Statement of Deficiencies

Statement of Deficiencies	(X1) Provider/Supplier/CLIA Identification Number 531312	(X3) Date Survey Completed 03/20/2025
Name of Provider or Supplier Cody Regional Health	Street Address, City, State 707 Sheridan Avenue, Cody, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.

(X4) ID Prefix Tag	Summary Statement of Deficiencies (Each deficiency should be preceded by full regulatory or LSC identifying information)
C0000	A complaint health survey for compliance with Emergency Medical Treatment and Labor Act (EMTALA) 42 CFR Part 489.20 Basic Section Commitments Relevant to Section 1867 Responsibilities and 42 CFR Part 489.24 Special Responsibilities of Medicare Hospitals in Emergency Cases, was conducted from 3/18/25 through 3/20/25. The survey was prompted by complaint intakes WY0004270 and WY00004301. Based upon the findings of the survey team, Cody Regional Health was found not in compliance with the requirements for C-2400, C-2406 and C-2409.
C2400	COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This STANDARD is not met as evidenced by: Based on medical record review, staff interview, video review, and review of facility policies and procedures, the facility failed to ensure 2 of 20 sample patients (#6, #10) received a medical screening examination. In addition, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#2) reviewed who had an emergency medical condition and was transferred to another facility. The findings were: Refer to C-2406 for details on the facility's failure to ensure patients #6 and #10 received adequate medical screening examinations. Refer to C-2409 for details on the facility's failure to ensure patient #2 was not transferred to another facility without the patient's written request or a certification signed by the physician stating the benefits outweighed the risks.
C2406	MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) "comes to the emergency department", as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital's emergency 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 (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital's obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer 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 if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual's source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) 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 applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital's dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of 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 have an emergency medical condition. This STANDARD is not met as evidenced by: Based on medical record review, staff and family interview, video review, and review of policies and procedures, the facility failed to ensure an appropriate medical screening examination (MSE) was completed for 2 of 20 sample patients (#6, #10) who presented to the emergency department (ED). The findings were: 1. Review of the 2/4/25 ED medical record showed patient #10 had a complaint of dehydration. After evaluation in the ED, the clinical impression was acute cystitis without hematuria and dehydration. The patient was given a prescription for Bactrim (antibiotic). A note in the chart dated 2/6/25 showed the urine culture results showed Escherichia coli (E. coli, rod shaped bacterium) and a message was left with the patient stating the Bactrim would be stopped and Cipro would be prescribed. Further review showed on 2/8/25 patient #10 returned to the ED via ambulance after recurrent falls at home, including down 6 stairs. The MSE consisted of a physical exam, laboratory, x-rays of the chest, shoulder and elbow, and CT scans of the head, chest, abdomen, pelvis and cervical spine. The following concerns were identified: a. The MSE did not include an EKG (electrocardiogram) to check for arrhythmia or ischemic changes to rule out syncope as a cause of the fall. In addition, a urinalysis was not completed to check for continued presence and/or progression of the previously diagnosed UTI, which can cause altered mentation, delirium or weakness. There was an order for a urinalysis but it showed "user autodiscontinue" due to patient discharge. b. Review of the results of the CT (computed tomography) scan of the chest, abdomen and pelvis showed " ...presumed laminectomy changes at the L3 level, with a minimally complex fluid collection in the posterior soft tissues measuring up to 9.8 cm, which extends from the spinal canal at the L3-L4 level to the overlying subcutaneous and cutaneous tissues. This may represent a postoperative fluid collection such as a seroma or hematoma versus pseudomeningocele." There lacked evidence of further evaluation of the lumbar spinal abnormalities. The physical examination did not include a focused examination of the lower back. c. Interview with a family member on 3/18/25 at 1:12 PM revealed the patient went to the ER [on 2/4/25] and was prescribed Bactrim. A couple of days later [2/8/25] s/he was back in the ED after the patient fell at home. Another family member took the patient out of state and s/he went to another hospital on 2/12/25 where s/he was diagnosed with urosepsis. d. On 3/19/25 at 3:55 PM the ED Director was asked about the lack of the urinalysis for the 2/8/25 visit. She stated the order was auto-discontinued. She stated per lab, it will auto-discontinue if it wasn't collected prior to discharge. e. The physician no longer worked in the facility and was unable to be interviewed during the survey. 2. Review of the ED log showed patient #6 arrived to the ED on 2/17/25 at 2:46 PM for "Eval per CPD [police]." The following concerns were identified: a. Review of the ED record showed only "Patient was unsure why [s/he] was here, LWBS [left without being seen] while waiting to be seen." There was no evidence the patient was provided a medical screening examination to determine whether or not the patient had an emergency medical condition, and there was no documented informed refusal of examination or treatment in the medical record. b. During a phone interview on 3/18/25 at 7:40 PM police officer #1 stated he took patient #6 to the ER on 2/17/25. He stated because s/he agreed to go voluntarily, he dropped him/her off at the ER. He stated that s/he apparently left the ED and so he went out to track the patient down. He stated staff at the ER stated they wouldn't be able to take the patient again because they had other Title 25s already (patients on psychiatric hold). He stated he tracked the patient down and put him/her on a Title 25 hold. He stated he then took the patient to the ER around 4:30 PM and sat in the drive-through entrance with him/her in the police car. He stated his Sergeant spoke to "the higher ups" at the facility and was told they couldn't take the patient. He stated his Sergeant gave him a piece of paper and he drove the patient to another hospital. c. During an interview on 3/19/25 at 8:48 AM the medical director (and physician in the ER on 2/17/25) stated the hospital would go on diversionary status if there was no capacity to safely hold psychiatric patients. He stated on that particular day (2/17/25), there was already two psychiatric patients in the ED and another one upstairs; so total of 3 psychiatric patients. He called senior leadership and they went on diversionary status for psych. He stated he did not personally speak to the police regarding patient #6. He was told there was a psychiatric patient they wanted to bring. He was asked to sign a document, and so he signed it. d. On 3/19/25 at 11:58 AM registration clerk #1 stated patient #6 was in earlier that day, but left before being seen. She stated the police officer stated they were going to be bringing him/her back, but the facility was on diversionary status. She stated she went in the back of the ER and told staff. She further stated she did not talk to the police or give them any papers. e. During an interview on 3/19/24 at 1:33 PM the Chief Clinical Officer stated diversionary status was called by senior leadership. He stated psychiatric diversion could be called if the facility already had multiple psychiatric patients. However, he stated if a patient presented to the ED, they would have an obligation to do a MSE. He stated if the police called ahead, they might tell them they were on divert status and to take to another hospital. However, if the police showed up with the patient on hospital property, the patient would be seen. On 2/17/25 he received a call from the ED regarding already having 3 psychiatric patients in house. He called the house supervisor and stated they would be on psychiatric divert status. f. On 3/19/25 at 3:39 PM registered nurse (RN) #1 stated she worked the ED on 2/17/25. She said patient #6 was in earlier and LWBS. She stated a police officer said the police were out looking for the patient and would be bringing them back. She told him they were about to go on psychiatric divert. She stated the police officer told her they needed something in writing, so she had the physician sign something. She stated she was not aware the patient was in the police car at the facility. g. During a phone interview on 3/19/25 at 4:21 PM police sergeant #1 stated that police officer #1 told him the ED stated they wouldn't take back the patient. He stated he personally went to the ED and talked to staff to make sure he understood that they wouldn't take the patient. He was told they were on divert status. He stated he would need something in writing. He stated he told the hospital that another officer was getting her and she was on her way. He stated the patient was in the cop car outside the entrance, but he told the officer not to bring him/her in yet. He stated the officer ended up taking the patient to another hospital. h. Review of video provided by the facility showed on 2/17/25 at 4:31 PM a police officer went into the ED and went up to the registration desk. At 4:34 PM a police car arrived at the drive-thru entrance of the ED and parked. That officer got out and walked towards the entrance of the facility (neither officer is on video at that time). The officer then went back to the police car and sat in the driver's seat. At 4:38 PM the officer inside the ED is seen talking to a staff member in scrubs. At 4:43 PM the staff in blue scrubs handed the police officer a piece of paper. That officer walked out and handed the paper to the police officer in the car. At 4:46 PM another police car arrives and the officer got out. The officer from the first police car is seen standing and talking to the other officer. Then the officer opens up the rear door to the first police car (the one that has been parked in the drive-thru entrance since 4:34 PM) and an individual (patient #6) gets out and stands up. The individual then is sat back down in the back of the police car and the police car drove off at 4:49 PM. i. Review of the "Law Enforcement or Examiner-Title 25" form showed patient #6 was placed on a hold on 2/17/25 at 5:31 PM due to texting suicidal statements. j. Review of the documentation provided to the police by the facility on 2/17/25 showed "CRH [Cody Regional Health] is on housewide psych divert per [name of Chief Clinical Officer]. We cannot except [sic] a title 25 at this time or psych patient." k. Review of the ER report from the other hospital (dated 2/17/25 and timed 7:15 PM) showed the patient presented to the ER with police due to suicidal ideation. Further review showed the patient received a medical screening examination, including a mental health assessment. The patient was discharged home. l. There lacked evidence the facility provided a medical screening examination to patient #6 despite law enforcement making a request on behalf of the patient. 3. Review of the facility's policy "EMTALA," undated, showed the facility shall " ...Provide an appropriate Medical Screening Examination (MSE) to any individual who comes to the emergency department." The policy defined MSE as " ...The screening process required to determine, with reasonable clinical confidence, whether an emergency condition does or does not exist." The policy defined "Comes to the emergency department" as " ...The patient is outside the dedicated ED but on hospital property within 250 yards of the main building and requests a medical evaluation or if unable to make this request a layperson observer would conclude that the person needs an emergency examination ..." 4. Review of the facility's policy "Trauma: Diversionary Status," undated, showed " ...Divert status applies only to those patients to be transferred to Cody Regional Health from another facility. Patients who would normally be brought directly to Cody Regional Health will be stabilized in the Emergency Department and transferred as needed in accordance with EMTALA."
C2409	APPROPRIATE TRANSFER CFR(s): 489.24(e)(1-2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital's files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This STANDARD is not met as evidenced by: Based on medical record review, staff interview, and review of facility policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#2) reviewed who had an emergency medical condition and was transferred to another facility. The findings were: 1. Review of the emergency room (ER) record showed patient #2 arrived on 2/27/25 at 10:37 PM. Review of physician notes showed the chief complaint was suicide attempt. The patient reported s/he had a gun to his/her temple, but was trembling prior to pulling the trigger and so the gun moved, missing him/her. The physician documented "Patient has been evaluated by [behavioral health agency]. I discussed the case with the evaluator. They agree with the plan to uphold the title [psychiatric hold] and seek placement for the patient." The physician later documented "...there is a bed available at [psychiatric facility] for [his/her] acute care and treatment. [S/he] agrees with the plan for transfer to that facility." Review of nursing progress notes showed on 2/28/25 at 6:03 PM the patient was transferred to a psychiatric facility via ambulance. The following concerns were identified: a. Further review of the ER record showed no evidence the patient requested the transfer in writing. Further, there was no certification by the physician stating the benefits outweighed the risks. In addition, there lacked documentation of the name of the person at the receiving facility who agreed to accept the transfer. b. During an interview on 3/19/25 at 11:48 AM the director of the ER and the director of quality confirmed there was no physician certification for the transfer of patient #2. They stated they didn't do a transfer certification if the patient was on a psychiatric hold (Title 25). They also confirmed the medical record of patient #2 lacked the name of the person at the psychiatric facility who agreed to accept the transfer. c. On 3/19/25 at 12:08 PM physician #1 (who arranged for the transfer for patient #2) stated the physician certification for transfers usually wasn't done for patients on Title 25 [involuntary hold]. 2. During an interview on 3/19/25 at 8:48 AM the medical director for the ER stated the physician certification for transfers should be completed, including for patients with psychiatric conditions who were on Title 25 [involuntary hold]. 3. Review of the facility's policy "EMTALA" (undated) showed "...An individual whose condition is unstable may be transferred for only one of two reasons: 1) The transfer is medically indicated. 2) The individual, or a responsible person acting on the individual's behalf, requests the transfer in writing and indicate the reasons for the request as well as indicate that he/she is aware of the risks and benefits of the transfer...Unstable patients may be transferred, and it is indicated, when CRH lacks the capability and resources, including physician expertise, necessary to stabilize or treat a patient's EMC [emergency medical condition]...When there is a medically indicated transfer or an unstable patient, the ED or WH&N [women's health and nursery] physician shall: 1) certify that the benefits to the patient from the transfer outweigh the risks of transfer. 2) Obtain the patient's informed consent 3) Arrange an appropriate transfer...The certification must be done in writing and must include the medical risks and benefits to the patient."