Cassia Regional 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: 42316 Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This had the potential for negative outcomes and life-threatening complications. Findings include: Refer to A2406 as it relates to the failure of the hospital to ensure a medical screening examinations were performed within their capability. Refer to A2409 as it relates to the failure of the hospital to provide an appropriate transfer. The effects of these practices put all patients presenting to the ED for emergency medical treatment at risk of a negative outcome.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 52363 Based on policy review, medical record review, and staff interview, it was determined the facility failed to ensure patients received an appropriate medical screening examination prior to discharge for 1 of 22 patients (Patient #22) whose records were reviewed. This put all patients presenting to the ED for emergency medical care at risk for negative outcomes. Findings include: A CAH policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Policy - Intermountain,” last reviewed March 2025, stated the CAH shall, “Provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the emergency department ... within the Hospital’s Capability and Capacity, conduct and document an appropriate MSE reasonably conducted to identify an Emergency Medical Condition (EMC).” This policy was not followed. An example includes: Patient #22 was an 8 week old female who presented to the ED on 12/11/24 at 11:05 AM with a chief complaint of shortness of breath. Documentation in the ED record under “History of Present Illness” stated, “8-week-old female presents to ED with parents for evaluation of turning blue episode when feeding earlier this morning. Reports having an episode about a week ago as well. Was seen recently and diagnosed with URI and congestion.” In the ED physician note under “Medical Decision Making/ED Course,” Provider D documented, “While in the emergency department patient appeared well, was placed on pulse oximetry and observed for a few hours ... Patient was fed while in ED and did not have any repeat episodes ... Transfer considered but with lack of hard objective findings during ED obs [observations] will try close management with PCP.” No diagnostic tests were ordered or performed during Patient #22’s ED visit. An ED discharge order was placed at 1:03 PM by Provider D with a disposition of “Discharge with close PCP follow-up this afternoon.” The infant was observed for approximately two hours in the ED. Later that same day, 12/11/24 at 5:03 PM, Patient #22 was evaluated by her PCP (Provider E) at the CAH’s outpatient clinic. The PCP documented the need for hospital admission for observation, and Patient #22 was admitted to the medical floor. Subsequently, on 12/11/24 at 8:17 PM, the CAH inpatient hospitalist documented, “7 days ago the infant developed a low-grade fever at 100.5 and was irritable ... 2 days later the infant had 2 different apneic spells ... Baby was seen in the ER twice with EMT transfer regarding those apneic events. Studies including Influenza RSV and COVID were negative. No other viral studies were done. No lab work was done. No blood cultures. No LP ... Since admission to the hospital the baby has had 2 apneic [not breathing] spells 1 for over 30 seconds with a rapid response and the second less than 10 seconds responding to stimulation. There were no efforts to breathe.” Due to observed episodes of apnea, a consultation was conducted with a physician at a higher level pediatric facility, who recommended the transfer of Patient #22. Life Flight was dispatched to facilitate the transfer via fixed wing air transport. The transport team arrived at the referring facility on 12/11/24 at 11:57 PM. According to Life Flight documentation, after evaluation by the transfer team RN and a telehealth critical care team member, it was determined, “given the frequency of apnea and duration of remainder transport time that it was in the best interest of this patient to intubate her prior to departure.” Patient #22 was intubated at 12:54 AM on 12/12/24 and departed for the receiving facility at 1:37 AM. An interview with Provider D was requested but he was unavailable. The ED Medical Director was interviewed on 5/07/25 beginning at 9:40 AM regarding Patient #22. When asked if he would have handled the case differently, he said no. When asked if any tests or diagnostics should have been done during the ED visit, he responded, “I don’t think I would have done anything different, each test has a risk vs benefit, I just can’t think of a useful test you could do. It’s easy to say in hindsight, but unnecessary tests can cause harm.” The lack of diagnostic evaluation and the decision to discharge Patient #22 based on observation, without further testing, represents a failure to provide an appropriate MSE per the CAH’s policy.”

“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: 42316 Based on policy review and medical record review, it was determined the CAH failed to ensure a transfer to another hospital was effected through qualified personnel and transportation equipment for 1 of 22 patients (Patient #11) whose records were reviewed. Failure to ensure an appropriate transfer put the patient at risk for deterioration during the transport to another hospital. Findings include: A CAH policy titled, “Emergency Medical Treatment and Labor Act (EMTALA) Policy - lntermountain” updated March 2025 stated, “Appropriate transfer. If an individual is to be transferred to another medical facility, the Hospital will: ... arrange for transfer by qualified personnel and appropriate equipment.” This policy was not followed. An example includes: Patient #11 was a 22 year old female who presented to the ED on 12/21/24 with a chief complaint of right upper quadrant pain. Her provider note from her ED visit stated, “This 22-year-old woman does not have a history of abdominal surgeries. She has had right upper quadrant pain for about a week. Pain is worse with eating. She had an ultrasound 1 week ago that showed gallstones without radiographic evidence of cholecystitis [gallbladder inflammation]. She has been advised to avoid fatty foods ... Unfortunately, the patient has developed choledocholithiasis [gallstones in the bile duct]. She was transferred via private vehicle to [area hospital] for ERCP and likely cholecystectomy [gallbladder removal surgery].” Patient #11’s provider note did not say what monitoring would be required during Patient #11’s transfer. It did not say if an ambulance was offered and/or was refused by Patient #11. It did not include documentation of a discussion of the risks of transporting by private vehicle. Patient #11’s record included a transfer form dated 12/21/24. It was signed by the Provider A and Patient #11. It stated, “As indicated below, the patient will be transferred by qualified personnel and transportation equipment including the use of necessary and medically appropriate life support measures.” The form included a checked box which said, “Private Vehicle.” It was unclear what personnel and transportation equipment were required for Patient #11. Provider A was interviewed on 5/06/25 beginning at 2:33 PM and Patient #11’s record was reviewed. He confirmed he remembered Patient #11. He was asked what type of discussions were had with patients when they went by personal vehicle, and if risks and benefits were discussed. He stated patients are concerned about ambulance expenses, but he always offers an ambulance. When asked what risks and benefits he discusses with patients when driving themselves, he stated the ambulance knows where to take patients, and people driving themselves can get lost. When asked what he would document in these cases he stated, “the patient prefers to go by private vehicle. This request is reasonable.” The CAH failed to ensure transfer to another hospital was effected through qualified personnel and transportation equipment.”