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Based on record review and interview, the facility failed to provide a face-to-face evaluation within one hour of restraint or seclusion for 2 (P-17, P-19) of 3 patients reviewed for restraint/seclusion resulting in the potential for violation of patient rights and poor patient outcomes. Findings include:

P-17
On 3/11/2025 review of the medical record for P-17 revealed he was placed into restraints multiple times from 12/16/24 through 12/17/2024. Face-to-face evaluations were not competed for 5 out of 5 episodes. Review of Restraint Orders reveals violent restraints were ordered on the following dates:
12/16/2024 0917 - No Face-to Face evaluation documented
12/16/2024 1236 - No Face-to-Face evaluation documented
12/16/2024 2001 - No Face-to-Face evaluation documented
12/17/2024 0003 - No Face-to Face evaluation documented
12/17/2024 0324 - No Face-to-Face evaluation documented

Nursing documentation from 12/16/24 0917 and 12/16/24 1614 reveals Face-to-Face evaluation: "yes" however, no note from the provider was found in documentation.

P-19
On 3/11/2025 review of the medical record for P-19 revealed she had been placed in restraints on two separate occasions. Face-to-face evaluations were not completed on 11/16/2024 at 0810 or 11/16/2024 at 0843. The documentation revealed the following:
11/16/2024 0810 No Face-to-Face evaluation
11/16/2024 0843 No Face-to-Face evaluation
11/16/2024 1532 Face-to-face evaluation documented

On 3/11/225 at 1200, an interview with the Emergency Department Medical Director (Staff X) was conducted and reveals he was aware that ED providers are required to document a Face-to-Face assessment within an hour of placing an order and providers have been made aware that this is a requirement and he will continue to educate providers at staff meetings.

Facility policy #17088390 titled "General Nursing-Restraint of Patients on Non-Behavioral Health Units Policy and Procedure" last revised 11/2024 states, "The physician must conduct a face-to-face assessment of the patient within one hour of the initiation of restraints. The face-to-face assessment must be documented and must include: 1. An evaluation of the patient's immediate situation; 2. The patient's reaction to the intervention; 3. The patient's medical and behavioral condition and
4. The need to continue or terminate the restraint."

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 log the arrival of 1(P-1) patient presenting to the Emergency Department and failed to provide a medical screening exam (MSE) for 1 (P-1) patient of 20 patients reviewed for medical screening exams, resulting in the potential for less than optimal outcomes for all patients seeking emergency care. Findings include:

See tags:

2405: Failure to keep a central log
2406: Failure to provide a medical screening exam.

Based on document review and interview, the facility failed to log 1 of 20 (P-1) patients presenting to the Emergency Department (ED) seeking emergency services resulting in the failure to identify patients leaving the facility without being seen and the potential for less than optimal outcomes. Findings include:

On 3/10/2025 at 1300 review of the facility Emergency Department (ED) Discharge Log from November 2024 through March 10, 2025 was conducted. P-1 was not found on the log for the date of service 2/22/2025.

Review of facility policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure", policy #17636849, last revised 2/2025 reveals under the Procedure, Section I, "...will maintain a log listing each individual who comes to the dedicated emergency department seeking medical care, including patients presenting to the Emergency Department", "The log entry will take place at the first point of contact and may be in a "log book", on a census sheet, or on a computer, depending upon the area involved." and "The log will contain the following information: The name or a description of the individual requesting emergency medical services; The location where the patient presented for emergency medical services or receives a medical screening examination; The disposition of the individual."

Based on interview and record review, the facility failed to provide an appropriate medical screening exam for 1 (P-1) of 20 patients reviewed for emergency medical treatment and labor act (EMTALA) requirements, resulting in the potential for an untreated emergency medical condition and poor outcomes. Findings include:

On 3/10/2025 at 1608 review of video footage from Facility-A from 2/22/2025 was conducted with the Lead Security Officer (Staff N) and revealed at 1207 two adults (older male and younger female) presented to the Emergency Department (ED) registration window (the ED Manager (Staff D) and the Director of Nursing (Staff C) identified the admitting representative at the window as Staff P). At 1208, Staff P is observed interacting with them and then leaving the registration window. At 1210 Staff P is observed returning to the registration window and interacting again with the two adults who then walked away from the registration window, sat down at a table near the registration window and walked out of the ED at 1229.

On 3/11/2025 at 0915 an interview with Staff P, the Admitting Registration Clerk working when P-1 and his daughter presented on 2/22/2025 at 1207 to the Emergency Department (ED). Staff P revealed she remembered speaking with P-1 and his daughter and that he came in complaining that his drainage tube from a recent gallbladder surgery had decreased output and he was having "pain" related to the surgery. Staff P reported she went back to the ED treatment area and spoke with staff about whether she should register P-1 to be seen. P-1 explained she could not remember who she spoke with when she went to the treatment area but did remember that the staff asked her if P-1 called his surgeon and then instructed her that to tell them that "if he had surgery somewhere else they are not going to be able to do anything" for him. Staff P revealed after this conversation she went back to the registration window and told the patient that "if he had surgery somewhere else, they should go back to where he had surgery" for treatment. Staff P recalled P-1 and his daughter sat at a table near the registration window and attempted to call someone on the phone, who she thought was the doctor s office. When queried why she did not register the patient and chose to ask whether he should be seen, Staff P stated, "I am not sure why I didn't just register him". When queried if she was familiar with EMTALA and if she has received EMTALA education, Staff P responded, "yes, we are not to refused patient care regardless of anything".

During an interview on 3/11/2025 at 1045 the nurse practitioner (Staff Y) revealed she did not remember discussing P-1 with Staff P but if she were asked, she would have told her to "register him so he can be seen". When queried if she received EMTALA training, Staff Y stated, "yes, anybody that presents to the facility should be seen and nobody is turned away."

In an interview on 3/11/2025 at 0938 the ED provider (Staff K) revealed he did not remember talking with Staff P about P-1 but if he were asked about whether the patient should be registered to be seen he would have said yes. Staff K added, "I would never want anybody to go out without an evaluation."

On 3/11/2025 interviews were conducted with all staff members working in the Emergency Department (ED) with Staff P on 2/22/2025 at 1207. The staff nurses (Staff S, Staff BB, Staff Z) and the clerk/assistant (Staff CC) revealed they did not remember speaking with Staff P about P-1 and were not aware a patient left the ED without a medical screening. All staff added they receive EMTALA education and are aware that all patients are entitled to a medical screening.

On 3/11/2025 at 1200 an interview with the Emergency Department (ED) Director (Staff X) was conducted and revealed he was not aware of the incident involving P-1. Staff X explained that P-1 "should have been registered and we can figure out what needs to be done". Staff X added all ED providers receive EMTALA education and are aware all patients must have a medical screening when they present requesting treatment.

Review of facility policy titled "Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure", policy #17636849, last revised 2/2025 reveals under the Policy section, "Any individual who comes to the Medical Centers or any of the facilities where the Medical Centers provider emergency services, who is in need of or request emergency services, will be treated in accordance with the law. The individual is entitled to and will receive, regardless of diagnosis, race, color, nationality, handicap, or financial status, an appropriate: Medical screening examination by a qualified medical personnel* to determine whether an emergency medical condition exists".