff Q stated the charge nurse did not attempt to stop them from leaving. When queried as to how he was unaware the facility was still on diversion, Staff Q stated it was very uncommon for a facility to be on diversion for such a long period and when in the field it was very easy to miss updates on their phones and/or tablets when tending to a patient or driving the ambulance.

Facility policy NUR-16 titled "Diversion (EMS Policy, NUR-16" retrieved 3/2025 states, "Diversion of ambulances may become necessary... If an ambulance disregards the diversion instruction and comes to the hospital, the hospital is obligated to provide the emergency screening exam and stabilizing treatment under EMTALA (Emergency Medical Treatment and Labor Act)."

Based on interview and record review, the facility failed to provide all information required for transfer for 3 (P-8, P-9, P-15) of 4 Emergency Department transfers reviewed resulting in the potential for unsafe and/or inappropriate transfers. Findings include:

Review of the medical record for P-8 revealed an "EMTALA (Emergency Medical Treatment and Labor Act) Transfer Form" dated 1/8/2025 that failed to document whether or not the patient had been stabilized. Review of physician notes also did not include comment on the patient's stability. Additionally, the form did not address the resources-both qualified personnel and medical equipment-needed to safely transport the patient.

Review of the medical record for P-9 revealed there was no EMTALA Transfer Form present. No documentation was found elsewhere in the medical record that described patient stability, benefits/risks of transfer, nor resources needed for transfer.

On 4/1/2025 at 1140, ED Manager Staff B stated the EMTALA Transfer Form should be filled out for every transfer to an outside facility.

Review of the medical record for P-15 revealed an EMTALA Transfer Form dated 1/13/2025 that failed to document whether or not the patient had been stabilized. Review of physician notes also did not include comment on the patient's stability. Additionally, the form did not address the resources needed to safely transport the patient.

Facility policy #17269324 titled "Transfers to Acute Care Hospitals, NUR-46" effective 1/2025 states, "Transfers to outside acute care hospitals or facilities, either by request of patient/family, medical necessity, or for services not provided at UMH-West are conducted with patient rights and safety ensured; and all regulatory/compliance requirements followed... A. Forms required for all transfers: 1. Physician Certification for Transfer/EMTALA Transfer Form... REQUIRED FOR EVERY TRANSFER. Must include name of receiving facility and name of accepting physician at receiving facility."

Facility policy #13463262 titled "Emergency Medical Treatment and Labor Act (EMTALA), COMP-18" effective 11/2023 states, "G. Transfers... 6. Transfers will be done by appropriate medical vehicle with appropriate medical personnel and appropriate life support equipment. Private vehicles do not meet EMTALA standards."