Southeast Georgia Health System -- Camden Campus

“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: 47717 Based on review of medical records, Medical Staff Rules and Regulations, policies and procedures and staff interview it was determined that the facility failed to ensure that an appropriate medical screening examination (MSE) and transfer were performed for one (P#1) of of 20 sampled patients. Specifically, the facility failed to provide an appropriate MSE, including psychiatric evaluation for P#1. In addition, the facility failed to provide appropriate transfer, by discharging P#1 who had ongoing suicidal ideations without appropriate safety precautions in place. Findings included: Cross refer to 2406 as it relates to the facility’s failure to conduct an appropriate medical screening examination. Cross refer to 2409 as it relates to the facility’s failure to effect an appropriate transfer.”

“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: 47717 Based on medical record review, policies and procedures and staff interviews, it was determined that the facility failed to provide an appropriate, ongoing medical screening examination to determine whether an emergency medical condition (EMC) existed, including psychiatric examination for one (P#1) of 20 sampled patients. Specifically, P#1 presented to the facility’s Emergency Department with complaint of a ‘psychiatric problem’ on 8/5/23. P#1 endorsed suicidal ideations with a plan during the triage assessment. P#1 was not assessed or seen by a psychiatrist and an appropriate psychiatric evaluation was not done as there was no assessment of judgement, insight or thought process during the ED stay. P#1 was discharged into the care of a family member on 8/8/23 at 10:30 a.m. and found deceased by hanging on 8/9/23. Findings included: A review of Patient (P)#1 medical record revealed she was admitted to the ED (Emergency Department) on 8/5/23 at 1:50 a.m. She was ambulatory on arrival to the ED and was accompanied by police officers. Police Officers found P#1 with two propane tanks in her car, “to blow self-up”. P#1 reported “I was just going to make myself pass out” per documentation in P#1 medical record. P#1 denied loss of consciousness and reported “I have been to four different facilities in this month”. On 8/5/23 at 2:00 a.m. Medical Doctor (MD) CC performed a medical examination on P#1. A review of systems revealed psychiatric symptoms were depression and suicidal. Additional review of systems information was that all other symptoms were reviewed and otherwise negative. MD CC further documented from his medical examination that P#1 was cooperative, mood and affect was depressed, abnormal/psychotic thoughts: suicidal, not homicidal, not delusional, no hallucinations. On 8/5/23 at 2:07 a.m. a 1013 Form (Certificate Authorizing Transport To Emergency Receiving Facility & Report of Transportation (Mental Health) was signed by MD CC. On 8/6/23 at 9:00 a.m. P#1 was examined by Nurse Practitioner (NP) HH. NP HH documented P#1 was a 1013 for safety and was medically cleared, waiting for mental health bed placement in another facility. On 8/7/23 at 9:09 a.m. P#1 was evaluated by NP II. NP II documented P#1 was currently waiting for acceptance to mental health facility. On 8/7/23 at 3:38 p.m. MD GG saw P#1 and performed a face-to-face evaluation. He documented P#1 was not hearing any voices, did not want help with methamphetamine abuse at that time. MD GG further documented that P#1 was alert and oriented and was without any suicidal or homicidal ideation. MD GG documented to continue with 1013 observation until able to transfer to mental health for psychiatric evaluation/treatment. On 8/8/23 at 3:45 a.m. MD FF documented that P#1 became agitated, wanted to be discharge so she can go to a facility in Florida that supposedly was set up for her. Unfortunately, she could not find a family member that could take the responsibility. MD FF further documented he did not feel that P#1 was safe being discharged on her own so he renewed her 1013 until she could be placed at a psychiatric facility for evaluation. P#1’s care was transferred to MD EE on 8/8/23 at 7:00 a.m. On 8/8/23 at 7:00 a.m. MD EE documented an addendum that P#1 was seen earlier for suicide ideation after she was using drugs. P#1 was anxious to go home. P#1 denied adamantly being suicidal or homicidal. MD EE further documented P#1’s father was here and spoke with him to arrange that inpatient hospitalization seemed reliable. P#1 would be discharged with substance abuse and depression. A further review of MD EE’s documentation revealed P#1 denied any suicidal or homicidal ideation and that P#1’s father was at the bedside and assumed care to The Way at Clearwater. P#1 was medically clear for discharge per MD EE progress notes. On 8/8/23 at 10:20 a.m. P#1 was discharged to her father. A review of the facility’s policy titled” Medical Screening Examination and Stabilization Policy” no policy number, last reviewed 11/1/21, revealed that it is the facility’s policy that when an individual comes to the dedicated emergency department (DED) and a request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC), an appropriate medical screening examination (MSE), within the capabilities of the hospitals DED (including ancillary services routinely available and the availability of on call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists, or with respect to a pregnant woman having contractions, whether the woman is in labor and whether the treatment requested is explicitly for an EMC. If an EMC is determined to exist, the individual will be provided necessary stabilizing treatment, within the capability and capability of the facility, or an appropriate transfer as required by EMTALA. Such stabilization treatment shall be applied in a non-discriminatory manner (a different level of care because if diagnosis, financial, status, race, color, national origin, or handicap). An interview was conducted on 9/4/24 at 1:10 p.m. in classroom one via telephone with Medical Director (MD) JJ. He revealed the facility is a medical clearance facility. A medical examination and laboratory reviews are conducted to see if there is any medical reason why person may be having a psychiatric crisis. If the person was cleared medically then it would be determined whether or not the person needed a 1013 or a 2013 order. When this is determined the facility would then decide as to where person would be sent to. It was not common but not unusual to rescind on a 1013 while person was in the ED for an extended period of time. Whatever was going on at the time of admission may have resolved or changed during an extended stay in the ED. The patient could be discharged to family if they were involved. An interview was conducted on 9/4/24 at 4:14 p.m. via telephone in classroom one with MD FF. He revealed he did not remember P#1. He further revealed it was not a common practice for a 1013 to be rescinded. It all depended on the patient’s situation regarding family support and the patient would have to be stable enough not to harm him/herself. An interview was conducted on 9/6/24 at 3:56 p.m. via telephone with MD CC. MD CC revealed the facility is a tricky facility because it does not have any psychiatry backup. He further revealed in other facilities he had worked in they would have a crisis coordinator who would come in and evaluate the patient. MD CC stated they do try to coordinator with other facilities to try to place the 1013 patients.”

“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: 47717 Based on review of medical records, policies and procedures and interviews with staff it was determined that the facility failed to provide one (P#1) of 20 sampled patients with an appropriate transfer. Specifically, P#1, a psychiatric patient with a history of prior inpatient hospitalizations and suicide attempts was seen in the facility’s Emergency Department (ED) under an involuntary hold for suicidal ideations. Attempts to transfer P#1 to an inpatient psychiatric facility were unsuccessful. After three days in the ED, P#1 was discharged in the care of a family member who reportedly had secured P#1 a bed in an inpatient facility out of state. Neither facility staff nor providers communicated with the reported intended facility. Findings included: A review of Patient (P)#1 medical record revealed she was admitted to the ED (Emergency Department) on 8/5/23 at 1:50 a.m. She was ambulatory on arrival to the ED and was accompanied by police officers. Police Officers found P#1 with two propane tanks in her car, “to blow self-up”. P#1 reported “I was just going to make myself pass out” per documentation in P#1 medical record. On 8/5/23 at 2:07 a.m. a 1013 Form (Certificate Authorizing Transport To Emergency Receiving Facility & Report of Transportation (Mental Health) was signed by MD CC. On 8/6/23 at 9:00 a.m. P#1 was examined by Nurse Practitioner (NP) HH. NP HH documented P#1 was a 1013 for safety and was medically cleared, waiting for mental health bed placement in another facility. On 8/7/23 at 3:38 p.m. MD GG saw P#1 and performed a face-to-face evaluation. MD GG documented to continue with 1013 observation until able to transfer to mental health for psychiatric evaluation/treatment. On 8/8/23 at 3:45 a.m. MD FF documented P#1 becoming agitated, wants to be discharge so she can go to some facility in Florida that supposedly was set up for her. Unfortunately, she could not find a family member that can take the responsibility there. MD FF further documented he did not feel that she is safe being discharged on her own so he renewed her 1013 until she could be placed at a psychiatric facility for evaluation. P#1’s care was transferred to MD EE on 8/8/23 at 7:00 a.m. On 8/8/23 at 7:00 a.m. MD EE documented an addendum that P#1 was seen earlier for suicide ideation after she was using drugs. P#1 was anxious to go home. P#1 denied adamantly being suicidal homicidal P#1’s father was here and spoke with him to arrange that inpatient hospitalization seemed reliable. P#1 would be discharged with substance abuse and depression. A further review of MD EE’s documentation revealed P#1 denied any suicidal or homicidal ideation and that P#1’s father was at the bedside and assumed care to The Way at Clearwater. P#1 was medically clear for discharge per MD EE progress notes On 8/8/23 at 10:20 a.m. P#1 was discharged to her father. A review of the facility’s policies and procedures titled “EMTALA-Transfer Policy, date approved 4/20/12, date reviewed 10/20/21, revealed the policy reflected the guidance under the Emergency Medical Treatment and Labor Act (EMTALA) and associated State Laws only. Any transfer of an individual with an emergency medical condition (EMC) would be initiated either by a written request for transfer from the individual legally responsible person acting on the individual’s behalf or by a physician order with the appropriate physician certification as required under EMTALA. EMTALA obligations regarding the appropriate transfer of an individual determined to have an emergency medical condition (EMC) would be applicable in any dedicated emergency care center of the Health System whether located on or off the hospital campus and in all other departments of the hospital located on Health System property. The policy further revealed Transfer of individual Who are Medically Stable. EMTALA Would Not Apply. An individual who had been medically stabilized could be transferred upon request or pursuant to pre-arranged transfer/treatment plan of state, county or other entities if the individual agreed to the transfer and all of the following conditions are met: For transferring an individual with a psychiatric condition, the individual would be considered stabilized when he/she is protected and prevented from injuring himself/herself or others. Consent. The individual must consent to the transfer; and Conditions of Participation (CoP). The applicable Medicare Conditions of Participation (CoP) applied to the transfer of a medically stable individual. An interview was conducted on 9/4/24 at 1:10 p.m. in classroom one via telephone with Medical Director (MD) JJ. He revealed the facility is a medical clearance facility. A medical examination and laboratory reviews are conducted to see if there is any medical reason why person may be having a psychiatric crisis. If the person was cleared medically then it would be determined whether or not the person needed a 1013 or a 2013 order. When this is determined the facility would then decide as to where person would be sent to. It was not common but not unusual to rescind on a 1013 while person was in the ED for an extended period of time. Whatever was going on at the time of admission may have resolved or changed during an extended stay in the ED. The patient could be discharged to family is they were involved. The patient may sign a “No Harm Statement” releasing the facility and physicians from any liability. An interview was conducted on 9/6/24 at 3:56 p.m. via telephone with MD CC. MD CC revealed the facility is a tricky facility because it does not have any psychiatry backup. He further revealed in other facilities he had worked in they would have a crisis coordinator who would come in and evaluate the patient. MD CC stated they do try to coordinator with other facilities to try to place the 1013 patients.”

“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: 50527 Based on review of medical records, policy and procedures, staff interviews, it was determined that the facility failed to provide an appropriate transfer when one (P#1) of 20 sampled patients was transferred from the Emergency Department (ED) to another facility and the transferring facility had the capacity and capabilities to provide care to P#1. Additionally, 13 medical records reviewed revealed patients were transferred to another facility and the medical record failed to reveal a signed physician certification form. Findings included: Cross Refer to 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: 50527 Based on a review of medical records, staff interviews, and facility policies, it was determined that the facility failed to appropriately transfer one (P#1) of 20 sampled patients. Patient (P#1), who was 11 weeks pregnant presented to the Emergency Department (ED) on 7/31/24 with complaints of abdominal pain, nausea, chest pain, and tachycardia and the ED provider determined that the patient required treatment. The ED provider transferred P#1 to another acute care facility when an accepting physician was not located at the facility. In addition, review of medical records for 13 patients transferred failed to include a signed physician certification form with an explanation of the risks and benefits documented. Findings Included: A review of P#1’s ED record revealed that she arrived on 7/31/24 at 3:05 p.m. for complaints of abdominal pain, nausea, vomiting, and chest pain. P#1 reported that she was 11 weeks pregnant. Continued review of the record revealed that P#1 had been in the ED six (6) days earlier on 7/25/24 with complaints of nausea and vomiting. Continued review of the record revealed that P#1 was seen by ED Medical Doctor (MD) BB at 3:19 p.m. A review of ‘History of Present Illness’ that P#1 presented with right upper quadrant abdominal pain that started one (1) day ago, P#1 reported nausea and vomiting, chest pain, and tachycardia (fast heart rate over 100 beats per minute) episodes. P#1 denied shortness of breath, fever or back pain. P#1 had a history of pregnancy and was seen in the ED six days prior and diagnosed with cholelithiasis (gallbladder inflammation). Physician orders included laboratory tests, ultrasound of abdomen, intravenous fluids, and medications for pain and nausea. A review of the abdominal ultrasound report at 4:45 p.m. revealed findings consistent with acute cholecystitis. A follow up abdominal MRI revealed normal findings with no evidence of choledocholithiasis (presence of stones in the bile duct). A review of MD BB ‘Notes’ at 6:18 p.m. revealed that P#1 was evaluated and treated for an emergency medical condition. A bedside ultrasound showed good fetal movement and fetal heart rate of 154 beats per minute. P#1 likely presenting with biliary pathology. Gastroenterology was consulted. Laboratory results showed urinary tract infection. Continued review revealed that MD BB “had multiple phone conversation consultations with the hospitalist, general surgery and OB/GYN fortunately, unable to admit patient here or in Brunswick and we will transfer Jacksonville Memorial and that this may be an EMTALA at the end of the day I have to take care of the patient.” A review of the ‘Impression and Plan’ revealed a diagnosis of acute upper quadrant abdominal pain, acute worsening transaminitis (elevated liver enzymes), concern for cholecystitis (inflammation of the gallbladder), pregnancy and acute tachycardia. A review of “Calls-Consults” revealed the following: At 6:43 p.m., MD BB spoke with MD DD, a surgeon. MD DD recommended that if OB admitted P#1 and she was not a high risk, MD DD would evaluate the patient. At 6:50 p.m., MD BB consulted with MD CC, OB/GYN, who declined the admission. At 6:58 p.m., MD BB spoke with MD FF, who declined admission. At 7:10 p.m., MD BB spoke with MD DD, who declined the admission. At 8:37 p.m., MD BB contacted the Medical Director, MD GG, who would speak with the Chief of Staff, MD HH. At 9:17 p.m., MD BB consulted with MD EE, a hospitalist, who declined the admission. At 9:17 p.m., MD BB called a surgeon at another facility who agreed to accept the patient but stated ‘that this could be an EMTALA violation’. P#1 was discharged on 7/31/24 at 9:40 p.m. via ambulance transport to another facility. A review of the facility’s policy titled, “EMTALA - Medical Screening Examination and Stabilization Policy,” (no policy number, last reviewed 11/1/21) revealed that the purpose of the policy is that when an individual comes to the dedicated emergency department (DED). A request is made on his or her behalf for an examination or treatment for a medical condition, or a prudent layperson observer would believe that the individual presented with an emergency medical condition (EMC) and appropriate medical screening examination (MSE) within the capabilities of the hospital’s DED (including ancillary services routinely available and the availability of on-call physicians), shall be performed by an individual qualified to perform such examination to determine whether an EMC exists. Continued review revealed that if an EMC is determined to exist, the individual will be provided necessary stabilizing treatment within the capacity and capability of the facility or an appropriate transfer as required by EMTALA. A review of the facility’s policy titled, “EMTALA - Provision of On-Call Coverage”, (no policy number, last reviewed 7/28/21), revealed that the purpose of the policy was to establish guidelines for the facility, including a specialty facility and its personnel to be prospectively aware of which physicians, including specialists and sub-specialists, are available to provide additional medical evaluation and treatment necessary to stabilize individuals with emergency medical conditions. A review of the policy “Admission from Emergency Care Center”, (no policy number, last reviewed on 3/10/23.) The purpose was to provide guidelines for the admission of patients from the Emergency Care Center to in-house units at either Campus. 2. In-House Units: 1. Med/Surg-primary medical/surgical/gynecology diagnosis ICU-critical cardiac/medical diagnosis 2. Maternity-primary obstetrics A further review of the policy lists the following procedure: A. General In-House Units: 1. The ECC physician consults with the primary medical provider or on-call physician to obtain the patient’s acceptance of their service. 2. Attending physician, admitting diagnosis, date, and time are documented on the Chart. E. Obstetrics a. If the patient is greater than or equal to 20 weeks gestational age, send to Miriam and Hugh Nunnally Maternity Care Center for evaluation by the primary gynecologist or their designee. b. If the patient is less than 20 weeks gestational age, proceed as any other general in- house admission. A review of the facility’s “EMTALA-Transfer Policy” (no policy, last reviewed 4/20/2021)The purpose of this policy is to establish guidelines for either accepting an appropriate transfer from another facility or providing an appropriate transfer to another facility for an individual with an emergency medical condition (EMC) who requests or requires a transfer for further medical care and follow-up to a receiving facility as required by EMTALA, 42 U.S.C., Section 1395 and all Federal regulations and interpretative guidelines promulgated there under. It is the responsibility of the leadership team, Patient Care Services, Risk Management, Quality, and Medical Staff to ensure compliance with this policy and procedure and that all requirements are met. 2. A transfer will be appropriate if: a. 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. 3. Higher Level of Care: A higher level of care should generally be the primary reason to transfer an individual with an EMC that has not been stabilized. The following are examples of higher levels of care: a. A receiving hospital with specialized capabilities or facilities that are not available at the health system (including, but not limited to, burn units, shock-trauma units, neonatal intensive care units or regional referral centers) must accept and appropriate transfer of an individual with and EMC who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual. The Chief Medical Officer (CMO) MD HH was interviewed by phone on 8/14/24 at 9:30 a.m. MD HH explained that physicians on the “on-call list” are expected to discuss patients with the ED MD and come to the facility to see the patient when the ED MD requests a patient to be seen. If a physician declines to see the patient, the ED MD can contact CMO HH, who will then call the on-call MD to discuss the case and why they declined to see or admit a patient referred to them by the ED MD. CMO HH explained that the general rule is that the OB/GYN does not admit pregnant women with a medical issue under 20 weeks gestation. He further explained that the hospitalist would generally admit pregnant patients with a medical diagnosis unrelated to pregnancy under 20 weeks gestation and they would then consult an OB/GYN to see the patient in the facility. CMO HH explained that if the pregnant woman had a surgical diagnosis, the on-call surgeon, was contacted to assess and/or admit the patient to the facility, and the OB/GYN MD will be consulted. CMO HH recalled being called by Medical Director GG about P#1. He recalled that P#1 was considered high risk obstetrical patient due to increased white blood count (WBC), elevated bilirubin (a yellow pigment in bile that if high in blood tests could indicate gallbladder issues), and tachycardia. CMO MD HH explained that they do not have the services at the facility to care for high-risk Obstetrical (OB) patients. CMO HH recalled that there had been questions about P#1 being septic and possibly needed surgery. MD HH was under the impression that P#1 was high-risk and there was concern about the fetus. An interview was conducted on 8/14/24 at 9:45 a.m. in classroom A with the Surgeon and Vice Chief of Staff (MD) DD. MD DD verified that he was the surgeon on-call when P#1 was in the ED. MD DD explained that the facility was limited by the services it provides as a small facility. MD DD explained that there was not a gastroenterologist (GI) or cardiologist on-call on evenings or weekends. The facility had a sister facility that provided these services, which was about one-half hour away. MD DD believed P#1 may have needed an Endoscopic Retrograde Cholangiopancreatography (ERCP - procedure that combines endscopy and X-ray imaging to diagnose and treat problems in the liver, gallbladder, bile ducts, and pancreas), which could only be done at the sister facility. A phone interview was conducted on 8/14/24 at 10:30 a.m. with Hospitalist (MD) EE. MD EE did not recall P#1, although he reviewed the chart, he stated that if he had been contacted, he would not have admitted her under their service because he believed P#1 was a surgical case and not medical due to the cholelithiasis diagnosis. MD EE stated that if the nausea was related to hydration or the urinary tract infection (UTI), he could have admitted; however, there was concern that she was only 18 years old and eleven (11) weeks pregnant. An interview was conducted in Classroom A on 8/14/24 at 11:00 a.m. with Obstetrics/Gynecology (OB/GYN) (MD) CC. MD CC was on call the day P#1 presented to the ED. MD CC recalled that P#1 had been in the ED earlier and that her liver function tests (LFT) and bilirubin were elevated on the return visit. Therefore, the medical issues were not pregnancy related. MD CC stated it was her understanding that the surgeon wanted P#1 seen by gastroenterology (GI). Therefore, since it was not pregnancy-related, she would not be the MD to admit the patient. MD CC explained that she did not feel she was the appropriate MD to admit P#1 because there was something more going on besides the pregnancy. MD CC said she would have been willing to follow the patient as a consultant. A phone interview was conducted on 8/14/24 at 1:00 p.m. with the surgeon (MD) FF. MD FF had been the on-call surgeon at the sister facility the day P# 1 presented to the ED on 7/31/24. MD FF recalled that MD BB, contacted him about transferring P#1 to the sister facility. MD FF did not believe that P# 1 needed to be transferred to the sister facility and felt that the facility could handle the case from his standpoint. He was aware that P#1 was 18 years old and 11 weeks pregnant with an increased bilirubin; but that P#1 did not need a higher level of care. MD FF explained that the facility could have admitted and observed P#1 and repeat the laboratory tests in the morning to see if there was a stone in the bile duct. He did not understand why the facility would not admit and observe P#1 at the facility. He stated that gastroenterology (GI) generally did not perform ERCPs for pregnant patients with gallstones. MD FF did not feel the bilirubin level at 3.0 was that high. He was aware that P#1 had been in the ED six (6) days earlier for hydration. MD FF did not consider P#1 high-risk but said that there was an issue with MDs being concerned about caring for pregnant patients. A phone interview was conducted on 8/14/24 at 1:30 p.m. with the Emergency Room Medical Director (MD) GG. MD GG stated that he relied on the ED physicians to make decisions about consults and admissions. He believed that when an ED physician consulted an on-call MD, the level of willingness varied between this facility and the sister facility. They are trying to work on the “culture” between the facilities. MD GG further explained that the hospitalists often handle the medical admissions at the sister facility, where they will consult the other specialists. MD GG said that this facility could do this. MD GG recalled speaking with MD BB about P#1 when MD BB was getting “push-back” from the on-call physicians. MD BB believed that P#1 needed to be admitted because she was high-risk and agreed to the referral to the outside facility and “let it play out.” MD GG explained that he expected the facility to be able to handle P#1 but that the on-call physicians would not admit her, so the transfer was necessary for P#1 care. MD GG made MD HH aware of the situation. During an interview on 8/14/24 at 2:43 p.m. in the conference room, Compliance Officer (CO) II explained that he was the individual who self-reported the potential Emergency Medical Treatment and Labor Act (EMTALA) violation on the Centers for Medicare and Medicaid Services (CMS) website. CO II recalled that he was first informed of the potential violation when a Risk Manager heard about it and reported it to CO II. CO II recalled that he began an investigation immediately which included reviewing the chart, interviewing individuals involved, and reviewing the policies regarding EMTALA. CO II recalled that at the end of the investigation, he felt that the facility had the capacity to admit the patient for further evaluation even though the patient did get a medical screening examination and a stabilization treatment. CO II said that the transfer may not have been appropriate. CO II said that after reporting the potential EMTALA violation, he has been coordinating with the executive medical staff and realizing areas for opportunities for improved physician communication and how to handle appropriate admissions and transfers. CO II said that meetings are being scheduled and that education will soon be dispersed to all physicians once they are available. An interview was conducted in the facility’s classroom A on 8/14/24 at 2:00 p.m. with Emergency Room (MD) BB, who cared for P#1 on 7/31/24. MD BB recalled that P#1 presented with pregnancy, tachycardia, right upper quadrant pain, elevated liver function tests, biliary pathology, and hyperemesis (persistent nausea and vomiting that may occur during pregnancy). He felt that something more was going on than just the pregnancy and ordered the ultrasound, labs, fluids, anti-emetics (medication used to prevent nausea and vomiting). He did the Magnetic Resonance Cholangiopancreatography (MRCP) (medical imaging used to visualize biliary and pancreatic ducts) to make sure P#1 did not have choledocholithiasis and the test results were negative. MD BB remembered discussing the case with the on-call surgeon twice, thinking P #1 might be surgical. He explained that MD DD wanted the OB/GYN MD to admit P#1 because she was pregnant. MD BB explained that it was the “perfect storm” where it was possibly surgical. The hospitalist doesn’t generally touch pregnant patients, and the OB/GYN MD generally doesn’t see patients under 20 weeks. It’s the facility’s culture, which is different from his experience at other facilities. MD BB explained that this situation would not have occurred if P#1 had presented to the sister facility. Generally, the OB/GYN and surgeons at the sister facility would have admitted the patient. MD BB remembered speaking to MD FF, the surgeon at the sister facility. MD FF told MD BB that he felt they could handle the case at their facility, which is why MD FF refused the transfer. MD BB explained that he could not hold P#1 for observation because he was the only MD in the ER. If something serious came in, he could not adequately oversee P#1’s care, and that was why he wanted her admitted. He was concerned that more was going on due to her tachycardia and laboratory test and felt she could not be safely discharged. MD BB stated that when the on-call physicians refused to admit, he called MD GG, who then called CMO HH. CMO HH advised that P#1 be transferred elsewhere. MD BB stated that he shared his concerns about a possible EMTALA violation with MD GG. A review of 13 medical records (P#1, P#3, P#4, P#5, P#6, P#8, P#10, P#12, P#13, P#15, P#16, P#17, and P#18) failed to reveal a signed physician certification for transfer. During an interview on 8/14/24 at 10:25 a.m. in the conference room, Emergency Room (ER) Manager (ERM) JJ said that when patients are transferred, they are given a general ER packet for transfer. ERM JJ said that the ER did not use the same transfer packet that is used in the Labor and Delivery or Obstetrics (OB) unit which contained a Physician Certification for Transfer Form. ERM JJ said that he was not sure why the ER did not use the form and said that this may be something they should include as well.”

“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: 42305 Based on medical record review, Medical Staff Rules and Regulations, policies and procedures and interviews with staff it was determined that the facility failed to conduct an appropriate transfer for one Patient (P) #1 of 20 sampled patients. P#1 arrived to the facility’s Emergency Department (ED) on 2/7/24 at 7:43 p.m. after sustaining a fall. A medical screening examination was conducted, and the decision was made to transfer P#1 as soon as possible to a higher level of care. P#1 arrived at the receiving facility at 9:00 p.m. Facility staff failed to confirm that the receiving hospital had accepted P#1; failed to complete a transfer packet including physician certification; and failed to provide the receiving facility with the required medical records.”

“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: 42305 Based on medical record review, Medical Staff Rules and Regulations, policies and procedures and interviews with staff it was determined that the facility failed to provide one Patient (P) #1 of 20 sampled patients with an appropriate transfer. The Emergency Department (ED) failed to complete a transfer packet including physician certification that the medical benefits outweighed the risks of transfer. The ED failed to confirm that the receiving facility had space and qualified personnel and agreed to accept P #1 as a transfer. Findings included: A review of the facility’s Central Log revealed that Patient (P) #1 arrived to the Emergency Department (ED) via Emergency Medical Services (EMS) and was registered as a patient on 2/7/24 at 7:43 p.m. Review of the Emergency Department (ED) record revealed that P#1 was triaged by the Registered Nurse (RN) EE at 7:48 p.m. The Medical Screening Exam (MSE) by the Medical Doctor (MD) FF at 7:48 p.m. revealed that P#1 had head trauma due to a fall, hip pain, and hematoma of her face. There were significant signs of external trauma. MD FF instructed the nurses to call 1 (800) Bad Hurt to get auto acceptance. Review of the MSE revealed that P#1 was accepted by 1 (800) Bad Hurt and transferred in critical condition due to trauma. Continued review P#1’s ED record failed to reveal a transfer packet and physician certification of the risks and benefits of transfer. The record failed to reveal documentation that the receiving hospital had space, qualified personnel and equipment and had agreed to accept and give appropriate transfer. There were no departure/transfer times observed in the medical record. Review of the EMS Pre-hospital Care Report on 2/7/24 at 8:30 p.m. revealed that P#1 arrived at the receiving hospital at 9:00 p.m. Review of the Medical Staff Rules and Regulations adopted by the health system on 3/27/2018, revealed that the Emergency Room Medical Director would have the overall responsibility for emergency care, subject to the authority of the Board. Patients with conditions whose definitive care was beyond the capabilities of the hospital would be referred to the appropriate facility, when in the judgment of the attending practitioner, the patient’s condition permitted such a transfer. No patient would be arbitrarily transferred, and inquiry would be made as to acceptance of the patient by the receiving hospital and physician. A copy of pertinent medical records would accompany the transfer. The hospital’s procedures for patient transfers to other facilities would be followed. Patients would be evaluated by a physician prior to discharge or transfer. Review of the “EMTALA - Transfer Policy”, Version 1, Reviewed 4/20/21, revealed that transfer of an individual with an Emergency Medical Condition (EMC) must have been initiated either by a written request for transfer from the patient’s legal representative or by a physician’s order. When an individual who had not been stabilized was transferred, a physician would sign a certification that the medical benefits outweighed the increased risk to the individual being transferred. The receiving facility would have available space and qualified personnel for the treatment of the individual and would have agreed to accept the transfer and to provide appropriate medical treatment. The policy further revealed that before any transfer could occur, the transferring hospital had to provide, within its capacity and capability, medical treatment to minimize the health of the individual or unborn child. The transferring hospital was required to call the receiving facility to verify the receiving hospital had available space and qualified personnel for the treatment of the individual. The receiving hospital must have agreed to accept the transfer and provide appropriate treatment. The transferring hospital must have documented its communication with the receiving hospital, including the request date and time and the name of the person accepting the transfer. The transferring hospital would send copies of all medical records related to the EMC that were available at the time of the transfer. The physician was required to sign an express written certification that, based on information available at the time of transfer, the medical benefits of transfer were reasonably expected to outweigh the increased risks to the individual or unborn child. The certification should have been specific to the condition of the patient upon transfer and contain a complete picture of the benefits to be expected from appropriate care at the receiving facility. The certification must have stated the reason for transfer. Review of the Fresh Trauma Transfer Policy poster from the receiving facility revealed that 1-800-BAD HURT would be called to initiate the transfer. Reports would include the time of injury, mechanism of injury, pre-hospital details, medication given, blood transfusions, pertinent labs and imaging, and injuries identified. An interview took place with the ED Nurse Manager (NM) AA on 3/11/24 at 3:15 p.m. in the Conference Room. NM AA said P#1 came into the ED with Emergency Medical Services (EMS) after a traumatic fall. P#1 was evaluated by a physician who informed the nurses to call Bad Hurt and transfer her quickly. The Unit Coordinator (UC) attempted to call. Whenever Bad Hurt is called, they are given vital signs, mechanism of injury, and basic information. The UC did not have all the relevant information, so Bad Hurt could not auto accept P#1. The UC was told to call back with the information needed. The call back never happened. If the UC had called back, the patient would have been auto accepted and there would be a name of the accepting physician. Transport would have been arranged from there. There was not usually physician-to-physician discussion with auto acceptance. Nurse-to-nurse communication would occur before or at transfer when the patient was ready to leave. The ED had a transfer sheet with patient information, vital signs, accepting physician, medications, and a place where the nurse gave a report. Any patient who transferred had to have a transfer form. The transfer sheet was not completed for P#1. A telephone interview took place with the Unit Coordinator (UC) CC on 3/11/24 at 5:18 p.m. UC CC said that she did not have P#1’s vital signs when calling, so Bad Hurt said to call back with more information. UC CC asked the clinical lead if transfer paperwork was needed, and he said no. The clinical lead had a patient coding at that time, so UC CC asked the primary nurse who was in the room with P#1 if an accepting physician was needed, and he said not to worry about it. The transfer center called back when P#1 was in route, and UC CC told them the patient was on their way. UC CC conferred with the clinical lead again, and he said they did not need to do any paperwork. A telephone interview took place with the Clinical Lead (CL) DD on 3/11/24 at 5:31 p.m. CL DD said MD FF came into the room where CL DD was working and said there was a trauma patient who needed to be gotten out as soon as possible. There was a huge baseball-sized hematoma (knot) on P#1’s head. The unit coordinator called the transfer center, and CL DD asked EMS if they could help transfer P#1. The ED did not have all the paperwork together when the unit coordinator tried to call the transfer center back. CL DD told UC CC not to worry about it, because they needed to get P#1 out of the ED. EMS put P#1 on the stretcher and out the door she went on her way to the other hospital. CL DD said he called 1-800- Bad Hurt, and they had not done an auto-accept. A telephone interview took place with the Triage Nurse (RN) EE on 3/11/24 at 6:05 p.m. RN EE said MD FF came in shortly after RN EE started triage. MD FF looked at P#1, asked a couple of questions, then said she needed to get transferred to trauma. MD FF spoke to EMS, and P#1 was going to be gotten out with the same squad that brought her to the ED. Later, RN EE got a call from the trauma nurse asking for a report. The trauma nurse said they had a patient there and they did not know what was going on. RN EE told the nurse what he remembered and gave them a report after the fact. The trauma hospital received a packet with nursing notes and MD assessments but did not get a transfer packet or doctor to whom MD FF spoke. A telephone interview took place with the Medical Doctor (MD) FF on 3/12/24 at 4:22 p.m. MD FF said P#1 had a large hematoma (knot) on her forehead, vomiting, and a painful hip. When MD FF said to call 1 (800) bad hurt, the EMS crew asked if they should have taken her to the trauma center first. When MD FF said yes, the crew offered to take her. MD FF said that whenever bad hurt was called, if the patient was at the trauma hospital within an hour, the patient was auto accepted. There was a golden hour with trauma. MD FF said patients were always auto accepted, and he could not remember the number of times he had spoken to a person. MD FF said there was a high probability of head trauma, and if P#1 was kept at the ED with a head trauma, there were no trauma services, including orthopedics, a trauma surgeon, etc. There was multi-organ involvement with the hip and head pain. MD FF normally signed transfer paperwork and told the unit coordinator it was trauma. The physician did not call bad hurt. A tour of the Emergency Department (ED) took place on 3/12/24 at 11:15 a.m. with the Quality Director and the Administrator. The unit coordinator provided a transfer packet to this surveyor that NM AA said would be completed at the time a patient was transferred and was not completed for P#1.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 31098 Based on observation and interview, the facility failed to ensure the maintenance of infection prevention standards in the surgical department. Specifically, the facility failed to ensure contaminated shoe covers were not worn from 1 of 1 decontamination room into a designated clean area of the surgical department. Findings included: During an observation on 01/22/2024 at 3:45 PM of the decontamination room, while accompanied by the Sterile Processing Manager (SPM), significant amounts of water in multiple puddles on the floor of the room were identified. Sterile Processing Department (SPD) Technician #14 was observed removing instruments from a rinse sink, placing them into a wire tray, and placing the tray onto a cart used to transfer items to a washing machine. In the process of transferring the tray from the sink to the cart, water was observed dripping onto the floor. Additionally, water was observed draining off the top of the cart onto the floor. Thereafter, the SPM directed the surveyor to exit the decontamination room via a doorway that opened to a short hallway in an operating room (OR) suite behind a red line, which indicated that the space was a clean area. At that time, the shoe covers worn by the surveyor and SPM were soaked in water from the decontamination room, which had now contaminated the floor in the clean OR area. On 01/23/2024 at 3:40 PM, the surveyor conducted an interview with the Patient Safety Manager, the Manager of Infection Prevention and the Infection Preventionist. The Manager of Infection Prevention stated the observation in question represented a coaching moment.”