Thomas Hospital

“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: 42144 Based on review of hospital Rules and Regulations, EMTALA (Emergency Medical Treatment and Labor Act) policy, medical records and interviews, it was determined Thomas Hospital failed to: 1. Provide an appropriate medical screening examination. 2. Provide an appropriate transfer that included a countersignature by the physician within the established timeframe. 3. Send to the receiving facility, all medical records related to the emergency condition which the patient has presented. Cross Refer to A 2406 and A 2409 for findings.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 46290 Based on review of the hospital rules and regulations and medical record (MR) review it was determined the hospital failed to provide an appropriate medical screening examination (MSE). This deficient practice affected one of one patient that required a consultation including Patient Identifier (PI) # 8, and had the potential to affect all patients who require consultations served by the hospital Emergency Department (ED). Findings include: Thomas Hospital Rules and Regulation Date Review: 10/22/24 Article 1, General Rules and Regulations 1.A.3 Admissions ...(d) Medical Screening Exams (1) Medical screening examinations, within the capability of the hospital, will be performed on all individuals who come to the hospital requesting examination or treatment to determine the presence of an emergency medical condition...Qualified medical personnel... are defined as: ... members of the Medical Staff with clinical privileges in Emergency medicine, Other Staff members... Article 2, Medical Records Content and Access ...2.A.2 Reports (a) The following reports or examinations performed on a patient...shall be incorporated into their medical records. 1. Consultations: Each consultant who may have occasion to examine a patient shall write his findings and recommendations on the progress notes... Consultations shall show evidence of a review of the patient’s record by the consultation, pertinent findings on the examination of the patient, the consultant opinion and recommendations. This record shall be part of the medical record. Article 3, Conduct of Care 3.A.1 Consultations (a) Any physician with clinical privileges in this Hospital can be called for consultation within his/her area of expertise.... (b) The attending physician is primarily responsible for requesting consultation when indicated and for calling in a qualified consultant. 1. Patient Identifier (PI) # 8 presented to the hospital ED on 8/19/24 at 4:28 PM with progressive auditory and visual hallucinations, paranoia, and delusions. Review of the ED provider note dated 8/19/24 at 4:28 PM revealed documentation the patient had poor concentration, delayed verbal responses, was anxious, displayed signs of paranoia and delusions, including beliefs that people were putting date-rape drugs directly into his/her bloodstream. The patient was brought in for evaluation of increasingly abnormal behavior including auditory and visual hallucinations over the course of the previous several months. The patient denied illicit drug use or alcohol use. The patient had no signs of trauma. Review of the Computed Tomography (CT) dated 8/19/24 at 7:41 PM revealed no evidence of acute intracranial finding. If clinically indicated, consider further evaluation with an MRI examination. There was no documentation of an MRI to assess the pituitary gland. Review of the nursing flowsheet dated 8/19/24 at 8:35 PM revealed PI # 8’s neurological status as alert, awake, confused, unable to follow commands, short term memory loss, and delayed speech. Review of the case manager progress note dated 8/20/24 at 5:25 PM revealed PI # 8’s spouse verbalized the patient had not received treatment for the Pituitary Adenoma but Magnetic Resonance Imaging (MRI) was conducted to ensure there were no changes in the tumor within the past one and half years. Review of the MR revealed no documentation a Neurosurgical and/or Endocrinology consult was provided. An appropriate MSE was not provided due to no documentation an MRI was performed and a Neurosurgical and/or Endocrinology consultation was provided for the patient with a known or suspected pituitary tumor experiencing progressive alteration in mentation.”

“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: 42144 Based on review of Policy and Procedure, General Rules and Regulations, medical record (MR) reviews and interview, it was determined Thomas Hospital failed to: 1. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another facility outweighed the risks of being transferred. 2. Send to the receiving facility, all medical records related to the emergency condition which the patient has presented. This deficient practice affected patient identifier (PI) # 6 and PI # 8, two of five transfer MR’s reviewed, and had the potential to affect all patients transferring from this hospital. Findings include: Hospital Policy: Transfer of Patients: EMTALA (Emergency Medical Treatment and Labor Act) Approval Date: 9/29/2022 Policy: 3. The physician at Thomas Hospital has determined that the patient is medically stable for transfer or has certified that the benefits of transfer outweigh the risks. Procedure: 4. The physician will complete and sign the Physician’s Summary of Risks and Benefits form...prior to transfer. 8. A copy of all available medical records, test results, and a copy of the completed transfer form should be sent with the patient on transfer. Copies of records not available at the time of transfer shall be sent to the receiving facility as soon as practical.... General Rules and Regulations Article 1 Date: None Provided 1.A.2. Advanced Practice Professionals... (b) Advanced Practice professionals may discharge a patient if the discharge/transfer criteria are met. (e) Regardless of the note type, notes by an Advanced Practice Practitioner must be countersigned within 24 hours. 1. PI # 6 presented to the emergency department (ED) on 9/4/24 at 12:01 PM with a chief complaint of suicidal. Review of the MR revealed the Patient Transfer Form contained a signed certification from the PA-C (Physician Assistant - Certified), that the medical benefit from transfer outweigh the risks of transfer, but no countersignature by the physician within the hospital’s established timeframe of 24 hours. Further review of the MR revealed no documentation the medical record was sent to the receiving facility on transfer. An interview conducted on 12/5/24 at 1:30 PM with EI (Employee Identifier) # 8, Director of Critical Care Services, confirmed the physician did not countersign the certification and there was no documentation the medical record was sent to the receiving facility on transfer. 2. PI # 8 presented to the ED on 8/19/24 at 4:28 PM with a chief complaint of psychiatric evaluation and adrenal adenoma. Review of the MR revealed the Patient Transfer Form contained a signed certification from the PA-C that the medical benefit from transfer outweigh the risks of transfer, but no countersignature by the physician within the hospital’s established timeframe of 24 hours. Further review of the MR revealed no documentation the medical record was sent to the receiving facility on transfer. An interview conducted on 12/5/24 at 1:30 PM with EI # 8, confirmed the physician did not countersign the certification and there was no documentation the medical record was sent to the receiving facility on transfer.”