Navicent Health Baldwin

“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: 49224 Based on a review of medical records, policy and procedures, observations, and staff interviews, it was determined that the facility failed to ensure that EMTALA signage was posted in the emergency department in places likely to be noticed by all individuals that entered to seek services. Further, the facility failed to ensure that medical records, including radiologic images, were transferred with the patient to the receiving facility in a timely manner. Findings: Cross refer to A 2402, as it relates to the facility’s failure to post EMTALA signage. Cross refer to A 2409, as it relates to the facility’s failure to ensure an appropriate transfer of P#1 to a receiving medical facility.”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 49224 Based on review of policy and procedures, observations and staff interviews, it was determined that the facility failed to ensure that EMTALA signage was posted in a conspicuous location in the ambulance entrance. Specifically, during a facility tour on 6/30/25 at 10:15 a.m. EMTALA signage was not observed at the entrance of the facility’s ambulance bay. Findings: A review of facility policy titled, “EMTALA Policy” effective 7/30/24 revealed that EMTALA signage was to be posted was referred to as the facility’s requirement to post signs conspicuously in the ED in a place or places likely to be noticed by all individuals that entered the ED as well as those individuals waiting for examination and treatment in areas other than the ED located on facility property that informed individuals of their rights under Federal law with respect to examination and treatment for emergency medical conditions EMSs and women in labor. A tour of the emergency department (ED) was conducted with Chief Executive Officer (CEO) AA, Director of Women’s Health (DWH) BB, and Emergency Department Manager (EDM) CC on 6/30/25 at 10:15 a.m. EMTALA signage was absent outside and inside the ED ambulance bay. An interview was conducted with EDM CC on 7/1/25 at 11:56 a.m. in a conference room. EDM CC stated that she had been the ED manager for the last three years. She agreed that she did not see signage posted at the ambulance bay at the time of the tour on 6/30/25 at 10:15 a.m.”

“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: 49224 Based on medical record review, staff interviews, and facility policies and procedures, it was determined that the facility failed to ensure that required documentation was transferred with P#1 to the receiving facility on 5/31/25. Specifically, P#1’s Consent to Transfer Form failed to show that P#1’s medical records and radiologic images were sent to the receiving medical facility in a timely manner. Findings: P#1’s medical record at transferring facility (Facility A) revealed that Section III Transport Information on P#1’s EMTALA Transfer Certificate failed to acknowledge who the report was given to at the receiving facility, the name of the transporter, and whether medical records and imaging were sent with transport to receiving facility B, the receiving medical facility. A review of P#1’s medical record at the receiving facility (Facility B) revealed P#1 arrived at facility B’s ED on 5/31/25 at 5:08 a.m. Page 14 of P#1’s medical record revealed P#1 received an appropriate MSE, but no image disc was provided from facility A. A review of facility policy titled, “EMTALA Policy”, no number, effective 7/30/24 revealed that an appropriate transfer was defined as one that occurred when (iii) the transferring facility sent to the receiving facility all medical records (or copies) related to the emergency medical condition (EMC) of the patient, available at the time of transfer, including records related to the EMC, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone results of the studies, and informed written consent for transfer or certification, and that any other records that were not readily available at the time of transfer were sent as soon as practicable after the transfer. An interview was conducted with EDM CC on 7/1/25 at 11:56 a.m. in a conference room. EDM CC stated a transfer form was completed on every patient prior to their transfer to another facility. She said the expectation was for medical records and necessary images to be sent with the patient or that the images be sent electronically if the receiving facility also had Powershare (the facility’s means of electronic transfer). She said her facility utilized Powershare (means of electronic transfer), which was a means to electronically send and receive radiologic images from facilities. She said the transporting activity should be documented onto the Consent to Transfer form and input into the patient’s electronic medical record. She further stated that the radiology department was responsible for pushing requested images out to the transport receiving facility.”