Princeton Baptist Medical Center

“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: 46290 Based on review of Medical Record (MR), hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure: 1. An appropriate medical screening examination was performed. 2. Patient consent was obtained prior to transfer to another hospital. 3. MRs related to the EMC (Emergency Medical Condition) available at the time of transfer were sent to the receiving hospital. 4. Risk and benefits of transfer to the individual’s health or the health of the unborn child were explained to the patient prior to transfer to another hospital. 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 Medical Record (MR), hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure an appropriate medical screening examination was performed for one (1) of seven sampled pregnant medical records reviewed, Patient #1. Findings include: Hospital Policy: EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening and Treatment of Emergency Medical Conditions (EMC) Policy Number: BBH CLN.04.01 Reviewed Date: 7/29/2024 Purpose: To ensure individuals presenting to... Facility’s emergency departments receive an appropriate Medical Screening Examination (MSE)... Policy: ...An individual is deemed to have come to the Dedicated Emergency Department (ED) if the individual: 1. Presents at a Dedicated ED and requests examination or treatment for a medical condition... Procedure: A. The Facility will provide an appropriate MSE within its capability to an individual coming to the Dedicated ED, including ancillary services routinely available, to determine whether or not an Emergency Medical Condition exists. Hospital Policy: Triage, Registration, and Treatment Policy Number: BBH CLN.04.01.PR.01 Reviewed Date: 7/29/2024 I. Procedure: ...C. Medical Screening Examination 1. An MSE will be provide by Qualified Medical Personnel to any individual who comes to the Dedicated Emergency Department... 2. The MSE will be performed by a physician or other Qualified Medical Personnel. The examination should be specific to the patient’s complaint and presenting symptoms. 1. PI # 1 presented to the hospital ED on 4/20/24 at 11:25 PM with a chief complaint of labor pains. Review of the ED physician’s History of Present Illness (HPI) evaluation dated 4/20/25 at 11:39 PM revealed PI # 1 was 38 weeks pregnant with third pregnancy, denied any vaginal bleeding or discharge, and the patient’s water was not broken. The physical exam documented the patient’s abdomen was firm and the patient was experiencing abdominal contractions. The ultrasound revealed the baby’s head was high in the uterus with a breech presentation. Further review of the ED physicians HPI evaluation dated 4/20/25 at 11:39 PM revealed no documentation of a vaginal pelvic exam to assess cervical dilation, the fetal position, and fetal station. Review of the MR revealed no documentation fetal heart tones were assessed. The hospital failed to ensure a complete MSE was performed. An interview was conducted on 5/8/25 at 1:59 PM with Employee Identifier (EI) # 3, Systems Director and Interim ED Medical Director, who stated, “I did a quick look for vaginal discharge, I did not do a vaginal pelvic exam.” Cross Refer to A2409.”

“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: 46290 Based on review of Medical Record (MR), hospital policies and procedures, and staff interviews, it was determined the hospital failed to ensure: 1. Patient consent was obtained prior to transfer to another hospital. 2. MRs related to the EMC (Emergency Medical Condition) available at the time of transfer were sent the receiving hospital. 3. Risk and benefits of transfer to the individual’s health or the health of the unborn child were explained to the patient prior to transfer to another hospital. This deficient practice did affect three of ten patients who were transferred from the hospital, including Patient Identifier (PI) # 1, PI # 3, PI # 7 and had the potential to affect all patients presenting to the hospital Emergency Department (ED) who would require a transfer to another hospital. Findings include: Hospital Policy: Emergency Medical Treatment Labor Act of 1986 (EMTALA) Policy Number: BBH CLN.04.01 Reviewed Date: 7/29/24 Purpose: To ensure individuals presenting to... Facility’s emergency departments receive an ... appropriate transfer in accordance with EMTALA... Emergency Medical Condition: A condition manifesting itself by acute symptoms of sufficient severity... such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy... Procedure: ...B. ...the facility will provide an individual who is determined to have an Emergency Medical Condition further medical examination and treatment as is required to stabilize the Emergency Medical Condition, including... arrange an appropriate transfer of the individual to another medical facility... Hospital Policy: Refusal of Treatment and Transfer Policy Number: BBH CLN.04.01.PR.02 Reviewed Date: 7/9/2024 Procedure: ...B. Transfer of Individuals with an Emergency Medical Condition... A decision regarding transfer of a patient may be made by...physician certification. 3. Transfer Process ...c. Facility must send to the receiving facility copies of all pertinent medical records available at the time of transfer... 1. PI # 1 presented to the hospital ED on 4/20/24 at 11:25 PM with a chief complaint of labor pains. Review of the ED nurse notes dated 4/20/25 revealed the following: At 11:40 PM, PI # 1 was experiencing contractions six minutes apart with pain a 10 on a 1-10 pain scale. At 11:48 PM, PI # 1’s contractions were two to four minutes apart until the patient was transferred to another hospital, on 4/21/25 at 12:20 AM via ambulance. Review of the ED physician’s History of Present Illness (HPI) evaluation dated 4/20/25 at 11:39 PM revealed PI # 1 was 38 weeks pregnant with third pregnancy, denied any vaginal bleeding or discharge, and the patient’s water was not broken. The physical exam documented the patient’s abdomen was firm and the patient was experiencing abdominal contractions. The ultrasound revealed the baby’s head was high in the uterus with a breech presentation. The patient was transferred to the receiving hospital. Further review of the ED physicians HPI evaluation dated 4/20/25 at 11:39 PM revealed no documentation of a vaginal pelvic exam to assess cervical dilation, the fetal position, and fetal station. Review of the MR revealed no documentation fetal heart tones were assessed. Further review of the MR revealed no documentation the risk and benefits to the unborn child were explained to the patient, the patient consented to the transfer to another hospital, and the MR was sent to the receiving hospital. An interview was conducted on 5/8/25 at 2:55 PM with Employee Identifier (EI) # 1, Director Clinical Quality Improvement, who confirmed there was no documentation the risk and benefits to the unborn child were explained to the patient, the patient consented to the transfer to another hospital, and the MR was sent to the receiving hospital. 47295 2. PI # 3 presented to the ED hospital via medical flight on 3/13/2025 at 2:52 PM with a chief complaint of Aortic Dissection. Review the ED physician’s HPI dated 3/13/25 at 2:54 PM revealed PI # 3 arrived for a massive type of aortic dissection and was diagnosed with a Dissection Thoracic Aorta Unspecified Part. Review of the Cardiothoracic Surgery consult dated 3/13/25 at 3:43 PM revealed PI # 3 had a history of Malignant Hypertension, presented with subacute dissection with acute onset spinal cord ischemia, reported a sudden onset of chest pain with bilateral lower extremity numbness, left lower extremity paralysis, and right lower extremity weakness. The computed tomography (CT) scan revealed a Type A dissection with thickened flap. Review of the MR revealed PI # 3 was transferred to another hospital on 3/13/25 at 5:55 PM. MR review revealed no documentation of a physician certification containing the risks and benefits of the transfer to another hospital, no documentation a consent for the transfer was obtained from the patient/family, and no documentation the medical records were sent to the receiving hospital. An interview was conducted on 5/8/25 at 2:48 PM with EI # 1 who confirmed there was no documentation of a physician certification containing the risks and benefits of the transfer to another hospital, no documentation a consent for the transfer was obtained from the patient/family, and no documentation the medical records were sent to the receiving hospital. 3. PI # 7 arrived at the hospital ED on 4/16/2025 at 10:28 AM with a chief complaint of Abdominal and Back Pain. Review of the ED physician’s HPI dated 4/16/25 at 10:36 AM revealed PI # 7 presented with right lower quadrant pain that radiated to the rectum. Review of the CT scan dated 4/16/25 at 3:45 PM revealed concern for ruptured ectopic pregnancy with large hemoperitoneum and probable active extravasation. Review of the MR revealed PI # 7 was transferred to another hospital on 4/16/25 at 5:17 PM. MR review revealed no appropriate risks, such as persistent hemorrhage, and a consent for transfer was documented. An interview was conducted on 5/7/25 at 2:45 PM with EI # 2, ED Assistant Nurse Operations Manager, who confirmed there was no documentation a consent for transfer was obtained from the patient/family.”