Arkansas Children’s 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: 51070 Based on review of policy, clinical record review, and interview it was determined the facility delayed care after accepting an out-of-state critical pediactric patient, in that it agreed to utilize hospital owned and operated medical transport services only after insurance had been verified. The failed practice had the likelihood of delaying care for all out-of-state pedicatric patients requesting use of hospital owned and operated medical transport. See tag A-2408”

“DELAY IN EXAMINATION OR TREATMENT CFR(s): 489.24(d)(4-5) (4) Delay in treatment. (i) A participating hospital may not delay providing an appropriate medical screening examination required under paragraph (a) of this section or further medical examination and treatment required under paragraph (d)(1) of this section in order to inquire about the individual’s method of payment or insurance status. (ii)A participating hospital may not seek, or direct an individual to seek, authorization from the individual’s insurance company for screening or stabilization services to be furnished by a hospital, physician, or nonphysician practitioner to an individual until after the hospital has provided the appropriate medical screening examination required under paragraph (a) of this section, and initiated any further medical examination and treatment that may be required to stabilize the emergency medical condition under paragraph (d)(1) of this section. (iii) An emergency physician or nonphysician practitioner is not precluded from contacting the individual’s physician at any time to seek advice regarding the individual’s medical history and needs that may be relevant to the medical treatment and screening of the patient, as long as this consultation does not inappropriately delay services required under paragraph (a) or paragraphs (d)(1) and (d)(2) of this section. Hospitals may follow reasonable registration processes for individuals for whom examination or treatment is required by this section, including asking whether an individual is insured and, if so, what that insurance is, as long as that inquiry does not delay screening or treatment. Reasonable registration processes may not unduly discourage individuals from remaining for further evaluation. A hospital meets the requirements of paragraph (d)(1)(ii) of this section with respect to an individual if the hospital offers to transfer the individual to another medical facility in accordance with paragraph (e) of this section and informs the individual (or a person acting on his or her behalf) of the risks and benefits to the individual of the transfer, but the individual (or a person acting on the individual’s behalf) does not consent to the transfer. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of a person acting on his or her behalf). The written document must indicate the person has been informed of the risks and benefits of the transfer and state the reasons for the individual’s refusal. The medical record must contain a description of the proposed transfer that was refused by or on behalf of the individual. This Standard is not met as evidenced by: 51070 Based on review of policy, clinical record review, and interview, it was determined the facility delayed care in that it required insurance authorization for its owned and operated, medical flight transport services which it agreed to provide upon request from an out-of-state facility, for transfer of a pediatric patient presenting with a life threatening emergency medical condition.. The failed practice created a delay that potentially led to negative outcomes for the patient. The failed practice had the likelihood of affecting all out-of-state pediatric patients for which medical flight services are requested by the sending hospital. A. Review of policy “Acceptance of Out-of-State Patients”, dated 07/10/24, showed that “Arkansas Childrens Hospital (ACH) must accept Out-of-State patients when EMTALA applies, and that ACH hospital has the capability and capacity to accept the patient”. The policy further showed that out-of-state patients should be financially cleared through request for clearance from Vice President of Revenue Cycle and/or ACH Director of Admissions. B. Review of policy “Request for Transport Services” dated 07/28/25, showed that out-of-state requests “Patients whose condition is deemed too critical to wait for approval may be picked up without prior insurance/Medicaid approval only with the approval of the ACH Administrator on Call.” C. Review of clinical record dated 06/22/25, showed Patient #1, a pediatric patient, of 26 (#1-#26) records reviewed, presented to an out-of-state hospital, which lacked pediatric intensive care services, with the following: a) Review of Emergency Department (ED) Physician note dated 06/22/25 at 12:04 AM, showed Patient #1 was admitted to the ED for a chief complaint of shortness of breath, rapid heart rate, and difficulty breathing. Additionally, the note showed Patient #1 had a history of hypoplastic left heart disease and was being followed by a transplant team in Indianapolis, however, she had been removed from the transplant list due to problems with oxygenation. b) Review of ED triage note dated 06/22/25 at 12:05 AM, showed Patient #1 had a blood oxygen saturation (SPO2) in the “mid 60s and having difficulty breathing”. c) Review of Electrocardiogram (EKG) dated 06/22/25 at 12:15 AM, showed Patient #1’s heart rate was 269 beats per minute (BPM). d) Review of vital signs dated 06/22/25 at 12:12 AM, showed Patient #1 had a temperature of 102.1 degrees Fahrenheit and respiratory rate of 41 breaths per minute (BPM), SPO2 63% and blood pressure reading of 106/75. e) Review of lab results dated 06/22/25 at 12:19 AM, showed a lactate level of 9.1 millimoles per liter (mmol/L). f) Review of clinical record dated 06/22/25 at 4:03 AM, showed the visit diagnosis was, tachycardia (primary), hypoplastic left heart disease, fever (unspecified fever cause), sepsis (due to unspecified organism), and acute respiratory failure with hypoxia. g) Review of post-mortem record dated 06/22/25 at 7:07 AM, showed Patient #1 had significant changes in heart rate and rhythm. Cardiopulmonary Resusitation (CPR) was initiated at 6:08 AM and eventually the code was stopped at parents request, and Patient #1 was pronounced dead at 6:53 AM. D. Review of out-of-state hospitals call center timeline, requesting transfer of Patient #1, dated 06/22/25 showed the following: a) At 1:46 AM, showed transfer was initiated with ACH Operations Center Registered Nurse (RN). It showed a face sheet was faxed and stated, “asked what insurance patient has and that they are reaching out to cardiologist to see if they will accept Patient #1”, also “will need to get approval for this transfer”. b) At 2:29 AM, showed ACH Operations Center RN called “stated that they will need to get approval from Indiana Medicaid” which does not have a 24-hour call number and ACH will have to wait for someone to answer. Further, “cannot accept as a transfer until that is done” and to “try and reach out to other facilities”. c) At 2:36 AM, showed call to ACH that facility will attempt to arrange transport with another medical flight provider. d) At 3:28 AM, showed ACH Operations Center RN “stated since patient is out of state resident needs approval” and should try to send to ACH Emergency Department (ED). e) At 3:47 AM, showed Patient #1 was accepted by ACH ED physician for ED-to-ED transfer. f) At 6:13 AM, showed ACH called to check on transport, and that outside hospital had tried to arrange transport through other medical flight providers. E. Review of ACH Operations Center Timeline dated 06/22/25 showed the following: a) At 1:47 AM, a request was initiated for Patient #1 to be sent the ACH. Also, ACH Operations Center recommended “consult cardiology, ACH financial, Manager on Call (MOC).” Additionally, mode of transport requested by outside hospital was “Angel One Transport” which is owned and operated by ACH. b) At 2:24 AM, showed a secure chat was sent to MOC and the response from MOC was, “may transfer only with Indiana Medicaid Approval. c) At 2:27 AM, showed a call from ACH financial who stated they will start the insurance verification process and that Indiana does not have a 24-hour call line so finance will have to leave a message and wait. b) At 3:29 AM, showed outside hospital will try to arrange local ground transport. d) At 3:35 AM, showed Patient #1 had been accepted to the ACH ED. e) At 7:05 AM, showed ACH was notified Patient #1 expired and transfer was cancelled. F. During an interview with the Director of Angel One/Operations Center on 08/12/25 at 11:07 AM, she confirmed the findings in A-E.”