Emory Hillandale Hospital

“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: 50617 Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide stabilizing treatment within its capability and capacity and an appropriate transfer for one patient (Patient #3 - P#3) of 20 sampled patients. Specifically, P#3, a five-year-old child was brought to the facility (Facility A) on 9/18/24 at 1:38 p.m. for a laceration to the head sustained while playing. P#3 was discharged at 4:37 p.m. and his parent was instructed to take him to the children’s hospital (Facility B). Due to lack of transportation, P#3’s parent called emergency medical services (EMS) from home to transport P#3 to Facility B. P#3 arrived at the ED at Facility B at 7:48 p.m. Treatment included sutures, administration of blood products and a CT of the head. P#3 was discharged home with parent on 9/19/24 at 1:41 a.m. Findings Included: Cross refer to A-2407 as it relates to the facility’s failure to provide stabilizing treatment within their capacity and capability to P#3. Cross refer to A-2409 as it relates to the facility’s failure to effect an appropriate transfer for P#3.”

“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: 50617 Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide stabilizing treatment within its capability and capacity for one patient (P) #3 of 20 sampled patients. Specifically, P#3, a five-year-old child was brought to the facility (Facility A) on 9/18/24 at 1:38 p.m. for a laceration to the head sustained while playing. P#3 was discharged at 4:37 p.m. and his parent was instructed to take him to the children’s hospital (Facility B). A review of an ambulance report dated 9/18/24 at 7:07 p.m. revealed that EMS was called to pick up P#3 at his residence for bleeding from a laceration. P#3 arrived at the ED at Facility B at 7:48 p.m. Treatment included sutures, administration of blood products and a CT of the head. P#3 was discharged home with parent on 9/19/24 at 1:41 a.m. Findings Included: A review of the facility’s Medical Screening, Treatment and Related Issues policy”, no policy number, effective date 10/3/23 stated that any individual who comes to the Emergency Department or Labor & Delivery Department requesting care would be offered an appropriate Medical Screening Examination to determine if the individual has an Emergency Medical Condition. If an Emergency Medical Condition exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the policy, “EMTALA - Transfers To/From Other Facilities”. PROCEDURE: A. Overview If an Emergency Medical Condition is determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer if the Hospital lacks the capacity and capability to provide the stabilizing treatment. Stabilizing treatment should be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, ethnicity, insurance status, color, national origin, sexual orientation, disease or handicap). Pediatric Patients All pediatric patients who come to the ED are covered by this policy. Pediatric patients are defined as patients who come to the ED and are less than 16 years of age; are 16 years of age or older who have conditions primarily identified as pediatric; or are currently under the care of a pediatric generalist or specialist. A review of P#3’s medical record from Facility A revealed that he arrived to at 1:38 p.m. on 9/18/24 for a head laceration obtained while playing. At 1:52 p.m. Registered Nurse (RN) HH applied “gauze and wraps” on P#3’s head. Continued review of ED record revealed that RN HH assigned “Patient Acuity 3 (Urgent)”. A review of “Emergency Department Provider Note” by Physician Assistant (PA) GG filed on 9/18/2024 at 5:48 p.m. revealed that P#3 had history of autistic disorder, was nonverbal, came to ED with scalp laceration. Further review revealed that assessment of “SKIN:1.5 inch laceration (cut) noted to posterior (back) scalp, actively bleeding”.Further review of the provider’s note failed to reveal any diagnostics data or tests were done. A review of HPI in “Emergency Department Provider note” failed to reveal any documentation of PECARN Criteria. A review of “MEDICAL DECISION MAKING” in PA GG’s note revealed the case was discussed with Medical Doctor (MD) OO and because P#3 was a pediatric patient and would need to remain still for the laceration repair it was advised to have P#3’s parent take him to the children’s hospital (Facility B). P#3’s head was wrapped, and parent was agreeable to take P#3 to Facility B. A review of the ambulance ‘Rescue Patient Care Report’ revealed that the ambulance arrived at P#3’s residence for bleeding from an open scalp wound on 9/18/24 at 7:08 p.m. A review of the narrative revealed that P#3 had sustained a head laceration while playing with his siblings. P#3’s parent explained that P#3 had been taken to Facility A earlier in the day and was discharged home with instructions to go to Facility B. P#3’s parent reported that they had to walk home from Facility A because they do not have transportation. P#3’s parent called 911 from home because the wound was still bleeding. While en route to Facility B, P#3 removed the gauze bandage it laceration began bleeding heavily. A softball sized hematoma was observed. The ambulance arrived at Facility B at 7:41 p.m. A review of P#3’s medical record from Facility B revealed that he arrived via ambulance at 7:48 p.m. with a scalp laceration. A review of the ‘ED Provider Notes’ dated 9/18/24 at 10:01 p.m. revealed that P#3 had a 6 cm scalp laceration with a continuously expanding hematoma. P#3 was initially hemodynamically stable, but the laceration continued to bleed through the dressing and tachycardia worsened. P#3 showed symptoms of anemia, and it was determined that P#3 required a transfusion of packed red blood cells. P#3 had the laceration repaired with sedation. A CT of the head was done, and findings were reviewed with the family. Post transfusion laboratory tests and vital signs were completed. P#3 discharged home with parent on 9/19/24 at 1:49 a.m. During a telephone interview on 10/1/24 at 4:35 p.m. with Physician Assistant (PA) GG., PA GG recalled that P#3 was brought into the Emergency Department (ED) by his parent. . PA GG stated that based on her (PA GG) evaluation, P#3 looked well overall, and was walking around the room, but was resistant to her (PA GG) touching him (P#3). PA GG stated that P#3 had a bandage, which was ‘kinda’ oozing some blood, and she (PA GG) told P#3’s parent P#3 would need to be still and calm in order to have the laceration sutured. PA GG recalled that she spoke with the attending (MD OO) about whether to attempt intra-nasal sedation (spraying a small amount of a sedative drug into the nose) on P#3, but MD OO said to transfer P#3 to a children’s healthcare facility. PA GG further stated that P#3’s parent was eager to go, and she (PA GG) assumed P#3’s parent had transportation to take P#3 to Facility B.”

“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: 50617 Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide an appropriate transfer for one patient (P) #3 of 20 sampled patients. Specifically, P#3, a five-year-old child was brought to the facility on 9/18/24 at 1:38 p.m. for a laceration to the head sustained while playing. P#3’s was discharged at 4:37 p.m. and his parent was instructed to take him to the children’s hospital (Facility B). A review of an ambulance report dated 9/18/24 at 7:07 p.m. revealed that EMS was called to pick up P#3 at his residence for bleeding from a laceration. Findings included: A review of the facility’s “Medical Screening, Treatment, and Related Issues policy”, no policy number, effective date 10/3/23 stated that the purpose of the policy was to set forth procedures to ensure that all Hospitals with Dedicated Emergency Departments (DED) in the EHC system met all the requirements set forth in the Emergency Medical Treatment and Labor Act (“EMTALA”), 42 U.S.C. § 1395, for the examination and treatment of patients for whom a request for emergency care was made. PROCEDURE: Pediatric Patients a. All pediatric patients who come to the ED are covered by this policy. Pediatric patients are defined as patients who come to the ED and are less than 16 years of age; are 16 years of age or older who have conditions primarily identified as pediatric; or are currently under the care of a pediatric generalist or specialist. h. The ED attending physician should utilize the resources of the nearest appropriate pediatric hospital for patients who require transfer to a pediatric facility, transfer to a tertiary pediatric facility for evaluation or care, or follow-up with a pediatric generalist or specialist; or in the case of a patient who has an established relationship with an appropriate pediatric care provider, the ED attending physician may utilize that provider. Appropriate Transfers of Unstabilized Individuals 1. The Hospital shall provide appropriate transfers of unstabilized individuals only if and when any of the following conditions have been met: The individual (or person acting on their behalf) requests a transfer and the Hospital has informed that person of the risks of a transfer as well as the Hospital’s obligations under this policy. b. A physician has signed a certification that the benefits of the transfer of the patient to another facility outweighs the risks, and such certification is entered into the patient’s medical record; or, 2. Unless an unstabilized individual (or person acting on their behalf) requests a transfer pursuant to Section D.1.a above, the Hospital shall not transfer any unstabilized individual if the Hospital has the capability and capacity to stabilize the individual. 3. In order to transfer an unstabilized individual, all of the following criteria must be met: a. The Hospital must provide all appropriate treatment within its capacity necessary to minimize the risks inherent in transfer. b. The receiving hospital must have the available space and qualified personnel for the treatment of the individual. c. The Hospital must send all pertinent medical records to the receiving hospital; d. The Hospital must obtain consent from the receiving hospital prior to initiating the transfer; and e. The Hospital must ensure that the transfer of an unstabilized individual is affected through qualified personnel and transportation equipment, including the use of medically appropriate life support. A review of P#3’s chart revealed a note by PA GG at 4:38 p.m. on 9/18/24 that P#3’s mother was instructed as follows: “Please go to facility B for repair of scalp laceration” (a cut on the head). Further review of PA GG’s note revealed following: “Disposition: Stabilized/Treated and Discharged”. A review of P#3’s ED record failed to reveal documentation that P#3’s parent was offered an appropriate transfer for P#3 to facility B. Instead, P#3’s mother was instructed to take P#3 to facility B. An interview was conducted on 10/1/24 at 2:27 p.m. with ED Unit Director (UD) CC in the conference room of the facility. During the interview UD CC acknowledged that P#3 should have been transferred to the facility B for further care. During a telephone interview on 10/1/24 at 4:35 p.m. with Physician Assistant (PA) GG., PA GG recalled that she spoke with the attending (MD OO) about whether to attempt intra-nasal sedation (spraying a small amount of a sedative drug into the nose) on P#3 to perform sutures on the laceration, but MD OO said to transfer P#3 to a children’s healthcare facility. PA GG further stated that P#3’s parent was eager to go, and she (PA GG) assumed P#3’s parent had transportation to take P#3 to Facility B. During a follow up telephone interview with PA GG on 10/4/24 at 3:04 p.m. PA GG stated that during her conversation with P#3’s mother, it never came up that P#3 and his family did not have transportation. PA GG acknowledged that she (PA GG) did not offer to transfer P#3 via ambulance to P#3’s parent. .PA GG stated that a transfer to another facility would have been triggered when the attending physician assessed P#3 and approved the transfer. Since MD OO did not come to assess P#3, PA GG assumed that P#3’s mother would take P#3 to Facility B and that was why she (PA GG) instructed P#3’s mother to take the P#3 to facility B.”