St Mary’s 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: 49416 Based on medical record review, policy review, and patient and staff interview, it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24: Responsibilities of Medicare Participating Hospitals in Emergency Cases. Refer to A - 2407 as it relates to the facility’s failure to provide an appropriate stabilizing treatment for 1 of 20 patients (Patients #8) whose record was reviewed. Refer to A - 2409 as it relates to the facility’s failure to ensure an appropriate transfer for 5 of 18 patients (Patients #3, #4, #7, #9 and #13) who were transferred and whose records were reviewed. Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the ER seeking emergency care.”

“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: 44100 Based on medical record review, staff interview, and policy review, it was determined the hospital failed to provide stabilizing treatment to the best of their ability for 1 of 18 Patients (Patient #8) whose records were reviewed and required a transfer. This had the potential to delay treatment for this patient and other transfer patients. Findings include: A hospital policy titled “Patient Transfer to Other Facility”, approved 04/03/25, was reviewed. The policy stated, “If a patient’s clinical condition requires resources and technical expertise not available within...transfer to a facility with the necessary resources and expertise may be indicated.” “To the extent possible, based on the patient’s condition, the risks and benefit associated with transfer to another facility should be discussed with the patient.” This policy was not followed. An example includes: Patient #8 was a 56 year old male who presented to the ED on 6/20/25 at 13:47 with a chief complaint of severe abdominal pain in all 4 quadrants with abdominal distension, pain rated at 10/10 with nausea and vomiting. Patient #8’s past medical history included renal failure and renal transplant 4 years ago, colon resection and ostomy 2/2/25. Patient #8 received a MSE at 13:52. The hospital was at that time on divert due to loss of power and subsequently no radiologic services. The ED Physician note stated patient was discharged 6/19/25 from an acute care hospital after abdominal surgery which resulted in an ileostomy. The ED Physician ordered morphine 4mg IV and ondansetron 4mg IV for pain and nausea control. No other stabilizing treatment was performed. No labs were drawn. There was no documentation of communication with the surgeon at the acute care hospital where Patient #8 had discharged the previous day; that hospital was located 184 miles north of this hospital. ED physician noted, “his examination is concerning for acute abdomen including intra-abdominal pathology such as SBO, perforation or other serious infection or cause of pain.” Nearby hospital was contacted to confirm CT was available. The ED physician note stated their ambulance was not available. Patient agreed to transfer via private vehicle to nearby hospital for a diagnostic CT rather than wait for available ambulance to transport. Patient #8 travelled 16 miles south to nearby hospital for a diagnostic CT and labs. Patient #8’s disposition on the ED log was listed as “transfer.” A request for the transfer form was requested. No transfer form was received prior to surveyor exit. Two more requests for the transfer form for Patient #8 were made via email without response. Patient #8’s medical record was reviewed in the presence of the DNS. The DNS confirmed in an interview on 6/24/25 beginning at 9:00 AM, that Patient #8 was driven to another hospital via private vehicle to obtain a diagnostic CT. She confirmed there was no documented discussion of other options or risks of private vehicle transport. The hospital failed to ensure diagnostics and stablizing treatment were not delayed for Patient #8.”

“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: 49416 Based on policy review, record review, and staff interview, it was determined hospital staff failed to ensure the risks and benefits of a transfer were documented prior to transfer 6 of 18 patients (Patients #3, #4, #7, #8, #9 and #13) whose records were reviewed and were transferred out of the hospital. This failed practice placed patients at risk of unsafe or potentially inappropriate transfer route. Findings include: Hospital policy titled “EMTALA” with reviewed date of 7/11/2023 was reviewed. The EMTALA policy stated under the section “Appropriate Discharge or Transfer” “Appropriate transfer ... arrange for transfer by qualified personnel and appropriate equipment.” This policy was not followed. Examples Include: 1.Patient #3 was a 40-year-old female who presented to the ED on 6/07/25 at 16:35 with reason for visit listed as “Post surgery bruising.” The patient was provided a MSE and transferred via private vehicle to an outside facility for a higher level of care. Patient #3’s medical record was reviewed, including her transfer form. The section on “Transport Agency/Equipment & Medical Personnel” had private vehicle marked. This section additionally stated, “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures.” The medical record did not document the risks and benefits of the transport via private vehicle. The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #3’s record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle. 2.Patient #4 was a 17-year-old male who presented to ED on 6/11/25 at 09:20 with reason for visit listed as “ABD pain.” Patient #4 was provided an MSE as well as X-ray and CT scan and medical record documented an “acute appendicitis.” Patient #4 was transferred via private vehicle to an outside facility for a higher level of care. Patient #4’s medical record was reviewed, including his transfer form. The section on “Transport Agency/Equipment & Medical Personnel” had private vehicle marked. This section additionally stated, “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures.” The medical record ED note dated 6/11/25 documented Patient #4 chose to go private vehicle with no documentation of the risks and benefits of transport via private vehicle. The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #4’s record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle. 3.Patient #7 was an 87-year-old male who presented to the ED on 5/19/25 at 15:12 with the reason for visit listed as “Stroke Symptoms.” Patient #7 was provided an MSE and transferred to an outside facility for a higher level of care via private vehicle. Patient #7’s medical record was reviewed, including his transfer form. The section on “Transport Agency/Equipment & Medical Personnel” had private vehicle marked. This section additionally stated, “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures.” The medical record did not document the risks and benefits of the transport via private vehicle. The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #7’s record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle. 5. Patient #8 was a 56 year old male who presented to the ED on 6/20/25 at 13:47 with a chief complaint of severe abdominal pain in all 4 quadrants with abdominal distension, pain rated at 10/10 with nausea and vomiting. Patient #8’s past medical history included renal failure and renal transplant 4 years ago, colon resection and ostomy 2/2/25. Patient #8’s medical record was reviewed. There was no trasnfer form documented. The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #8’s record was reviewed. The DNS reported there was no transfer currently in the chart but would review scanned in documents. Upon review DNS emailed surveyor and reported, “it does not appear there was a Transfer form filled out. Just the phone call to Syringa and the RN to RN phone call. Medical Records could not find a transfer form in his chart.” 4.Patient #9 was a 60-year-old female who presented to the ED on 5/03/25 at 19:42 with the reason for visit listed as “injured right knee.” Patient #9 was provided an MSE, her medical record documented a “fracture above of distal humerus above total knee prosthesis” and transferred to an outside facility for a higher level of care via private vehicle. Patient #9’s medical record was reviewed, including her transfer form. The section on “Transport Agency/Equipment & Medical Personnel” had ambulance/BLS and private vehicle both marked. This section additionally stated “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures.” The medical record did not document the risks and benefits of the transport via private vehicle. The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #9’s record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle. 5.Patient #13 was a 57-year-old male who presented to the ED on 6/16/25 at 11:45 with reason for visit listed as “SOB.” Patient #13 was provided a MSE and medical record documented a “right lower lobe and perihilar infiltrate with increasing right sided pleural effusion: and transferred to an outside facility for a higher level of care via private vehicle. Patient #13’s medical record documented, “he has O2 tanks for drive.” Patient #13’s medical record was reviewed, including his transfer form. The section on “Transport Agency/Equipment & Medical Personnel” had ambulance/BLS and private vehicle both marked. This section additionally stated, “The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures.” The medical record did not document the risks and benefits of the transport via private vehicle. The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #13’s record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle. The hospital failed to ensure complete and accurate transfer documentation was provided to the receiving facility. Failure to include essential documentation can lead to delays in treatment, medication errors and inadequate continuity of care, compromising patient safety and well-being.”