Mad River Community Hospital

“PATIENT CARE ASSIGNMENTS CFR(s): 482.23(b)(5) A registered nurse must assign the nursing care of each patient to other nursing personnel in accordance with the patient’s needs and the specialized qualifications and competence of the nursing staff available. This Standard is not met as evidenced by: 39700 Based on interview and record review, the hospital failed to provide competent licensed nurses to care for patients in the Intensive Care Unit ICU) when the hospital failed to validate the competency of a licensed nurse (LN) assigned to care for a patient in the Intensive Care Unit (ICU). This failure had the potential to comprise patient safety and quality of care delivered to Patient 1. Findings: During an interview and record review on 5/19/26 at 10:30 a.m. with the Human Resources Generalist (HRG), the Chief Nursing Officer’s (CNO) personnl file was reviewed. The HRG confirmed the CNO had not attended nursing orientation nor had the CNO completed required nursing competencies prior to providing patient care in the ICU. During an interview on 5/19/26 at 2:05 p.m. with the CNO, CNO stated on 3/27/26 and 3/28/26 he was the primary nurse assigned to Patient 1 in the ICU. CNO stated he did not have ICU competencies or any other patient care competencies validated at this facility prior to caring for Patient 1. In the continued interview, CNO indicated that he has not been assigned direct patient care in the ICU since 2009 when he was a staff Registered Nurse (RN) at a 119-bed facility in another state but never in California. Review of a document titled “Staffing Plan, ICU/CCU” dated 04/2002 and last revised 06/25 indicated “A Registered Nurse with training and experience in intensive care unit nursing shall be responsible for the nursing care and management of the intensive care unit when a patient is present [and] Competency [of staff] is assessed at initial employment and during the orientation process.””

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 39700 Based on interview and record review, the hospital failed to assign a Registered Nurse (RN) to the Medical/Surgical/Telemetry unit and assigned care of the three patients on the unit to a Licensed Vocational Nurse (LVN) without a present and responsible RN to oversee their care on the night shift from 7 p.m. 3/23/26 until 7 a.m. on 3/24/26. This failure had the potential to compromise patient safety or cause harm to the three patients present on the unit. Findings: During a concurrent interview and document review with the Chief Nursing Officer (CNO) on 5/20/26 at 7:30 a.m., the document titled, “Nursing Shift Staffing”, dated 3/24/26, was reviewed. The CNO stated on 3/23/26 RN 1 was scheduled on the medical/surgical/telemetry unit, would function as the house supervisor for that shift. CNO indicated he did not contact any of the house supervisors or nursing unit managers to cover the role of the nursing supervisor. During ongoing interview with the CNO, CNO stated there were only three medical/surgical patients and the LVN would be able to provide the care required and RN 1 could manage the house supervisor role as well as provide oversite of the care of the medical/surgical patients. CNO sstated the role of the house supervisor was to round in all units of the hospital, assign patient bed placement when admitted, assist in emergencies, arrange for staffing for the next shift, and contact the operating room crew if needed. CNO stated these duties would require RN 1 to leave the Medical/Surgical/Telemetry unit during the shift. Review of a document titled, “House Supervisor Report”, dated 3/24/26, indicated there were three medical/surgical patients, three Intensive Care Unit (ICU) patients with with one anticipated medical/surgical patient with a patient admission pending. The “House Supervisor Report” for 3/23/26 was not provided despite requests. Review of a document titled, “Nursing Administrative Supervisor 24-hour Staffing Plan”, indicated on the night shift from 7 p.m. 3/23/26 until 7 a.m. 3/24/26, the charge RN for the medical surgical unit called in sick, the second scheduled RN, RN 1, was pulled to function as the house supervisor as the scheduled house supervisor had also called in sick. Per the staffing plan, one (LVN) was the only assigned nurse on the medical/surgical/ telemetry unit to provide care for three patients with one pending admit. Review of a document titled, “MEDSURG Staffing Matrix”, dated 3/23/2026 indicated for a census of 1-6 patients there would be 2 RN ’ s, census of 7-12 patients staffing would include 3 RN ’ s, census of 13-17 4 RN ’ s, census of 18-20 5 RN ’ s and census of 21-24 6 RN ’ s. Review of a document titled, “Staff Job Description & Performance Evaluation”, indicated “the Registered Nurse is responsible for the assessment and reassessment of the patient, taking into consideration the data collected by other members of the health care team [such as LVNs] ... Provides leadership for the nursing patient care team and collaborates with other departments.””

“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: 35598 Based on interview, and record review, the facility failed to meet the regulatory requirements under Emergency Medical Treatment and labor Act (EMTALA) as evidenced by: 1. The facility failed to maintain a central log of individuals who presented to the Emergency Department (ED) seeking care when 1 of 22 sampled patients’ (Patient 1) information was not entered into the central log when Patient 1 presented to the ED seeking care on 5/1/2025. ( Refer to A-2405); and 2. The facility failed to ensure a triage (process of prioritizing patients in need of medical attention) and a Medical Screening Exam (MSE- an exam to determine if an emergency medical condition exists) for 1 of 22 sampled patients (Patient 1) who presented to the Emergency Department (ED) when Charge Nurse 1 (CN1) encouraged Patient 1’s representative to take Patient 1 to another local ED (Refer to A-2406).”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 47138 Based on interview and record review, the facility failed to maintain a central log of individuals who presented to the Emergency Department (ED) seeking care when 1 of 22 sampled patients’ (Patient 1) information was not entered into the central log when Patient 1 presented to the ED seeking care on 5/1/2025. This failure resulted in Patient 1 presenting to the ED for care and not being entered into the required log for tracking and quality assurance. Findings: In an interview with a Licensed Clinical Social Worker (LCSW) on 7/8/2025 at 2:13 p.m., the LCSW, who works for the County Mental Health Services, indicated he received a call from the community health clinic Director of Behavioral Health Care (DBHC) regarding a patient (Patient 1) who exhibited signs and symptoms of a mental health crisis. An agreement was made to meet at the Hospital parking lot for the LCSW to further assess Patient 1. The LCSW stated Patient 1 was was assessed as being gravely disabled and placed on a 5150 hold ( allows for the involuntary hold of an individual who is experiencing a mental health crisis and is deemed a danger to themselves or others) by the LCSW. The LCSW stated both he, the DBHC, and Patient 1 presented to the Hospital ED on 5/1/2025 at approximately 12:00 p.m. During an interview on 7/8/2025 at 3:45 p.m. with the Chief Nursing Officer (CNO), a policy for ED log was requested and a policy was not provided. During an interview on 7/9/2025 at 8:30 a.m., with the Emergency Department Manager (EDM), EDM indicated logging ED patients was done by registration staff as patients come into the ED. The EDM stated, “It does happen that patients come in, but they leave before we could get their name. We can’t control them leaving before we get their details.” During a concurrent record review and interview with the CNO and the EDM on 7/9/2025 at 9:40 a.m., the ED log for 5/1/2025 from the time, “2:51 a.m. - 23:37 [11:37 p.m.]” did not include an entry for Patient 1. The CNO and EDM confirmed Patient 1 was never placed on the log despite spending approximately 23 minutes in the ED lobby, while Patient 1’s representative spoke with the ED charge nurse before being encouraged or advised to seek care at another hospital ED.”

“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: 47138 Based on interview and record review, the facility failed to triage (process of prioritizing patients in need of medical attention) and provide a Medical Screening Exam (MSE- an exam to determine if an emergency medical condition exists) for 1 of 22 sampled patients (Patient 1) who presented to the Emergency Department (ED) when Charge Nurse 1 (CN1) encouraged Patient 1’s representative to take Patient 1 to another local ED. These failures resulted in the delay of treatment and stabilization of a possible emergency medical condition when Patient 1, who was having a potential mental health crisis and was gravely disabled, was encouraged to leave the ED prior to triage or receiving a MSE and seek care and treatment at another local ED. Findings: In an interview with a Licensed Clinical Social Worker (LCSW) on 7/8/2025 at 2:13 p.m., the LCSW, who works for the County Mental Health Services, indicated he received a call from the community health clinic Director of Behavioral Health Care (DBHC) regarding a patient (Patient 1) who exhibited signs and symptoms of a mental health crisis. An agreement was made to meet at the Hospital parking lot for the LCSW to further assess Patient 1. A review of a document dated 5/1/25 and identified by LCSW as the 5150 he wrote on 5/1/25 (allows a qualified professional to place someone on an involuntary 72-hour mental health hold), the document indicated Patient 1 presented, “as nonreality based. [Patient 1] was clearly responding to internal stimuli, [Patient 1] had tangential thought process (a type of disorganized thinking). Writer attempted to discuss why [Patient 1] and writer were talking with [Patient 1]. [Patient 1] explained that she was going to get her medications taken care of, then stated JP isn’t sure if I should tell you ...[Patient 1] proceed to exit the vehicle and have a conversation with herself about why she shouldn’t have exited the vehicle. Writer and [Patient 1] discussed her nutritional situation to which [Patient 1] made non-sensical statements. Writer ask (sic) where you get food, [Patient 1] made good eye contact and stated from the grocery store. Writer asked about the last time [Patient 1] had eaten. [Patient 1] proceeded to have another conversation with herself about not giving that information to writer. Writer ask (sic) if you were to go home right now how would you keep yourself safe? [Patient 1] replied I don’t know”. The document continued, “Writer discussed options with Behavioral Health Team, Writer completed 5150 hold due to [Patient 1] not being grounded in reality, inability to acquire and consume nutrition and inability to make a plan for safety or future plan.” In a continued review of the document dated 5/1/25 and identified by LCSW as the 5150, the document revealed, “Writer presented 5150 hold to (Hospital) ED. Charge nurse explained that they were low on available beds and would prefer to not take [Patient 1]. Charge nurse requested [Patient 1] be taken to [another local hospital] ED. Writer met with community clinic MH (Mental Health) at other hospital [hospital name] ED due to they were transporting. Writer presented [Patient 1] and 5150 at other hospital ED and [Patient 1] was admitted.” A review of a document provided by the Chief Nursing Officer (CNO), dated 5/3/2025, and described by the CNO as a written statement from CN 1, indicated, “I was working on Thursday May 1, and a coworker told me there was another 5150 hold in the waiting room and the case worker wanted to talk with someone. I went out to speak with them and they told me about the patient. I told them we had 4 holds currently and that most of the other beds had patients in them. I mentioned that with a fifth hold we would be down to having two functional ED beds if we wanted to stay in ratio [law mandating number of patients assigned to the care one nurse]. I explained it would be quite some time to get his patient a bed due to this ... I stated that we would of course take the patient, but if he didn’t want to wait he could do as he pleases. He decided to head to the other facility. Kind regards, CN [name].” During a telephone interview with CN 1 on 7/9/25 at 10 a.m., CN 1 confirmed he wrote the statement at the request of the CNO. During a concurrent interview and review of the ED lobby monitoring video, on 7/9/2025, at 10:50 a.m., with the ED Manager (EDM) and CNO, the ED lobby camera footage, dated 5/1/25, at 12 p.m., revealed Patient 1 and DBHC entered the ED lobby and sat down at approximately 12:03 p.m. Shortly after LCSW entered and rang the doorbell into the ED, at which time, CN 1 came to the door and spoke to DBHC and LCSW. Patient 1, DBHC, and LCSW left the ED lobby at approximately 12:23 p.m. CNO and EDM confirmed Patient 1 was in the ED lobby for approximately 23 minutes and left without triage or medical screening exam. During a telephone interview on 7/9/25 at 2:13p.m., with LCSW, LCSW stated he presented to the Hospital ED with Patient 1 and was greeted by CN 1 who stated there was one bed open in the ED and the need was to keep it open for emergencies in the community. LCSW stated CN 1 further stated, “We would prefer you take her to [name of other local ED]. LCSW stated Patient 1 was not triaged nor was a medical screening exam completed. LCSW stated CN 1 nor any other ED staff requested Patient1’s name or any other identifiable information. LCSW believes they were in the ED about 20 minutes. During a telephone interview with DBHC on 7/14/25 at 11:57 a.m., DBHC stated, on 5/1/25 he presented to the ED with Patient 1 and LCSW. DBHC stated CN 1 “refused” to accept the 5150 document and indicated Patient 1 needed to be taken to another local hospital ED as the Hospital only had one bed available and it had to be held for a “community emergency”. DBHC stated he remembered CN 1 saying, “We don’t want to take this patient”. DBHC stated he, LCSW, and Patient 1 left the ED lobby after approximately 15-20 minutes. DBHC stated at no time was Patient 1 triaged nor offered a MSE. Review of a policy titled, “Triage”, dated 1/22, indicated, “Triage is the initial assessment and screening of patients who present to the Emergency Department (ED) for intervention...An ED Registered Nurse who has a minimum of six months ED experience and completed the Triage competency, will triage all patients who present for care in the ED...Following triage, a medical screening examination (MSE) is performed on all patients; this will be done by the ED physician or ED provider...MSE’s are performed based on the triage level assigned by the triage RN...The documentation by the triage nurse will include name, chief complaint, vital sign, priority and any treatment initiated at that time ...” Review of a policy titled, “EMTALA [Emergency Medical Treatment and Labor Act] Compliance”, dated 10/18, indicated, “The Hospital’s EMTALA obligation is triggered when an individual comes by him or herself or with another person or by ambulance to the Emergency Department; and a request is made by the individual, or on the individual’s behalf or a prudent layperson observer would conclude from the individual’s behavior or appearance, a need for examination or treatment of an emergency medical condition (EMC). In such a case, the Hospital has incurred an obligation to provide an appropriate medical screen exam (MSE) for the individual and stabilizing treatment within their capacity and capability, or an appropriate transfer ...The Hospital is obligated to provide the services necessary to determine if an EMC is present and provide stabilizing treatment.””

“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: 41175 Based on staff interviews, Emergency Department’s (ED) policy and procedures, and ED patient record reviews, the hospital failed to comply with 42 CFR § 489.24 - Special Responsibilities of Medicare Hospitals in Emergency Medical Treatment and Active Labor Act (EMTALA). This failure resulted in the transfer of one patient (Patient 100) to a facility which did not have the capabilities to provide higher level of care for her condition and could potentially affect other ED patients who needed to be transferred to other facilities. Findings: During an EMTALA Survey on 9/24/25 to 9/25/24, the surveyor determined the ED failed to ensure one patient (Patient 100) was provided an appropriate transfer when the transferring physician provided an incomplete report of Patient 100’s condition to the physician at the accepting facility. Patient 100’s CT scan finding at the ED was significant enough to escalate to an even higher level of care needed than previously discussed with Hospital 2, and its omission in the report resulted in Patient 100 be transferred to a facility which did not have the capabilities to care for her condition. (Cross Reference A-2409).”

“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: 41175 Based on interview and record review, the facility failed to ensure a complete interfacility physician-to-physician reporting, which included critical patient information for one of 21 sampled Emergency Department (ED) patients (Patient 100). This failure did not comply with the facility policies and procedures, and resulted in Patient 100 being transferred to a facility which did not have the capabilities to care for her condition and for her to experience a subsequent transfer to another facility within hours. Findings: During an interview on 9/24/24 at 11:30 a.m., the Complainant stated Patient 100 was inappropriately transferred from Hospital 1 ED to Hospital 2 ED. The Complainant stated, while at the Hospital 1 ED, Patient 100 had a Computed Tomography (CT) scan (a medical imaging procedure) that showed an ascending aorta dissection (a life-threatening condition wherein there is a tear in the inner layer of the large blood vessel branching off the heart). The Complainant stated Hospital 1’s ED Physician was aware of the CT scan finding but did not disclose this information to the ED Physician at Hospital 2. The Complainant stated Patient 100 was accepted at Hospital 2, though Hospital 2 did not have the capabilities to care for her aortic dissection. During an interview on 9/24/24 at 2:05 p.m., the ED Registered Nurse (RN) stated the ED Physician identified a patient’s need to be transferred to another facility. The ED RN stated, due to the small size of Hospital 1, patient transfers occurred often. The ED RN stated patients got transferred to other facilities when Hospital 1 did not have an available bed to admit a patient, and/or when a patient required a higher level of care and specialty services. The ED RN stated part of the transfer process was a discussion of the patient’s condition between the transferring and accepting Physicians. During an interview on 9/24/24 at 2:39 p.m., the ED Tech stated a patient’s transfer got initiated when the ED Physician determined if a patient needed to be transferred. The ED Tech stated she would then start contacting hospital transfer centers (services that triage requests made by Physicians needing to transfer a patient). The ED Tech stated transfer centers would call the hospital back, and a physician-to-physician report would occur. The ED Tech stated after the report, the transferring facility had to confirm whether the patient was accepted or not. A review of Patient 100’s, “Emergency Room Outpatient Record,” indicated she was brought in by ambulance to Hospital 1’s ED on 9/12/24 at 9:44 p.m., for chief complaints of increasing shortness of breath and rib pain after a fall. Patient 100’s, “Radiology Report,” dated 09/12/24, indicated chest x-ray (an imaging of the heart, lungs and bones) findings that included pneumonia (an inflammation of the lungs caused by an infection), and small bilateral pleural effusions (fluid buildup in the thin cavity between both sides of the lungs and chest wall). Further review of Patient 100’s Radiology Report include a chest CT scan, dated 9/12/24, which indicated, “There are bilateral pleural effusions. Appears to be a large pulmonary embolus (a life-threatening blockage in a lung artery caused by a blood clot) in the main pulmonary artery and right pulmonary artery right pulmonary artery is nearly occluded [sic] ... Also appears to be a possible dissection involving the ascending aorta ... [ED Physician A] was told these findings at 11:55 p.m., September 12, 2024.” A review of Patient 100’s, “Emergency Note,” dated 9/12/24, indicated, “Medical Decision Making: ... Patient’s chest x-ray ... consistent with pneumonia ... suggestive of non-STEMI (a type of a heart attack) ... will need transfer to a higher level of care for cardiology ... CT of the chest shows a pulmonary embolism on the right side which is large ...” The Emergency Note, signed by ED Physician A, did not mention the aortic dissection. A review of Patient 100’s, “Patient Transfer Communication,” indicated an initial call was made to Hospital 2’s transfer center on 9/12/24 at 11:07 p.m., and provided details of, “DX (Diagnosis): NSTEMI, BILATERAL PNEUMONIA, PE (pulmonary embolism) ... NEEDS: CARDIOLOGY ... BED: ICU (Intensive Care Unit) ...” There was no documentation of the aortic dissection among Patient 100’s diagnoses in the document. Further review of the document indicated that on 9/12/24 at 12:56 a.m., Hospital 2 called back and requested a, “doc to doc,” then the call was transferred to ED Physician A. The document further indicated that on 9/13/24 at 1:05 a.m., an acceptance information was received from Hospital 2, with ED Physician B as the accepting Physician. A review of Patient 100’s, “Interfacility Transfer Form,” dated, “9/13/24,” indicated, “Reason for Transfer: NEEDS CARDIOLOGY NONE @ [HOSPITAL 1] ... Pt (Patient) Diagnosis: NSTEMI, BILATERAL PNEUMONIA ...” The aortic dissection was not included among the list of diagnoses in the document. A review of Patient 100’s, “ED: Nursing Progress and Discharge Notes,” indicated Patient 100 was transferred out to Hospital 2 on 9/13/24 at 1:34 a.m. A review of Patient 100’s transfer records to Hospital 2 indicated, “Diagnosis: ...NSTEMI, bilateral pneumonia, PE ... Reason: Higher Level of Care ... Service: Cardiology ...” The document included a timeline which indicated, “9/13 0102 (1:02 a.m.) ... spoke with [ED Physician B] and was able to connect him with a Peer to peer with [ED Physician A]. [ED Physician B] accepted patient ...” A review of Patient 100’s, “ED Provider Notes” at Hospital 2, dated “9/13/24”, indicated, “0230 (2:30 a.m.): I have reviewed material sent from [Hospital 1] on the patient and the patient’s CTA of the chest shows a large PE in the main and right pulmonary artery. Patient also has a dissection of the ascending aorta ... I have called and discussed with cardiothoracic surgeon, [Cardiothoracic Physician C] who recommends ... that the patient should be transferred to [Hospital 3] ...” During an interview on 9/25/24 at 2:08 p.m., ED Physician B stated recalling Patient 100. ED Physician B stated he was the accepting Physician and confirmed having a peer-to-peer discussion with ED Physician A. ED Physician B stated he was notified of Patient 100 having pneumonia and pulmonary emboli, and her needing cardiology services and an ICU bed. ED Physician B stated the aortic dissection was not mentioned during the discussion. ED Physician B stated he discovered the dissection during his review of Patient 100’s medical records after her arrival at Hospital 2. ED Physician B stated he consulted with a Radiologist and Hospital 2’s on-call Cardiothoracic Physician C, who both reviewed the CT scan and confirmed the aortic dissection. ED Physician B stated management of the aortic dissection became the top priority for Patient 100, and stated Cardiothoracic Physician C recommended a transfer to Hospital 3 for higher level of care. ED Physician B stated he would not have accepted Patient 100’s transfer had he been notified of the aortic dissection during the peer-to-peer discussion. During an interview on 9/25/24 at 4:26 p.m., ED Physician A stated recalling Patient 100 as, “very complicated,” and confirmed himself as the transferring Physician. ED Physician A stated was aware of the dissection, but for an unknown reason, missed mentioning it during his discussion with ED Physician B. ED Physician A stated recalling the radiologist’s concern over the large pulmonary emboli, and stated he, “may have been affected by it,” making him focus on the management of the emboli over the more critical aortic dissection. ED Physician A stated Patient 100’s CT scan finding required a cardiothoracic service and not just cardiology. ED Physician A stated he should have consulted with a Cardiothoracic Physician before transferring Patient 100 to Hospital 2. Further review of Patient 100’s, “ED Provider Notes,” at Hospital 2, dated “9/13/24,” indicated, “0425 (4:25 a.m.): Patient was accepted for transfer to [Hospital 3] CT surgery [Cardiothoracic Physician D] who will take the patient directly to OR ... [Patient 100] presented with concern for imminent decline requiring constant monitoring and attendance of care. The patient has had a high probability of imminent deterioration threatening life or limb ...” The document was signed by ED Physician B. A review of Patient 100’s, “Transfer Consent,” at Hospital 2, indicated she was transferred to Hospital 3 on 9/13/24 at 6:17 a.m., approximately four hours since her transfer to Hospital 2, via an air ambulance. During an interview on 9/25/24 at 4:40 p.m., Hospital 1’s Chief Nursing Officer (CNO) stated she was familiar with the process of transferring patients out of the ED as she had also functioned as a hospital provider. The CNO stated, after a Physician determined a patient needed to be transferred, the patient was notified, and a consent obtained. The CNO stated staff, usually the ED Tech, would call transfer centers with the patient information such as the diagnoses and specialty or level of service needed. The CNO stated the transferring and accepting Physicians conducted a, “doc-to-doc,” report. The CNO stated this allowed the transferring Physician to give as many details as possible about the patient and helped the accepting Physician decide whether to accept the patient. The CNO stated ED Physician A should have included a significant finding of an aortic dissection in his discussion with ED Physician B. During an interview on 10/1/24 at 11 a.m., Cardiothoracic Physician C stated he became aware of Patient 100 when ED Physician B requested a consult and a review of Patient 100’s CT scan. Cardiothoracic Physician C stated he confirmed the findings of an ascending aorta dissection. Cardiothoracic Physician C stated the usual protocol for aortic dissections was to take them in for an immediate surgery. Cardiothoracic Physician C stated Hospital 2 normally would have been able to accept patients with aortic dissections, but they were incapable of providing care for Patient 100 at the time as they had limited manpower in the facility. Cardiothoracic Physician C stated that if he been consulted while the transfer was being arranged, he would have notified ED Physician A of their inability to accept Patient 100 at the time. A review of the facility policy titled, “Interfacility Patient Transfer & Transfers for Testing or Off-Premises Services,” last reviewed, “1/22,” indicated, “Patients are not transferred except upon patient request, upon request of the responsible party acting on behalf of the patient, or upon the written certification of the physician that the risks of transfer outweigh the reasonably anticipated benefits of proper treatment at another facility, consistent with the procedures set forth ... Patient Dispensation: A process that determines continued patient care or discharge conducted by a qualified medical provider who has primary responsibility to assure that all referrals, follow-up care and/or transfer requirements are met and documented ... The transferring provider makes provider to provider contact to explain the case and obtain provider acceptance of the patient ...””