The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

SOUTHWEST MEMORIAL HOSPITAL 1311 N MILDRED RD CORTEZ, CO 81321 Oct. 25, 2018
VIOLATION: COMPLIANCE WITH 489.24 Tag No: C2400
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in 489.24, related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

Findings:

1. The facility failed to meet the following requirements under the EMTALA regulation:

Tag A2402 - Posting of Signs - The facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility. Specifically, there was no EMTALA signage at the main entrance to the hospital, the emergency department (ED) ambulance bay, or in the ED waiting area outside patient registration.

Tag A2406 - Medical Screening Exam - The facility failed to ensure a medical screening examination was provided to a patient who presented to the emergency department for chest pain in one of four internal reporting events reviewed (Patient #21).
VIOLATION: POSTING OF SIGNS Tag No: C2402
Based on observation and interviews the facility failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted at relevant locations in the facility.

Findings include:

Facility policy:

The EMTALA (Emergency Medical and Labor Treatment Act) policy read, the hospital must post conspicuously, in the dedicated emergency departments and all areas in which individuals routinely present for treatment of emergency medical conditions and wait prior to examination and treatment, (such as entrance, admitting areas, waiting room or treatment room) signs that specify the rights of an individual under the law with respect to examination and treatment for emergency medical conditions and women who are pregnant and are having contractions.

1. The facility failed to post signs, specifying the rights of individuals seeking examination and treatment for emergency medical conditions and women in labor, at entrances and waiting areas used by patients seeking emergency services and by pregnant women. Specifically, there was no EMTALA signage at the main entrance to the hospital, the emergency department (ED) ambulance bay, or in the ED waiting area outside patient registration.

a. On 10/23/18 at 8:50 a.m., a tour of the facility was conducted with the executive assistant (Assistant #1). Observations of the main entrance of the hospital showed a temporary sign posted outside of the building, which indicated an emergency room entrance. There was no EMTALA signage posted within the entrance door and hallway.

A continued facility tour of the ED waiting room showed no evidence of signage which described patients' rights under EMTALA. The only sign noted was posted in the hallway past the ED registration desk. The sign could not be visualized from the ED patient waiting area. This was in contrast to policy which stated the hospital must post rights of an individual under the EMTALA law, in a conspicuous area; including entrance, admitting areas, waiting room or treatment room.

b. A tour of the ED's ambulance bay, including the door and surrounding areas, showed no evidence of any signage describing patients' rights under EMTALA. At 9:32 a.m., Assistant #1 confirmed the ambulance bay was recently painted and there were no signs present.

c. On 10/23/18 at 10:07 a.m., a tour of the family birthing center was conducted, there was no signage posted which described patients' rights under EMTALA. According to Assistant #1, the back way to the birthing center from the ED was blocked off at the end of the hall. She said the current path from the ED registration desk to the birthing center was through the main hospital lobby.

Obstetric (OB) registered nurse (RN #2) and RN #3 were interviewed. Both worked in the family birthing center. RN #3 stated most patients would bypass the ED registration and come straight to the unit. She stated the door directly to the ED was blocked for construction. RN #2 stated any patient who was more than 20 weeks pregnant would come directly to the family birthing center from the main hospital entrance. She then confirmed the patients were not being transported through the hall past registration (where the EMTALA sign was noted), since 10/3/18.
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
Based on interviews and document review, the facility failed to ensure a medical screening examination was provided to a patient who presented to the emergency department for chest pain in one of four internal reporting events reviewed (Patient #21).

Facility findings:

Facility policy:

The EMTALA (Emergency Medical Treatment and Labor Act) policy read, for the purpose of this policy, an individual is deemed to have "come to the emergency department" if the individual:

Presents at the dedicated emergency department, and request examination or treatment for a medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs examination or treatment of a medical condition; or

Presents on hospital property, other than a dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual's appearance or behavior, that the individual needs emergency examination or treatment

According to the policy's definitions;

An Emergency Medical Condition is:

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 either:

Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, or serious impairment to bodily functions, or serious dysfunction of any bodily organ or part.

A Medical Screening Exam (MSE) is the screening process required to determine with reasonable clinical confidence whether an emergency medical condition does or does not exist.

1. The facility failed to ensure patients presenting at the emergency department seeking emergency medical care received a medical screening exam.

a. Review of the internal report, dated 2/23/18, revealed on 2/22/18 at 6:11 p.m., Patient #21, came into the emergency department (ED) for chest pain. According to the comment entered by patient registration staff (Registrar #6), the patient was taken to the ED but the registrar was told by an ED unit clerk (Employee #7) to take the patient to the ED waiting area. The note further revealed, Registrar #6 asked the patient to come back to the registration office; however, the patient said she would call her mother and go to another facility.

Review of the investigation comments documented by the prior ED director (Director #10), on 2/27/18 at 10:09 a.m., showed Employee #7 was interviewed. According to the documentation, Patient #21 was seen at the facility's walk in clinic, on hospital property. The provider at the clinic called the ED and spoke with the on duty physician assistant (PA). The note stated the PA told Employee #7 the patient had anxiety and when the patient arrived at the ED, she was to be sent to the waiting room as the department was very busy. The internal report investigation showed the facility only identified concerns with the patient not being registered in the emergency department log.

During a tour, on 10/23/18 at 9:35 a.m., ED registered nurse (RN #12) stated all patients who presented to the ED with chest pain were considered emergent. She then said patients who were considered emergent would go straight to a room in the ED for examination.

The facility was unable to provide any evidence which showed Patient #21 was triaged (determining the priority of patient treatments) by nursing staff and received an MSE by qualified medical personnel (QMP) to determine if a emergency medical condition existed. This was in contrast to policy.

b. On 10/25/18 at 1:30 p.m., an interview was conducted with the Director of Human Resources (Director #8) and the Quality Improvement Risk Management Coordinator (Coordinator #9). According to the internal report document, both were involved with Patient #21's event follow up. However, Coordinator #9 stated it was the responsibility of the prior ED director to follow up with staff about any EMTALA concerns. Coordinator #9 stated if a patient presented with chest pain, the patient needed an MSE right away.

Upon exit, the facility could not provide evidence which showed they identified and implemented measures to ensure nursing staff triaged all patients who presented to the ED with chest pain and these patients received a MSE to determine if an emergency medical condition existed.