Tallahassee Memorial Healthcare

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 29722 Based on patient and staff interviews, patient medical record review, review of the Unit’s telemetry binder and review of the facility’s policy and procedure, the facility failed to provide care in a safe setting by failing to follow their policy and procedure to ensure the correct identity of the patient when telemetry services were ordered for 1 of 3 patient records reviewed. (Patient #3) The findings include: On 01/21/2026 at approximately 10:20 AM an interview was conducted with the Internal Medical Unit Manager (UM) regarding the hospital’s process when patients are ordered to receive telemetry services. The UM identified they have quite a few patients on telemetry services and that telemetry is done from a monitoring station located on another floor of the hospital. The UM states the order for telemetry comes in through EPIC (the hospital’s electronic medical record system). The nurse sees the order and acknowledges it. A sheet (Telemetry Transmitter Receipt) is sent to the telemetry unit to request telemetry services. The telemetry unit then notifies the floor when the telemetry box is ready. A staff member from the unit goes down to the Telemetry Unit and the Telemetry Transmitter Sign-out section of the Receipt is completed by the Cardiac Telemetry Surveillance Center (CTSC) and the Unit Staff member. The telemetry box is brought back up to the unit, and while the staff member is bedside with the patient, a bedside verification is completed with the CTSC and the acknowledgement is signed-off by the bedside nurse or tech. A similar process is done by CTSC. This process should be completed within 1 hour of receiving the telemetry box. On 01/21/2026 during a random review through the Internal Medicine Unit’s Telemetry binder, Patient #1, a patient transferred to the Unit on 1/17 with orders for telemetry services. Telemetry Transmitter Sign-out sheet was completed and transmitter box signed out to Unit staff at 3:19 PM. The “Telemetry Bedside Verification” was left blank. Per review of electronic record, indicates telemetry - Yes, box number 2350 , “on”, and rhythm - ST (Sinus Tachycardia), documented at 2:48 PM. A review of the corresponding “CTSC Cardiac Telemetry Bedside Verification” form (completed by telemetry unit) indicates bedside verification was completed on 01/17/2026 at 5:29 PM. On 01/21/2026, continued review of the Internal Medicine Unit’s Telemetry binder, Patient #2, a patient transferred to the Unit on 01/19 with orders for telemetry services. Telemetry Transmitter Sign-out sheet was completed and transmitter box signed out to Unit staff at 9:34 PM. The “Telemetry Bedside Verification” was left blank. Electronic medical record entry at 2300 (11:00 PM) indicates - Telemetry Yes; Cardiac Rhythm - A-fib (atrial fibrillation); status - on; telemetry box number 2020. Per review of the CTSC Cardiac Telemetry Bedside Verification (completed by the telemetry unit) indicates bedside verification completed at 23:34 (11:34 PM). On 01/21/2026 at 10:30 AM an interview was conducted with the family member for Patient #3. The family member stated the patient was admitted through the Emergency Room last Tuesday, and they were not aware that telemetry services had been ordered for the patient until she overheard some nurses discussing an issue with the signal and began to check the patient and realized he did not have a telemetry box on. The patient was then placed on telemetry on Sunday. The family member states since then, the patient has had episodes of atrial fibrillation and has been placed on a heparin drip. On 01/21/2026, continued review of the Internal Medicine Unit’s Telemetry binder, for Patient #3, admitted to the Unit, early morning hours of 01/14/2026, with order for telemetry services for arrythmia Management. However, the telemetry binder failed to have the patient #3’s Telemetry Transmitter Receipt in the book. The Unit Manager then produced the “Telemetry Transmitter Sign-out sheet/receipt” - stating that there was an issue with this patient and somehow the box had been placed on another patient. The UM stated she was still investigating. A review of the Telemetry Transmitter Sign-out sheet was noted to be complete and the transmitter box 2340 signed out to Unit staff at 01:55 AM. The “Telemetry Bedside Verification” was documented at 2:00 AM. CTSC Cardiac Telemetry Bedside Verification (completed by the telemetry unit) indicates bedside verification completed at 02:01 AM. Review of the electronic record indicates no documentation or confirmation of telemetry services or rhythm until 01/15/2026 at 2300 (11:00 PM) with a normal sinus rhythm. Additional rhythm and telemetry status noted on 1/16 at 2300 with a normal sinus rhythm. There was nothing documented on 01/17/2026. Per the UM, nurses did a room-to-room search and located box 2340 on Patient #4. Patient #4 was not ordered to receive telemetry services, nor did Patient #4 have a Telemetry Transmitter Receipt. Per the Risk Manager, Patient #3’s telemetry box was placed on 01/18/2026 at 00:32 AM with sinus tachycardia. A review of the facility’s policy and procedure entitled “Cardiac Monitoring”, effective 01/21/2025, indicates “II. PROCEDURE: A. When an order for telemetry is entered, the Centralized Telemetry Surveillance Center (CTSC) will be notified. B. The CTSC will maintain, and issue cardiac telemetry monitors to the inpatient units. CTSC will track the monitor channel number and patient identification information. The inpatient unit and CTSC staff will confirm the issued monitor’s channel number. C. Any available staff member may collect telemetry monitors from the CTSC. Unit staff that have been trained on placing telemetry monitors may place and remove telemetry monitors. D After the telemetry monitor has been applied or receiving a patient on telemetry, the RN/LPN (Registered Nurse/Licensed Practical Nurse) will notify the CTSC and verify the following with the CTSC while at the patient’s bedside: 1. Patient’s name and MRN number. 2. Room number, 3. Channel number of the telemetry unit 4. The tracing is clear and transmitting, as necessary 5. The nurse will notify the Monitor Tech (MT) if the patient has a Do Not Resuscitate (DNR) or their resuscitation status changes 6. The nurse will notify the MT if the patient has a pacemaker, ICD, or an antiarrhymic infusion.”

“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: 52621 Based on interviews, patient medical records reviews, review of the facility’s emergency call list for Urology and review of the facility’s policy and procedure, the facility failed to comply with their obligation of Medicare requirements to provide stabilizing urological treatment within their service capabilities, by failing to contact the on-call urologist to provide stabilizing treatment for a patient with a urological emergency medical condition resulting in an inappropriate transfer for 1 out 21 patients (Patient #2); and failed to maintain records of transfers as part of the permanent medical record for 2 of 21 patient transfer records reviewed (Patent #2 and #17). This practice may cause a delay in emergency treatment and potential harm to patients. Cross Refer to A 2403, A 2407 and A 2409.”

“HOSPITAL MUST MAINTAIN RECORDS CFR(s): 489.20(r)(1) [The provider agrees,] in the case of a hospital as defined in §489.24(b), (including both the transferring and receiving hospitals), to maintain medical and other records related to individuals transferred to or from the hospital for a period of 5 years from the date of the transfer. This Standard is not met as evidenced by: 52621 Based on interviews, records reviews and facility policies, the facility failed to maintain records of transfers as part of the permanent medical record for 2 out of 21 records reviewed. (Patient #2, #17). The findings include: A record review of Patient #2 and #17’s medical records, with documentation of an emergency medical condition requiring transfer to another facility, were reviewed. Both records are missing the required physician’s certificate of transfer. On 10/29/25 at approximately 2:25 PM an interview was conducted with the Emergency Department Nurse Manager. He confirmed that the physician certification for transfer for Patient #2 was not available for review in the patient’s medical record. He explained that Staff A, Registered Nurse completed the transfer forms on paper and sent all originals to the receiving facility. On 10/29/25 at approximately 1:30 PM, an interview was conducted with the Transfer Center Specialist. She states that she does not have a copy of the physician transfer certification for Patient #2. On 10/29/25 at approximately 1:47 PM, an interview was conducted with the Senior Health Information Management in Medical Records. She explained that if a paper version of a transfer was completed, it would have been scanned in the patient’s medical record. She confirmed that she does not have a transfer certification on file for Patient #2. On 10/30/25 at approximately 12:47 PM, during records review, the Emergency Department Nurse Manager Operations confirmed that the physician certification for transfer for Patient #17 was not available for review in the patient’s medical record. On 10/30/25 at approximately 4:10 PM, a follow-up interview was conducted with the Risk Manager Associate. He stated being aware that physician’s transfer certification must be maintained in the patient’s medical record for 5 years per EMTALA regulations. A policy titled:” EMTALA” effective and last revised 07/23/25 was reviewed. The policy indicates that transfer records and logs inclusive of the Central Log will be maintained in the (hospitals) Transfer Center in accordance with (hospital) Transfer Procedures and (hospital) Policy Record Retention Maintenance.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 52621 Based on interviews, patient medical record reviews, review of the facility’s emergency on call log, audio recordings, media report, and review of the facility’s policy and procedure, the facility failed to provide within their service capabilities, the necessary stabilizing treatment after an emergency medical condition was determined for 1 of 21 patients records reviewed, (Patient #2). The findings include: A review of Patient #2’s medical record, who presented to the Emergency Department at 5:20 AM with a complaint of left lower quadrant pain and vomiting was found to have a left kidney stone with obstruction, documented as an emergency medical condition on 09/12/25. Patient #2’s pertinent medical history includes right nephrectomy (the removal of one kidney). A review of the laboratory results for Patient #2, dated 9/12/25, drawn at 5:32 AM, revealed an elevated Blood Urea Nitrogen (BUN) level of 30mg/dL (Normal range 8-24 mg/dL), a blood test that measures a waste product removed by the kidneys with urination, an elevated Creatinine level of 1.5 mg/dL (Normal range 0.7-1.3 mg/dL), a waste product filtered by the kidneys and removed with urination, a moderately decreased Estimated Glomerular Filtration Rate (eGFR) of 48.6 (Normal range 90 mg/mmol,) a blood test that measures how well your kidneys are functioning. A review of the Computed Tomography (CT) of the abdomen and pelvis with contrast (a dye used to enhance the visibility of the structures in the body) performed on 09/12/25 at 7:20 AM for Patient #2 was reviewed. It revealed a 4 millimeters (mm) distal left ureter obstructing stone with edematous appearance (a hard deposit in the kidney lodged in the tube that carries urine from the kidney to the bladder). A recorded phone conversation filed with the Central Transfer Center, dated 09/12/25 at 10:12 AM between the transfer and receiving facility was reviewed. EMTALA questions from the receiving facility confirmed that an emergency medical condition for patient #2 existed and the transferring facility had the capability to treat with urology services. Staff B, MD reported to the receiving Emergency Department physician, Patient # 2, as an established patient with a urologist that does not have privileges at the facility, with a kidney stone and uncontrolled pain. On 10/29/25 at approximately 10:25 AM, a phone interview was conducted with Patient #2. Patient #2 relayed that the attending physician informed him that the CT scan revealed a kidney stone with obstruction. The patient inquired about the available physician, and the attending physician informed him at that time that he would be transferred to a different facility where his urology group practices. The patient stated that he was not given the option or choice to receive treatment at the facility and was not made aware that the on-call urologist was contacted. He recalled that he did not urinate again after providing the urine sample upon admission, until after surgery that was performed at the receiving facility, approximately 8-9 hours later; and was informed later that his creatinine level had increased to 2.3, which caused him concerns. Patient #2 stated that his treatment was delayed due to his transfer and the need for an on-call surgical team at the receiving facility. On 10/28/25 at approximately 11:08 AM an interview was conducted with the Emergency Department (ED) Medical Director. He explained that if the Emergency Medical Condition (EMC) is emergent the patient will be stabilized first. A call would be made to the on-call urologist. On 10/29/25 at approximately 2:50 PM, a follow up interview was conducted with ED Medical Director. He confirmed that the facility has the capability to treat kidney stones and has a urologist on call. He further indicated that a patient with kidney stones should be offered treatment at the facility since it is within its capability, and per EMTALA regulations. On 10/29/25 at approximately 4:40 PM, a phone interview was conducted with Staff B, Doctor of Medicine (M.D.), the attending physician for Patient #2 on 09/12/25. Without recalling the specifics, she stated that the patient was likely transferred because the facility could not handle the urology caseload at that point. She does not recall specifically asking Patient #2 whether he preferred to remain at the facility or be transferred to continue care with his urology provider. She explained that while urology coverage was available, there was uncertainty about whether the remaining providers could manage the overall patient volume, however, didn’t remember calling the on-call urologist to have him make that determination. She clarified that the patient was an established patient of the other urology group and that her understanding was that the patient would be transferred because the facility could not accommodate that group’s patients. A review of the facility’s Emergency Physicians Schedule for 09/12/25 revealed no open shifts, indicating that the emergency department was fully staffed. On 10/30/25 at approximately 9:01 AM, an interview was conducted with the ED Nurse Manager Operations. She sated she feels there are enough physicians in the ED to care for the volume and the needs of the patients. On 10/30/25 at approximately 1:42 PM, an interview was conducted with the Assistant Risk Manager. He stated that on 09/12/25, the ED had only one urology case, Patient #2. A review of the Emergency Department on-call list for 09/12/2025 revealed a urologist was on-call on 09/12/25. A policy titled:” EMTALA” effective and last revised 07/23/25 was reviewed. C2-Emergency Medical Condition is described as a condition manifesting itself by acute and severe symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, organs or part. C4-Stabilizing treatment when the MSE indicates that the person has an EMC, TMH will provide treatment within the capabilities of the staff and facilities routinely available at TMH (on-call physicians and ancillary services) as required to stabilize the patient before the person is discharged or transferred to another facility. C5-Appropriate discharge or transfer, once the person is stabilized, TMH may discharge or transfer the person as appropriate. The person’s stabilized condition should be documented in the medical records. A medically unstable person will not be discharge or transfer unless the patient requests in writing a discharge or transfer to another facility after being informed of TMH’s EMTALA obligations and risks of discharge or transfer and a physician certifies in writing that the benefits of discharge or transfer outweigh the risks. A review of the facility’s policy and procedure titled “”TMH MEDICAL STAFF EMTALA & EMERGENCY DEPARTMENT ON-CALL POLICY,” approved by the Medical Executive Committee on January 7, 2025, Approved by the Board on January 22, 2025, indicates on page 5, “2.H If a patient who comes to the ED (i) requests that a particular physician be contacted to provide necessary stabilizing treatment, the physician is on TMH’s Medical Staff, or (ii) is known to have an attending physician on TMH’s Medical Staff in the appropriate specialty, all attempts will be made to contact the requested/attending physician prior to contacting the physician listed on the on-call schedule. In these situations, the requested/attending physician (or their alternate) is expected to respond within the time frames outlined in Paragraph 2.B of this Section, If the requested/attending physician is unavailable, the physician listed on the on-call rotation schedule will be contacted to provide the necessary consultation or treatment for the patient. A review of a local newspaper dated 07/09/2025 revealed an article reporting that the urology group ended its nearly 50-year partnership with the facility and is now providing services elsewhere. The article included statements from the facility’s Vice President and Chief Communications Officer indicating that the facility remains committed to providing safe, high-quality urologic care to the community. The article further stated that patients presenting to the Emergency Department with emergent urologic needs will continue to be evaluated and treated by one of the facility’s qualified urology providers.”

“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: 52621 Based on interviews, patient medical records reviews and review of the facility’s policy and procedure the facility failed to meet its obligation to provide treatment within its capability for a patient with an emergency medical condition, resulting in an inappropriate transfer for 1 out 21 patients, (Patient #2). The findings include: A review of Patient #2’s medical record, who presented to the Emergency Department on 09/12/25 at approximately 5:20 AM with a complaint of left lower quadrant pain and vomiting, was found to have a left kidney stone with obstruction, documented as an emergency medical condition. Patient #2’s pertinent medical history includes right nephrectomy (the removal of one kidney). An Emergency Department progress note documented by Staff B, Doctor of Medicine (MD,) dated 09/12/25 at 10:13 AM, stated that the patient was established with a different urology group, and was found to have a left kidney stone with uncontrolled pain, set to transfer to another facility. A review of the laboratory results for Patient #2, dated 09/12/25, drawn at 5:32 AM, revealed an elevated Blood Urea Nitrogen (BUN) level of 30mg/dL (Normal range 8-24 mg/dL), a blood test that measures a waste product removed by the kidneys with urination, an elevated Creatinine level of 1.5 mg/dL (Normal range 0/7-1.3 mg/dL), a waste product filtered by the kidneys and removed with urination, a moderately decreased Estimated Glomerular Filtration Rate (eGFR) of 48.6 (Normal range 90 mg/mmol, a blood test that measure how well your kidneys are functioning. A review of the Computed Tomography (CT) of the abdomen and pelvis with contrast (a dye used to enhance the visibility of the structures in the body) performed on 09/12/25 at 7:20 AM for Patient #2 was reviewed. It revealed a 4 millimeters (mm) distal left ureter obstructing stone with edematous appearance (a hard deposit in the kidney lodged in the tube that carries urine from the kidney to the bladder). A review of transfer information documentation from the Patient #2 Medical record on 09/12/25, revealed a high priority emergency medical transfer to a different facility listing the reason as “services not available”. A review of the Certification for Transfer dated 09/12/25 at 10:27 AM, revealed the reason for transfer was that the patient was establish with a different urology group. A recorded phone conversation filed with the Central Transfer Center, dated 09/12/25 at 10:12 AM between the transfer and receiving facility was reviewed. EMTALA questions from receiving facility confirmed that an emergency medical condition for patient #2 existed and the transferring facility had the capability to treat with urology services. Staff B, MD reported to the receiving Emergency Department physician, Patient # 2, was an established patient with urologist that does not have privileges at the facility, with a kidney stone and uncontrolled pain. On 10/29/25 at approximately 10:25 AM, a phone interview was conducted with Patient #2. He reported that his pain level upon arrival was approximately 9 out of 10 and had decreased to about 1 out 10 at the time of discharge. The attending physician informed him that the CT scan revealed a kidney stone with obstruction and explained that his urology group no longer held privileges at the facility. As a result, he would need to be transferred. The patient inquired about the next available physician, and the attending physician informed him at that time that he would be transferred to a different facility where his urology group practices. The patient stated that he was not given the option or choice to receive treatment at the facility and was not made aware that there was an on-call urologist available. He recalled that he did not urinate again after providing the urine sample upon admission, until after surgery, approximately 8-9 hours later; and was informed later that his creatinine level had increased to 2.3, which caused him concerns. Patient #2 stated that his treatment was delayed due to his transfer and the need for an on-call surgical team at the receiving facility. On 10/28/25 at approximately 11:08 AM an interview was conducted with the Emergency Department (ED) Medical Director. He explained that if the Emergency Medical Condition (EMC) is emergent the patient will be stabilized first. He further indicated that a discussion would follow with the patient to provide him with the choice of receiving treatment at the facility or being transferred. A call would be made to the on-call urologist, and if the decision is made to transfer the patient, the transfer center will initiate the transfer process after obtaining approval from the receiving facility. On 10/29/25 at approximately 2:50 PM, a follow up interview was conducted with ED Medical Director. He confirmed that the facility has the capability to treat kidney stones and has a urologist on call. He further indicated that a patient with kidney stones should be offered treatment at the facility since it is within its capability, and per EMTALA regulations. On 10/29/25 at approximately 4:40 PM, a phone interview was conducted with Staff B, Doctor of Medicine (M.D.), the attending physician for Patient #2 on 09/12/25. She explained that the facility suddenly lost the urology group without sufficient notice, leaving the remaining urologists challenged to manage the increased patient volume during the challenging transition after their departure. Without recalling the specifics, she stated that the patient was likely transferred because the facility could not handle the urology caseload at that point. She noted that they had only recently received guidelines outlining which urology patients to keep and which to transfer. She does not recall specifically asking Patient #2 whether he preferred to remain at the facility or be transferred to continue care with his urology provider. However, she indicated that she would likely have had that conversation, though she is unsure if it was documented in her progress note. She explained that while urology coverage was still available, there was uncertainty about whether the remaining providers could manage the overall patient volume, however, she didn’t remember calling the on-call urologist to have him make that determination. She clarified that the patient was an established patient of the other urology group and that her understanding was that the patient would be transferred because the facility could not accommodate that group’s patients. On 10/30/25 at approximately 9:01 AM, an interview was conducted with the ED Nurse Manager Operations. She stated that she feels there are enough physicians in the ED to care for the volume and the needs of the patients. On 10/30/25 at approximately 1:42 PM, an interview was conducted with the Assistant Risk Manager. He stated that on 09/12/25, the ED had only one urology case, and that was Patient #2. A review of the facility’s Emergency Physicians Schedule for 09/12/25 revealed no open shifts, indicating that the emergency department was fully staffed. A review of the Emergency Department on-call list for 09/12/2025 revealed a urologist was on-call on 09/12/25. A policy titled:” EMTALA” effective and last revised 07/23/25 was reviewed. C2-Emergency Medical Condition is described as a condition manifesting itself by acute and severe symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy, serious impairment to bodily functions, organs or part. C4-Stabilizing treatment when the MSE indicates that the person has an EMC, (hospital) will provide treatment within the capabilities of the staff and facilities routinely available at TMH (on-call physicians and ancillary services) as required to stabilize the patient before the person is discharged or transferred to another facility. C5-Appropriate discharge or transfer, once the person is stabilized, (hospital) may discharge or transfer the person as appropriate. The person’s stabilized condition should be documented in the medical records. A medically unstable person will not be discharge or transfer unless the patient requests in writing a discharge or transfer to another facility after being informed of (hospital’s) EMTALA obligations and risks of discharge or transfer and a physician certifies in writing that the benefits of discharge or transfer outweigh the risks.”