University of Arkansas Medical Sciences

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 50014 Based on review of policy and procedures, clinical record and interviews it was determined that the facility failed to ensure the notice of rights requirements were met. By not allowing the patient to give consent for treatment, the veracity of patient information, give consent to bill insurance, give consent to photography and give consent to release of information, had the likelihood of affecting all patients receiving treatment in the hospital. Findings follow: A. Review of UAMS Medical Center Policies and Procedures Number: HA.01.016 Policy Title: Admission Forms/Consent review/revised: September 2022, showed “Purpose: I. To ensure all patients admitted to the UAMS Medical Center receive copies of required forms. Ensure that signatures are obtained on all appropriate documents ... Policy: I. The policy of UAMS Medical Center is to ensure that: A. All employees within the Hospital Admissions and procedure areas are expected to have patients or designee sign all documents at time of registration. .... Definitions: I. Admission and Outpatient consent: A. Gives consent for treatment. B. States information the patient is giving is true. Describes UAMS liability as it relates to valuables. D. Gives consent to bill insurance. ....F. Consents to photographs and recordings. G. Discusses release of information (privacy practice). ...I. Should the patient leave the unit, UAMS is not liable for any harm.” B. Review of Patient #1’s clinical record on 02/26/26 at 9:30 AM, showed there was no evidence of an admission form packet with a signature. C. In an interview with the UAMS Director of Accreditation and Regulatory Compliance on 02/26/26 at 9:45 AM, he stated, “There were not any admission forms completed by the patient.” He confirmed A-C at the time of the interview.”

“FORM AND RETENTION OF RECORDS CFR(s): 482.24(b) The hospital must maintain a medical record for each inpatient and outpatient. Medical records must be accurately written, promptly completed, properly filed and retained, and accessible. The hospital must use a system of author identification and record maintenance that ensures the integrity of the authentication and protects the security of all record entries. This Standard is not met as evidenced by: 50014 Based on policy review, record review, and interview, it was determined the facility failed to ensure a signed consent for treatment was obtained and documented in the medical record for 1 of 1 patient (Patient #1). The failed practice has the likelihood of affecting all patients receiving care in the facility by placing patients at risk of receiving procedures or treatments without documented informed consent and limiting the patient’s ability to participate in decisions regarding care. A. Review of policy titled “Authorization Consent Signature: updated February 2023, showed the following: 1. “Authorization and Consent signature must be obtained upon hospital admission, unless patients’ condition does not permit. Access Staff member must make every attempt to get consent signed. Authorized individuals or nearest relatives (i.e. spouse, parents, legal guardian, children at legal age, etc.) may sign the consent form for patients that are unable to sign due to medical condition.” B. Review of polity titled “Admission Forms/Concents” updated September 2022, showed the following: 1.”Purpose: To ensure all patients admitted to the UAMS Medical Center receive copies of required forms. Ensure that signatures are obtained on all appropriate documents.” 2. “Admission and Outpatient consent: A. Gives consent for treatment B. States information the patient is giving is true ...D. Gives consent to bill insurance E. States health information exchange process may be used (unless patient opts out) 2 F. Consents to photographs and recordings G. Discusses release of information (privacy practice).” C. Record review of Patient #1’s clinical record showed no evidence of signed admission forms. D. During interview on 02/26 /2026 at 12:30 PM, the Director of Accreditation and Regulatory Compliance confirmed the findings in C.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 44854 Based on policy and procedure review, medical record review, and interview, it was determined the facility failed to accept an appropriate transfer for one of one (#1) patient requiring specialized Gastroenterology (GI) services not offered by the transferring facility. By not accepting Patient #1 the facility delayed the specialized treatment needed for Patient #1. The failed practice had the likelihood to affect any patient needing the specialized services provided by the facility. Findings follow: A. Review of Policy and Procedures of the University of Arkansas for Medical Sciences (UAMS), “EMTALA Compliance,” dated 03/24, showed the following: 1) UAMS shall accept the transfer of patients covered by EMTALA for other facilities when the individual being transferred requires specialized capabilities that are not offered or not available at the transferring facility, if UAMS has the current capacity and capability to provide necessary treatment to the patient in accordance with its normal accommodation processes. 2) UAMS will defer to the transferring physician’s judgement with respect to the need for transfer when the transferring physician identifies Emergency Medical Condition (EMC) that the transferring hospital does not have the capacity or capability to stabilize. B. During an interview on 04/29/25 at 1:30 PM, ARC Program Manager confirmed the findings in A. C. Review of Patient #1’s Clinical record from the transferring facility CHI St. Vincent Hospital Hot Springs ED (Emergency Department) showed the following: 1) Admission was from 03/23/25 at 7:14 PM to 03/23/25 at 11:38 PM. 2) Provider Note dated 03/24/25 at 10:09 PM, by Physician #1 showed “63 y/o (year old) F (Female) here for evaluation of GI (Gastrointestinal) bleeding left lower quadrant abdominal pain, shortness of breath, and chest pain. Patient woke up last night around 130 (1:30 AM) and had bright red rectal bleeding. She states this happened 2 more times. She developed lower quadrant abdominal pain and states that she had diverticulitis in the past with similar symptoms. She also noticed that she was having some mild chest pain and shortness of breath which is atypical for her. She is on Xareltoper her report. On arrival she is satting(oxygen saturation) 88% on room air and does not wear oxygen at baseline. Patient has a past medical history (PMH) of Anemia, Blood disorder, CAD(coronary artery disease), Cancer (CMS/HCC), Depression, , Diverticulitis, GERD (gastroesophageal reflux disease), Headache, HTN (hypertension), Hyperlipidemia, IBS (irritable bowel syndrome).” 3) Review of Laboratory results dated 03/23/25 at 7:40 PM showed the following: Hematocrit 28.2% (reference range 36%-48%), Hemoglobin POC (Point of Care): 8.2 g/dl (grams per deciliter). 4) Review of ED Medical Decision Making and Plan of Care dated 03/23/25 showed “63-year-old female here for evaluation of left lower quadrant abdominal pain rectal bleeding. Differential diagnose includes diverticular bleed, lower GI bleed of other cause, among other causes. Patient is hypoxic 88% on arrival and this is a new finding for her. She was started on 2 L nasal cannula. She is left lower quadrant abdominal pain on exam. Protonix given as well as a small dose of Ativan as she was very hesitant to go to the CT scanner. Labs show that her hemoglobin has gone down to 8 from a baseline of around 10, her CMP is unremarkable, her BNP is 348, her troponin is minimally elevated at 42. CT abdomen/pelvis was completed with unremarkable firndings and CTA chest revealed possible pulmonay edema and pulmonary hypertension.. We do not have GI coverage at this facility at this time. I discussed with (Named Physician #5) with internal medicine who does not feel comfortable keeping the patient given that we do not have GI coverage. I discussed this with UAMS Medical Center by phone and discussed it with Physician #2 with gastroenterology. He indicates it is very unlikely that she would receive intervention overnight by gastroenterology but he was okay excepting [sic] the patient through internal medicine. The transfer center operator (Named) then discussed this with internal medicine who then refused the patient because they felt that the patient would not likely get GI intervention overnight. I confirmed with the transfer coordinator that they did currently have capacity and capability to take care of this patient but were refusing to transfer. Patient was subsequently transferred to North Little Rock Baptist after discussion with her transfer center.” D. Review of UAMS Medical Center Patient #1 Medical Record dated 03/23/25 from 9:18 PM to 9:54 PM showed the following phone call communication with CHI St Vincent Hospital Hot Springs: Entered by RN (Registered Nurse)#1 03/23 at 2118(9:18PM) Ownership Claimed by RN #1. 03/23 at 2118(9:18PM) Request type set to Hospital Transfer - ED to Inpatient 03/23 at 2121(9:21PM) Call from CHI St Vincent Hospital Hot Springs Physician #1 calling for ED-IP (Inpatient) transfer of 63/f( 63 year old female) 03/23 at 2131(9:31 PM) Call to UAMS Medical Center Physician #2 03/23 at 2132(9:32 PM) Transfer type set to ED to Inpatient 03/23 at 2137(9:37 PM) Call UAMS Medical Center Physician #2 03/23 at 2143(9:43 PM) Call to UAMS Medical Center Physician #3 After Informing him of pt’s presentation, hx and plan from GI, Physician #3 does not wish to accept this pt at this time. If the pt begins to bleed or has a significant change in status, he wishes for OSH to call back and we can involve GI and/or IR. 03/23 at 2150(9:50 PM) Call to CHI St Vincent Hospital Hot Springs Physician #1, RN#1 called to notify of UAMS Medical Center Physician #3 decision. Will call back if pt has any change in status 3/23 at 2154(9:54 PM) Request Canceled Reason: Transport Denied due to Medical Necessity” E. Review of Patient #1’s Clinical record from the receiving facility Baptist Health Medical Center North Little Rock ED (Emergency Department) showed the following: 1) Review of Admissions demographics showed Patient #1 was admitted to the ED on 03/24/25 at 12:57 AM and admitted to Inpatient on 03/24/25 2) Review of Laboratory results showed the following: a) On 3/24/2025 at 01:55 (1:55 AM) Status: Hematocrit 27.1% (reference range 36%-48%) (a decrease of 1.1% from 03/23/25 at 7:40 PM), Hemoglobin POC: 7.4 g/dl (a decrease of 0.8 g/dl since 03/23/25 at 7:40 PM). b) Repeat Hemoglobin post 1 unit PRBC (Packed Red Blood Cells) given on 03/24/25 at 8:31 AM was 8.2 g/dl. c) On 03/24/25 at 2:25 PM, the Hemoglobin was 8.3 g/dl.”