Pioneers Memorial Healthcare District

“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: 28183 Based on observation, interview, and record review, the hospital failed to ensure nursing staff routinely checked a Neonatal Intensive Care Unit (NICU) crash cart (a cart containing medications and supplies for a medical emergency) and removed expired items. Findings: On 4/28/26 at 12:02 P.M., an observation of the NICU was conducted. On top of the NICU crash cart was a sticker titled “Crash Cart Item Check.” The sticker indicated the first item in the cart to expire was a small laryngoscope blade, commonly used for placing a breathing tube in a neonate. The sticker indicated the date of expiration was 3/22/26. The crash cart was then opened and supplies were inspected. The laryngoscope blade package indicated an expiration date of 3/22/26. In addition, a separate package containing the handle for the laryngoscope indicated an expiration date of 4/3/26. The NICU Nurse Manager (NNM) stated during an interview on 4/28/26 at 12:12 P.M. that the Health Unit Coordinator checked the crash cart monthly, and the RNs check it daily and document in the crash cart log. The NNM acknowledged the expired items should have been checked and removed from the crash cart. The Neonatal Crash Cart Log was then reviewed. The log indicated daily checks, but did not include checking expiration dates. On 4/28/26 at 12:21 P.M., the Chief Nursing Officer (CNO) stated during an interview that the expectation is that nurses check the crash cart daily for expired items. The CNO acknowledged, “They’re not looking at this.” The CNO further stated that the daily Neonatal Crash Cart Log should include checking expiration dates. According to the hospital’s policy, Crash Cart/Exchange Program, last revised 10/1/25, “Each patient care area with a crash cart will complete and document the crash cart integrity at the beginning of the shift as follows ...The check shall be completed by a registered nurse ...” In addition, “Any missing, expired, or malfunctioning items must be reported immediately, documented on the log, and the cart exchanged.””

“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: 26660 Based on interview, and record review, Hospital A (the only provider of specialized capabilities for the county), did not develop, implement, or maintain a written policy and procedure in accordance with EMTALA regulations to ensure that requests for transfer of patients who are protected under EMTALA with unstable emergency medical conditions from Hospital B which lacks specialized capabilities were accepted and not refused. As a result, patients with unstable emergency medical conditions may potentially be denied transfer from Hospital B to Hospital A for necessary specialized capabilities and treatment without regard to Hospital A’s ability to accommodate additional patients. Findings: On 2/16/24 at 10A.M., an investigation was initiated due to the complaint that Hospital A attempted to refuse a request for transfer from Hospital B of Patient 1 that had an unstable emergency medical condition due to Hospital A’s “staffing issues”. During an interview with the Chief Nursing Officer (CNO) on 2/16/24 at 10:00 AM, the CNO stated the index case Patient 1, a patient in labor was a requested transfer from Hospital B’s emergency department. The on-call OB/GYN (obstetrics and gynecology) MD 1 stated he was not contacted by Hospital B, but he reached out to the charge nurse/triage nurse for OB at Hospital A who had concerns that they did not have a bed or nurse to care for the patient. MD 1 stated he reached out to Hospital B to have them contact their on-call OB/GYN MD 2 who has OB/GYN privileges at both Hospital B and A to have him assess whether the patient was safe for transfer via ambulance. MD 2 ordered the patient to be transferred and she arrived at Hospital A and delivered two hours later. CNO stated Hospital A was not on bypass status. The OB unit at Hospital A was able to accommodate the patient by triaging lower acuity patients to free up a bed. CNO stated Hospital A has OB/GYN and Pediatric services and Hospital B does not have these services and therefore Hospital A tries not to refuse OB or Peds transfers from Hospital B. CNO stated the providers met after this incident and came up with the plan that if Hospital A lacks the capacity (lack of beds or nursing staff) they would refuse the transfer. CNO stated Hospital A and Hospital B does not have a current transfer agreement that is updated to reflect Hospital A’s status as the only hospital in the county that has OB/Pediatrics. Per the CNO only the physicians have the authority to accept or deny a patient transfer. During an interview on 2/16/24 at 10:40 AM with the OB/Perinatal Director (OPD) Perinatal Manager (PM). The PM stated the transfer is physician to physician and only the physicians have the authority to accept or deny a transfer, however sometimes the OB unit is too full and may not have a bed or nursing staff availability to accommodate transfers from Hospital B and the nurse may communicate this to the physician on call and they may not accept the transfer due to lack of capacity. OPD stated she discussed the case with MD 1 the OB on call who stated he was not contacted by Hospital B and had concerns about the status of the patient and was informed by Hospital A’s OB charge nurse/triage nurse that they were at maximum capacity and should not accept the transfer. There was no mention by OPD and PM of Hospital A’s ability to accommodate additional patients in the instance of a request for transfer for higher level of care and the “lack of nursing staff or beds” to care for the patient. During an interview on 2/13/24 at 12:25 PM with (MD 1) the on call OB physician for Hospital A, MD 1 stated that he was contacted by the triage nurse at Hospital A notifying him that Hospital B was sending a pregnant patient with ruptured membranes and meconium (the earliest stool of a mammalian infant resulting from defecation) to Hospital A. MD1 stated he did not refuse to accept Patient 1, but he did reach out to Hospital B to have them call their on call OB physician MD 2 to make the determination if it was safe to transfer Patient 1 via ambulance. MD 1 stated he was notified by the charge nurse at Hospital A that “she did not have a nurse to care for the transferred patient”. MD 1 stated he did not agree that lack of a bed or nursing staff was an acceptable reason to refuse a transfer of a patient that required a higher level of care. An Interview on 2/13/24 at 12:32 PM with (MD 2) the on-call OB doctor for Hospital B, MD 2 stated he was contacted regarding patient 1 presenting in labor and what appeared to be ruptured membranes with meconium staining. He stated that Hospital B did not have perinatal services and this patient would require transfer to a hospital that did have perinatal services (higher level of care) due to the complications of meconium and higher risk to the patient and the infant, so he recommended the transfer to Hospital A. He stated that he deemed Patient 1 to be safe for transfer via ambulance to Hospital A and that he has OB privileges at both Hospital B and Hospital A. A review of MD 2’s credential files on 2/16/24 at 10:45 AM at hospital A indicated that MD 2 had OB/GYN privileges granted 10/1/23-9/30/25. An interview on 2/16/24 at 11:50 AM with MD 5 the past department chair for OB/GYN, MD 5 stated when Hospital B closed their OB/GYN and Pediatric services leaving Hospital A with the only hospital in the county with those services it came as a surprise to everyone, and they have been trying to come up with a process to facilitate emergency transfers. MD 5 stated the plan has been for Hospital B to call the on-call OB doctor for Hospital A to get acceptance for transfer, however he acknowledged that in Patient 1’s case there was a communication issue with MD 1. Review of Transfer agreement on 2/16/24 at 12:45 PM between Hospital B and Hospital A dated 3/10/93, has not been updated to reflect Hospital A’s status as the only hospital with OB/GYN and Pediatric services in the county. An interview on 2/20/24 at 10:24 AM with Medical Director for Pediatric services (MD 6). MD 6 stated that a pregnant woman with ruptured membranes and with meconium staining would require a higher level of care and therefore should be transferred from Hospital B that does not have OB or perinatal services to Hospital A which does provide OB/perinatal and neonatal services due to the potential increased risk of infection and respiratory distress to the infant.”

“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: 26660 Based on interview, and record review, Hospital A (the only provider of specialized capabilities for the county), did not develop, implement, or maintain a written process in accordance with EMTALA recipient hospital responsibilities to ensure that requests for transfer of patients who are protected under EMTALA with unstable emergency medical conditions from Hospital B which lacks specialized capabilities were accepted and not refused. As a result, patients with unstable emergency medical conditions may potentially be denied transfer from Hospital B to Hospital A for necessary specialized capabilities and treatment without regard to Hospital A’s ability to accommodate additional patients. Findings: On 2/16/24 at 10 A.M., an investigation was initiated due to the complaint that Hospital A attempted to refuse a request for transfer from Hospital B of Patient 1 that had an unstable emergency medical condition due to Hospital A’s “staffing issues”. During an interview with the Chief Nursing Officer (CNO) on 2/16/24 at 10 A.M., the CNO stated the index case Patient 1, a patient in labor was a requested transfer from Hospital B’s emergency department. The on-call OB/GYN (obstetrics and gynecology) MD 1 stated he was not contacted by Hospital B, but he reached out to the charge nurse/triage nurse for OB at Hospital A who had concerns that they did not have a bed or nurse to care for the patient. MD 1 stated he reached out to Hospital B to have them contact their on-call OB/GYN MD 2 who has OB/GYN privileges at both Hospital B and A to have him assess whether the patient was safe for transfer via ambulance. MD 2 ordered the patient to be transferred and she arrived at Hospital A and delivered two hours later. CNO stated Hospital A was not on bypass status. The OB unit at Hospital A was able to accommodate the patient by triaging lower acuity patients to free up a bed. CNO stated Hospital A has OB/GYN and Pediatric services and Hospital B does not have these services and therefore Hospital A tries not to refuse OB or Peds transfers from Hospital B. CNO stated the providers met after this incident and came up with the plan that if Hospital A lacks the capacity (lack of beds or nursing staff) they would refuse the transfer. CNO stated Hospital A and Hospital B does not have a current transfer agreement that is updated to reflect Hospital A’s status as the only hospital in the county that has OB/Pediatrics. Per the CNO only the physicians have the authority to accept or deny a patient transfer. During an interview on 2/16/24 at 10:40 A.M., with the OB/Perinatal Director (OPD) Perinatal Manager (PM). The PM stated the transfer is physician to physician and only the physicians have the authority to accept or deny a transfer, however sometimes the OB unit is too full and may not have a bed or nursing staff availability to accommodate transfers from Hospital B and the nurse may communicate this to the physician on call and they may not accept the transfer due to lack of capacity. OPD stated she discussed the case with MD 1 the OB on call who stated he was not contacted by Hospital B and had concerns about the status of the patient and was informed by Hospital A’s OB charge nurse/triage nurse that they were at maximum capacity and should not accept the transfer. There was no mention by OPD and PM of Hospital A’s ability to accommodate additional patients in the instance of a request for transfer for higher level of care and the “lack of nursing staff or beds” to care for the patient. During an interview on 2/13/24 at 12:25 P.M., with (MD1) the on call OB physician for Hospital A, MD1 stated that he was contacted by the triage nurse at Hospital A notifying him that Hospital B was sending a pregnant patient with ruptured membranes and meconium (the earliest stool of a mammalian infant resulting from defecation) to Hospital A. MD1 stated he did not refuse to accept Patient 1, but he did reach out to Hospital B to have them call their on call OB physician MD2 to make the determination if it was safe to transfer Patient 1 via ambulance. MD 1 stated he was notified by the charge nurse at Hospital A that “she did not have a nurse to care for the transferred patient”. MD 1 stated he did not agree that lack of a bed or nursing staff was an acceptable reason to refuse a transfer of a patient that required a higher level of care. An Interview on 2/13/24 at 12:32 P.M., with (MD2) the on-call OB doctor for Hospital B, MD 2 stated he was contacted regarding patient 1 presenting in labor and what appeared to be ruptured membranes with meconium staining. He stated that Hospital B did not have perinatal services and this patient would require transfer to a hospital that did have perinatal services (higher level of care) due to the complications of meconium and higher risk to the patient and the infant, so he recommended the transfer to Hospital A. He stated that he deemed Patient 1 to be safe for transfer via ambulance to Hospital A and that he has OB privileges at both Hospital B and Hospital A. A review of MD2’s credential files on 2/16/24 at 10:45 A.M., at hospital A indicated that MD 2 had OB/GYN privileges granted 10/1/23-9/30/25. An interview on 2/16/24 at 11:50 A.M., with MD 5 the past department chair for OB/GYN, MD 5 stated when Hospital B closed their OB/GYN and Pediatric services leaving Hospital A with the only hospital in the county with those services it came as a surprise to everyone, and they have been trying to come up with a process to facilitate emergency transfers. MD 5 stated the plan has been for Hospital B to call the on-call OB doctor for Hospital A to get acceptance for transfer, however he acknowledged that in Patient 1’s case there was a communication issue with MD 1. Review of Transfer agreement on 2/16/24 at 12:45 P.M., between Hospital B and Hospital A dated 3/10/93, has not been updated to reflect Hospital A’s status as the only hospital with OB/GYN and Pediatric services in the county. An interview on 2/20/24 at 10:24 A.M., with Medical Director for Pediatric services (MD 6). MD 6 stated that a pregnant woman with ruptured membranes and with meconium staining would require a higher level of care and therefore should be transferred from Hospital B that does not have OB or perinatal services to Hospital A which does provide OB/perinatal and neonatal services due to the potential increased risk of infection and respiratory distress to the infant.”