White River 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: 37145 Based on policy and procedure review, medical record review and interview, the hospital failed to adhere to the provider’s agreement that required a hospital to be compliant with §42 CFR 489.24, Special responsibilities of Medicare hospitals in emergency cases. The hospital was not in compliance with the EMTALA Emergency Medical Treatment and Labor Act) requirements. See A2406 and A2409 for details.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) 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 (b) 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) 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 applicable declaration of a public health emergency, as provided for by 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: 37145 Based on clinical record review, policy review, observation, and interview, the facility failed to ensure one (#1) of one patient received an appropriate medical screening exam (MSE) before Patient # 1 was transferred, in active labor, to ensure or minimize the transfer risk to Patient # 1 and health of the unborn child. The failed practice affected Patient #1 and had the likelihood to affect all patients presenting to the Emergency Department (ED). Findings follow: A.Review of the Policy and Procedure titled “Patient transfers and Emergency Medical Treatment and Active Labor Act (EMTALA) policy with reviewed/revised date of 10/2018, showed the following: 1) “Emergency Medical Condition : Means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the patient (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.” 2) “ With respect to a pregnant woman who is having contractions: That there is inadequate time to affect a safe transfer to another hospital before delivery; or That transfer may pose a threat to the health or safety of the woman or the unborn child. 3) “ Labor: means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor.” 4) “MSE (medical screening exam) refers to the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical medical condition exists, or a woman is in labor.” 5) “ To stabilize or Stabilized: With respect to an Emergency Medical Condition, means to provide such medical treatment of the condition necessary to assure that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta.” 6) “ A MSE is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to the discharge or transfer.” 7) “ For a patient who has not been stabilized, a physician must have signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the patient or in case of a woman in labor, to the unborn child, from being transferred. The certification must contain a summary of the risks and benefits on which it is based. An express written certification is required. Physician certification cannot be implied from the findings in the patient medical record and the fact that the patient was transferred.”. B. Review of the (Named) Paramedic Ambulance Service report dated 12/02/2023, showed the following: “Dispatched at 10:44 AM on 12/02/23, to residence for female who thinks her water broke, responded emergent with lights and sirens. Upon arrival we entered home and found 19 YO (years old) sitting at kitchen table having labor pains. Patient stated she thinks her water broke and there was blood. Patient stated she is 34 weeks pregnant, is having intense labor pains every minute to 2 minutes. Has had prenatal care. Patient stated she feels the need to poop. Patient’s water is broke, and she has bleeding and fluids coming from vagina. vitals are 132/90, Pulse 123, respiratory rate 22. Birth is eminent and we transferred to (Named) transferring facility. Vital signs 134/89, 127 pulse, 22 respirations. Patient feels like she has to push and has pressure with extreme labor pains rating 10/10. Arrived at (named) transferring facility at 11:10 AM. We were asked to wait after Doctor saw patient. Doctor stated, ‘patient is dilated to 4 and 50 % (per cent) effaced. And is not having baby anytime soon.’ Patient is having labor pains every 45 seconds to one minute lasting 1 minute. Doctor stated, ‘while doing ultrasound baby is head down.’ After they put her on LR (Lactated Ringers and examined again patient was put back on our stretcher and we were told to transport to (named) receiving facility. Dispatch notified at 11:39 AM.” C. Review of the (Named) transferring hospital ED Physician history and physical report dated 12/02/23, showed, “History of present illness narrative time ssen by provider: 12/02/23at 11:46 am.19 y/o (year old) female presenting via EMS (Emergency Medical Services) with preterm labor. PT. (patient) started having contraction about 4:30 am, pt. had blood mucous show. Contaction about every 1-2 minutes. This is pt. first pregnancy. Timing: Intermittent and getting worse. Physical exam 12/02/23 at 11:14 am pulse rate 140 beats per minute. Pt. crying out with contractions. Contraction appear every 1-2 minutes and last less than 30 seconds. Pelvic exam with dilation at 4 cm (centimeters) , effacement 50 %.. ED progress: PT. in active labor preterm 34 weeks. Fast short contractions without change in dilation or effacement. Accepted by (named) Physician OB/GYN. Clinical Impression:: Preterm labor in third trimester without delivery.” D. Review of the QWHONN (The Association of Women’s Health, Obstetric and Neonatal Nurses) Maternal Fetal Triage Index (MFTI) showed, “ Maternal heart rate over 130, and imminent birth such as active maternal bearing down efforts was a stat (immediate) Priority 1 and suugests the patient needed emergent preparation for delivery.”Reference(https://acog.org/clinical/clinical-guidance /committee-opinion/articles/2016/07/hospital-based-triage-of-obstetric-patients)the accepting facility was 45 minutes away and transfer reqired placing the patient with a lower level of care (EMS) instead of the hospital Physician. . E. Review of the (Named) Paramedic Ambulance Service report dated 12/02/23, showed the following: “We lowered stretcher by patient’s bed and moved her over via draw sheet to stretcher, we secured patient to stretcher with straps x 5. Patient continues to have labor pains every 1 minute or less, we loaded stretcher into place. Vitals 123/82, 147 pulse, 18 respiratory rate. I checked patient and no head is showing but labor (pain) is every 30 to 45 seconds and lasting 1 to 2 minutes. We transported Patient Emergent with lights and sirens. Patient’s labor became more intense, and patient stated she could feel the baby’s head coming out. I checked and baby is crowning. I got OB (obstetric) kit out and got ready for delivery at approximately 12:15 PM. I had partner pull over due to patient is in eminent delivery. My partner got in the back with me, and baby is breech, coming out butt first and then legs. Baby’s shoulders were stuck, and I helped get left shoulder out then right shoulder, baby’s head is stuck, and Mom stopped pushing. I had Mom keep pushing and my partner put 2 fingers in lifting babies face while I reached in and looped cord from babies’ neck and I helped get babies head out. This took a few minutes with encouraging Mom to push while I hooked my hands around baby’s head and got him out. Baby delivered at 12:17 PM.” F. Review of the (Named) Paramedic Ambulance Service report dated 12/02/23, showed “Baby is not breathing and limp with Apgar score of 1. Baby had a faint pulse and not breathing and apneic. I suctioned and began giving baby chest compressions for approximately 15 to 20 seconds. Baby started breathing slightly, I continued to rub and stimulate baby and put him on blow by O2 (oxygen) and he started whimpering and HR (heart rate) came up. I suctioned baby’s nose and mouth again. Baby pink in color except for feet, hands, and buttocks. After baby began crying, I laid baby on Mom’s chest and covered him to keep him warm while my partner got a heat pack and wrapped in towel to lay baby on for heat, baby is skin to skin contact on mother, I then clamped cord above and below the area I cut. We began transport to (named) receiving facility and baby’s vitals are HR 150, baby’s SPO2 (oxygen saturation now 97 % (percent) on blow by O2 and HR 172, APGAR is 9.” G. Review of the (Named) Paramedic Ambulance Service report dated 12/02/23, showed, “Mom has delivered placenta that is on stretcher, is alert and oriented, bleeding is minimal and controlled. Vitals are 124/86, 99 pulse rate, and 20 respiratory rate. Pain is 4/10. I massaged uterus and she is only bleeding slightly.Report called to OB. At destination at 12:50 PM.” H The findings A through E were confirmed with the ED Director.”

“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: 37145 Based on review of policy and procedure, clinical records and interview, the facility failed to conduct an appropriate transfer for one (#1) of one patients transferred from the emergency department to other facilities emergency department. The facility failed to ensure a complete “Patient Transfer Summary Form” which identified the risks and benefits of the transfer to the patient/patient’s representative, and unborn child, and the notification and acceptance of the receiving facility. The failed practice did not ensure the patient/patient’s representative was informed of the risks and benefits of the transfer to herself and unborn child. The findings follow: A.Review of the Policy and Procedure titled “Patient transfers and Emergency Medical Treatment and Active Labor Act (EMTALA) policy with reviewed/revised date of 10/2018, showed the following: 1) “Emergency Medical Condition : Means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the patient (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.” 2) “ With respect to a pregnant woman who is having contractions: That there is inadequate time to affect a safe transfer to another hospital before delivery; or That transfer may pose a threat to the health or safety of the woman or the unborn child. 3) “ Labor: means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician certifies that, after a reasonable time of observation, the woman is in false labor.” 4) “MSE (medical screening exam) refers to the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical medical condition exists, or a woman is in labor.” 5) “ To stabilize or Stabilized: With respect to an Emergency Medical Condition, means to provide such medical treatment of the condition necessary to assure that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the patient from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta.” 6) “ A MSE is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation documented in the medical record prior to the discharge or transfer.” 7) “ For a patient who has not been stabilized, a physician must have signed a certification that, based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the patient or in case of a woman in labor, to the unborn child, from being transferred. The certification must contain a summary of the risks and benefits on which it is based. An express written certification is required. Physician certification cannot be implied from the findings in the patient medical record and the fact that the patient was transferred.” B. Review of Patient #1’s clinical record showed the following: 1) Patient #1 was admitted to the Medical Complex emergency room via ambulance in preterm labor having intense labor pains every minute or two. Patient #1 required obstetrical service. 2) Medical Complex satellite communication note dated 12/02/23 showed,” status discharged OB (obstetrics) at (Named Receiving Facility) contacted to let them know PT (patient) is in route via ambulance, did not receive 2 G (grams) Ampicillin d/t (due to) not having the correct concentration and did not receive Betamethasone IM (intramuscularly) d/t not having it here at this facility.” 3) Review of (Named Transferring Facility) records showed there was no evidence of a completed Patient Transfer Summary Form.”