PRINTED: 031300016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 By WING 11(1912015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) in SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL . (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A2400 489.200) COMPLIANCE WITH 489.24 I A2400 [The provider agrees] in the case of a hospital as . defined in to comply with ?489.24. This STANDARD is not met as evidenced by: I Based on review of the Hospital?s Emergency I Department (ED) logs, review of medical records, and policy review. it was determined the Hospital failed to comply with the provider agreement as I defined in 42 CPR. ?489.20 and 42 C.F.R. ?489.24. The findings included: a. The HOSpital failed to provide a medical screening examination (MSE) that was, within reasonable clinical confidence, sufficient to determine whether or not an Emergency Medical Condition (EMC) existed. See 42 C.F.R. ?489.24- Medical Screening Exam (A2406) for patient specifics. I b. The Hospital failed to ensure the patient's EMC was treated and stabilized prior to discharge/transfer. See 42 C.F.R. ?489.24- Stabilizing Treatment (A2407) for patient I specifics. A2406 489.24(a) 489.24(c) MEDICAL SCREENING A2406 EXAM . Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether I or not eligible for Medicare benefits and regardless of ability to pay) "comes to the i emergency department", as defined in paragraph ofthis section, the hospital must provide an appropriate medical screening examination I LABORATORY OR REPRESENTATIVES SIGNATURE TITLE 1X6) DATE Any deficiency statement ending with an asterisk denotes a de?ciency which the institution may be excused from correcting providing it is determined that other safeguards provide suf?cient protection to the patients. (See instructions.) Except for nursing homes. the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above ?ndings and plans of correction are disclosable days following the date these documents are made available to the facility. If de?ciencies are cited. an approved plan of correction is requisite to continued program participation. FORM Previous Versions Obsolete Event Facility ID: 430034 If continuation sheet Page 1 0f 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 03I'30i2016 FORM APPROVED OMB NO. 0938?0391 STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIERICLIA AND PLAN OF CORRECTION IDENTIFICATION 430084 (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A BUILDING COMPLETED 3' 1111912015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREET ADDRESS, CITY. STATE, ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4; In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION Ixsi (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCE) TO THE APPROPRIATE DATE DEFICIENCY) A2406 Continued From page 1 I A2406 within the capability of the hospital's emergency I 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 If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph of this section, or an appropriate transfer as defined in paragraph of this section. Ifthe hOSpital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as Specified in paragraph of this section. (2) Nonapplicability of provisions of this section. Sanctions under this section for inappropriate transfer during a national emergency 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 located in an emergency area, as specified in section 1135(g)(1) of the Act. 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 I applicable declaration of a public health I emergency, as provided for by section 1135(e)(1) i (B) of the Act. FORM Previous Versions Obsolete Event 4KXY11 Facility ID: 430084 If continuation sheet Page 2 of 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES 03/30/2016 FORM APPROVED OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (X1) AND PLAN OF CORRECTION IDENTIFICATION NUMBER: 430084 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING COMPLETED 8' 11111912015 NAME OF PROVIDER OR SUPPLIER PHS INDIAN HOSPITAL AT ROSEBUD STREETADDRESS. CITY. STATE. ZIP CODE 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 Use of Dedicated Emergency Department for . Nonemergency Services lf an individual comes to a hospital's dedicated I emergency department and a request is made on his or her behalf for examination or treatment for i a medical condition, but the nature ofthe request makes it clear that the medical condition is not of i 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 I have an emergency medical condition. This STANDARD is not met as evidenced by: Based on medical record review, review Of the ED log and policy review, it was determined the Hospital failed to provide a timely medical screening examination (MSE) that was, within I reasonable clinical confidence, sufficient to determine whether or not an Emergency Medical Condition (EMC) existed for three of thirty?one sample patients #34, and #37) who I presented to the Emergency Department (ED). The findings included: 1. Review of the 3/3/2015 ED record for patient I #31 evidenced that this 2 year old was brought to I the ED at 6:35 PM by his mother. The mother indicated that the child had a "fever with runny nose 7 days". The nursing triage assessment listed "fever, hands cramping, difficulty breathing I - wheezing, ill 6 days, (2/27/2015) (respiratory virus infection), and difficulty breathing/fever/dehydrated." I a. Provider (FF) charted that the Child's external (x4) .9 SUMMARY OF DEFICIENCIEs Io PLAN OF CORRECTION (st (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2406 Continued From page 2 I A2406 FORM Previous Versions Obsolete Event ID: 4KXY11 Facility lD: 430034 If continuation sheet Page 3 of 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: 03/30/2016 FORM APPROVED OMB NO. 0938-0391 e. There was no evidence in the ED provider's documentation on 3/3/2015 to show that the prior outpatient records were reviewed, no evidence a pediatrician was consulted, no evidence this pediatric patient was fully assessed for vomiting, I dehydration, or his overall physical status or any discussion ofthe medical decision made concerning any diagnostic testing such as chest x-ray or laboratory studies. There was no I evidence that the ED physician had evaluated for possible progression of the patient's respiratory infection (pneumonia) or severity of dehydration (electrolyte imbalance) with the presentation of cramping in his extremities and continued vomiting. 'The hospital failed to provide a comprehensive MSE of this patient prior to his discharge home. 2. Review of the ED log revealed that patient #37 presented to the ED on 4/23/2015 at 7:17 PM with "chest pain". The nursing assessment - triage indicated "Patient put on monitor. Shows SVT (Supraventricular tachycardia) type 160 Stat EKG shows Afib (Atrial fibrillation). Patient has no history. Please see critical care for all care. Dr. _(name) notified." The EKG I showed Atrial fibrillation with Rapid Ventricular response (RVR). At 7:20 PM, the patient's blood pressure (BP) was 169/126. pulse (P) 180, I respirations (R) 24, pain 8 (8 out of 10), and 02 saturation 98%. The pain was described as "pain I through to back". The patient was assigned an of2. i a. The (Emergency Severity index) triage I algorithm stratification of patients into five STATEMENT OF DEFICIENCIES (X1) (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION A BUILDING COMPLETED 430084 8- WING 11/19r2015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE. ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION Ixsr (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING TAG CROSS-REFER ENCED To THE APPROPRIATE DATE DEFICIENCY) . I A2406 Continued From page 4 A2406 FORM Previous Versions Obsolete Event ID14KXY11 Facility ID: 430084 if continuation sheet Page 5 of 13 PRINTED: 03(30i'2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (XI) PROVIDERISUPPLIERJICLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBERS A. BUILDING COMPLETED 430084 B. WING 11119I2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE, ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID I PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE DEFICIENCY) A2406 Continued From page 5 - A2406 groups, from LEVEL 1(most urgent to LEVEL 5 1 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs. Given the possibility of progression ofthis patient's condition to reSpiratory failure, hemodynamic instability or cardiogenic shock, this patient should have been triage as ESI level 1 - immediate care, life threatening conditions that requires immediate lifesaving interventions. b. The patient's MSE by the medical provider was noted to have been done at 8:15 PM, almost one hour after admission to the ED. Although the nursing assessment showed chest pain and shortness of breath, the Review of the Systems by the ED provider revealed that the patient denied chest and denied shortness of breath. The vital signs (VS) listed in the I provider's MSE were taken on 7/22/2014. The I MSE did not show review of the V3 for the current ED visit which indicated hypertension (BP 169/126), tachycardia (P 180) and a chest pain at level of 8 of 10. 0. Although the EKG showed Afib with RVR, the MSE did not show a comprehensive evaluation for possible new onset Congestive Heart Failure (no chest x-ray, ultrasound or BNP (B-type natriuretic peptide) which is suggestive of a failing heart muscle and ventricular damage. The hospital failed to provide a comprehensive MSE of this patient in a timely manner. this elderly patient arrived in the ED at 9:09 AM on 3/27/2015 after being found outside. Nursing i 3. Review of patient #34'3 ED record indicated i I FORM Previous Versions Obsoiete Event ID: 4KXY11 Facility ID: 430084 If continuation sheet Page 6 of 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES 03(30f2016 FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED 430084 8- WING 11(1912015 NAME OF PROVIDER OR SUPPLIER CITY, STATE. ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (x4) SUMMARY STATEMENT OF DEFICIENCIES ID I PROVIDERS PLAN OF CORRECTION (X5) PREFIX . (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE i DEFICIENCY) A2406 Continued From page 7 A2406 sounds in both lungs, the ED provider indicated I the patient had no cyanosis or labored breathing. A Chest x-ray revealed a right lower lobe infiltrate. The hospital failed to provide a comprehensive . MSE of this patient in a timely manner. i A2407 STABILIZING TREATMENT A2407 (1) General. Subject to the provisions of paragraph ofthis section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either? within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph of this section. (2) Exception: Application to inpatients. If a hospital has screened an individual under paragraph of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities underthis section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. FORM Previous Versions Obsolete Event ID: 4KXY11 Facility ID: 430034 If continuation sheet Page 8 Of 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE 8: MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 indicated that the child had a "fever with runny nose 7 days". The nursing triage assessment listed "fever, hands cramping, difficulty breathing - wheezing, 6 days, (2/27/2015) (respiratory virus infection), difficulty breathing/fever/dehydrated.? a. Provider (FF) charted that the child's external ear and TMs (tympanic membranes) were clear and that the Child had a viral The noted history of present illness included fever, runny nose, no sob (short of breath) and vomiting. There was no description of the vomiting or of possible dehydration The patient was discharged home after only thirty minutes in the ED. There was no stabilizing treatment provided for the reported vomiting and possible dehydration The child was returned to the outpatient clinic the next day for further treatment of vomiting andi dehydration. 2. Review of the ED log revealed that patient #37 presented to the ED on 4123/2015 at 7: 17 PM with "chest pain". The nursing assessment triage indicated ?Patient put on monitor. Shows SVT type 160 Stat EKG shows Afib (Atrial fibrillation). Patient has no history. Please see I critical care for all care. Dr. _(name) notified." The EKG showed Atrial fibrillation with Rapid Ventricular response (RVR). At 7:20 PM, the patient's blood pressure (BP) was 169/126, pulse (P) 180, respirations (R) 24, pain 8 (8 out of 10), and 02 saturation 98%. The pain was described as "pain through to back". The patient's MSE by the medical provider a. STATEMENT OF DEFICIENCIES {x1} PROVIDERISUPPLIERIOLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A BUILDING COMPLETED 430084 3- 11I19I2015 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 (M) in SUMMARY STATEMENT OF DEFICIENCIEs iD PROVIDERS PLAN OF CORRECTION (XS) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) A2407 Continued From page 9 . A2407 FORM Previous Versions Obsolete Event ID: 4KXY11 Facility ID: 430034 If continuation sheet Page 10 of 13 PRINTED: 03f30f2016 DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391 STATEMENT OF DEFICIENCIES (x1) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION A BUILDWG COMPLETED 430084 8- WING 1111912015 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS CITY. STATE. ZIP CODE PHS INDIAN HOSPITAL AT ROSEBUD 400 SOLDIER CREEK ROAD ROSEBUD, SD 57570 (M) (9 SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THEAPPROPRIATE DATE DEFICIENCY) A2407 Continued From page 10 I A2407 I I was noted to have been done at 8:15 PM, almost one hour after admission to the ED. The MSE did not Show a comprehensive evaluation for new onset Congestive Heart Failure CHF). There was . no chest x?ray. ultrasound or BNP (B?type natriuretic peptide) which is suggestive of a I failing heart muscle and ventricular damage. I b. Review of the nursing Critical Care Flow Sheets revealed the patient had been give four doses of Diltiazem. used to treat hypertension and angina and one dose OfAtivan, a benzodiazepine used to treat anxiety. These I medication were given without physician orders (medications given priorto the MSE by the medical provider). This delay in MSE and delay in documentation Of orders created a potential for delay in stabilizing treatment. I C. There was no medical decision-making I discussion regarding possible cardioversion to I treat the patient's SVT. d. The physician's plan was to transfer the patient to a hospital in Sioux Falls. Nursing notes indicated the physician had talked to the cardiologist in Sioux Falls but there was no I indication that arrangements were made for . transfer Of this patient to Sioux Falls. A change in the plans to transfer the patient to a hospital in Rapid City was noted at 9:00 PM. At 9:50 PM the tribal ambulance service indicated they were not able to take the patient by ground transportation. I Transport of this patient with possible new onset I CHF, new onset Atrial fibrillation and chest pain Should have been completed by quickest transport and with trained staff who would be able to handle a cardiac emergency (such as the FORM Previous Versions Obsolete Event ID14KXY11 Facility ID: 430084 If continuation Sheet Page 11 of 13 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE MEDICAID SERVICES PRINTED: FORM APPROVED OMB NO. 0938-0391 Life Flight crew). I e. At 10:00 PM the air ambulance transport was . notified and the patient was transferred to the receiving hospital's flight team at 11:10 PM. f. Although the physician indicated the patient was stable at time of transfer the patient experienced an episode of nausea and her BP dropped when she was moved from the bed to a cot. She required a bolus of IV fluid to raise the BP before transfer. g. Family interview revealed that the patient was admitted to the Rapid City hospital and required cardiac surgery. When the family member was asked about the Sioux Falls hospital, she that she was told that the hospital refused the transfer. The family member verified I with the Sioux Falls hospital that it had not . refused the transfer and was not even asked to . accept the transfer, but to provide consultation. 3. Review of patient #34's ED record indicated . this elderly patient arrived in the ED at 9:09 AM on 3/27/2015 after being found outside. Nursing i documentation indicated he was very cold to I touch, nonverbal, agitated, combative, and had decreased breath sounds. The ED nurse's note . indicated the patient had "pursed lip breathing?. I The patient's fingers were dusky/cyanotic (blue color) and his skin was mottled (discolored . areas). The patient had a "compromised mental status" and "smells of ETOH (alcohol)". I a. The ED provider did not conduct a MSE until . an hour after the patient arrived in the i ED. The treatment orders were not placed for STATEMENT OF DEFICIENCIEs (X1) PROVIDERISUPPLIERICLIA (x2) MULTIPLE CONSTRUCTION (st DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. BUILDING 430084 WING 1111912015 NAME OF OR SUPPLIER CITY, STATE. ZIP CODE 400 SOLDIER CREEK ROAD PHS INDIAN HOSPITAL AT ROSEBUD ROSEBUD, SD 57570 W) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION {st (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION TAG REGULATORY OR IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE I DEFICIENCY) A2407 Continued From page 11 A2407 FORM Previous Versions Obsolete Event Facility ID: 430034 If continuation sheet Page 12 of 13