OSF Saint Anthony’s Health Center

“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: 34824 Based on document review and interview it was determined the Hospital failed to ensure compliance with 42 CFR 489.20 and CFR 489.24. Findings include: 1. The Hospital failed to ensure the on-call surgeon responded when contacted resulting in pt being to transferred to another hospital. (See A-2404) 2. The Hospital failed to provide medical treatment within it capacity that minimizes the risks to the individual’s health. (See A-2409 A) 3. The Hospital failed to complete an appropriate summary of the risks and benefits of transfer, specific to the individual’s condition. (See A-2409 B)”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 50645 Based on record review and interview, it was determined 1 of 3 patients (Pt #1) that was transferred on the weekend, the facility failed to ensure the on-call surgeon responded when contacted resulting in the patient being to transferred to another hospital. Findings include: 1. On 9/17/25, Pt #1 presented to the Emergency department on 9/14/25 at 7:33 PM with a chief complaint of appendicitis. Pt #1 had a CT (computed tomography) which indicated an appendicitis that required surgery. A Clinical note dated 9/14/25 stated, “Multiple pages to surgeon have been unanswered. (Pt #1) has been stable, will continue to try... House Supervisor has also made calls, no answers. Will transfer (Pt #1).” 2. The call schedule from 9/14/25 was reviewed and indicated E #4 was on call. The log also indicated E #4 failed to answer. 3. A request was made for a written policy outlining the escalation process to be followed when the on-call physician does not respond to a call. The facility was unable to provide or produce a policy addressing this situation. 4. An interview was conducted on 11/25/25 at approximately 10:15 AM with Charge Nurse (E#8). E#8 stated, “(E #4) was on call and that the nurse and I both tried to call (E#4) multiple times, at least 3-4 times with no answer ...’”

“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: 50771 A. Based on document review and interview, 3 of 3 (Pt #1, Pt #21, Pt #22) surgical patient transfer records, the facility failed to provide medical treatment within it capacity that minimizes the risks to the individual’s health. Findings include: 1. A review of the policy titled “Plan for the Provision of Patient Care (effective 12/8/23) was completed. Policy noted “ ...Surgery Department 1. Hours of Operation: The surgery Department provides twenty-four (24) hour coverage, seven (7) days a week ...Emergency surgery is performed as needed by an on-call team at times other than normal operating hours ...2. Scope of Service ...b ....Emergency procedures are general surgery, urology, orthopedic, obstetric and gynecological procedures ...d. Appropriate and clinically necessary support services needed to provide patient care services are either provided directly by the hospital per hours of operation and staffing mix as deemed appropriate for the surgical services patient population, or by contracted services ...3. Staffing: a. A call team of at least two members is available for any after-hours emergency cases. B. For all surgical cases, each operating room is staffed by one RN Circulator, one scrub tech or RN and one RNFA. Additional personnel may be utilized through random on-call. C. A Nurse Director, with the OR Supervisor, oversees daily operations of all Surgical Services.” 2. Pt #1 presented to the Emergency Department (ED) on 9/14/25 at 7:33 PM with a complaint of abdominal pain. A Computed Tomography (CT) was done and indicated Pt #1 had appendicitis (an inflammation of the appendix), requiring surgery. Pt #1’s record indicated ED staff were unable to get a hold of the surgeon on call and Pt #1 was transferred to (hospital B) for surgery on 9/15/25. 3. Pt #21 presented to the ED on 8/16/25 at 4:22 PM with a complaint of right lower quadrant abdominal pain. A CT was done was done and indicated Pt #21 had appendicitis, requiring surgery. Pt #21’s record indicated there was no surgical capability available at (hospital A) on weekends and Pt #21 was transferred to (hospital C) on 8/16/25 at 9:43 PM for surgery. 4. Pt #22 presented to the ED on 8/22/25 at 7:26 PM with a complaint of vomiting and abdominal pain. A CT was done and indicated Pt #22 had appendicitis, requiring surgery. Pt #22’s record indicated there were no surgical capabilities available at (hospital A) on weekends and Pt #22 was transferred to (hospital D) on 8/23/25 at 12:44 AM. 5. An interview was conducted on 11/25/25 at approximately 3:30 PM with the Chief Nursing Officer (CNO - E#2). E#2 stated “We have not had the surgery department staffed on the weekends since February and staff have been updated since then that we are still not staffed...there is an on call schedule for surgeons as a courtesy for ED physicians to call and consult...there have been postings for staff vacancies, and the agency was unable to fulfill the Registered Nurse First Assist/RNFA and/or RN and Surgical Patent Care Tech (PCT), so we are still trying to hire for those vacancies ...” The CNO verbally agreed there was a lack of 24/7 (24 hours a day, 7 days a week) staffing in the operating room. When asked if the hospital notified IDPH of surgery department closure on the weekends, E#2 stated “No, we did not know to notify anyone...so we did not...” B. Based on document review and interview, 3 of 3 (Pt #1, Pt #21, Pt #22) surgical patient transfer records, the facility failed to complete an appropriate summary of the risks and benefits of transfer, specific to the individual’s condition. Findings include: 1. Pt #1 presented to the Emergency Department (ED) on 9/14/25 at 7:33 PM with a complaint of abdominal pain. A Computed Tomography (CT) was done and indicated Pt #1 had appendicitis (an inflammation of the appendix), requiring surgery. Pt #1 was transferred for surgical services. The transfer form included, “Request for transfer: Higher Level of Care: Specialty Service - General Surgery... Benefits of Transfer: Specialized equipment and /or services at receiving facility; Continuity of Care... Risk of Transfer: Death; Physical deterioration; Loss of function; Psychological deterioration...” Continuity of Care is not relevant to the patient’s presentation. Psychological deterioration is not relevant to this patient’s presentation. The summary of risks and benefits of transfer are not specific for this patient’s presentation. 2. Pt #21 presented to the ED on 8/16/25 at 4:22 PM with a complaint of right lower quadrant abdominal pain. A CT was done was done and indicated Pt #21 had appendicitis, requiring surgery. Pt #21 was transferred for surgical services. The transfer form included, “Request for transfer: Higher Level of Care: Specialty Service - General Surgery... Benefits of Transfer: Specialized equipment and /or services at receiving facility; Continuity of Care... Risk of Transfer: Death; Physical deterioration; Loss of function; Psychological deterioration...” Continuity of Care is not relevant to the patient’s presentation. Psychological deterioration is not relevant to this patient’s presentation. The summary of risks and benefits of transfer are not specific for this patient’s presentation. 3. Pt #22 presented to the ED on 8/22/25 at 7:26 PM with a complaint of vomiting and abdominal pain. A CT was done and indicated Pt #22 had appendicitis, requiring surgery. Pt #22 was transferred for surgical services. The transfer form included, “ The transfer form included, “Request for transfer: Higher Level of Care: Specialty Service - General Surgery... Benefits of Transfer: Specialized equipment and /or services at receiving facility; Continuity of Care... Risk of Transfer: Death; Physical deterioration; Loss of function; Psychological deterioration...” Continuity of Care is not relevant to the patient’s presentation. Psychological deterioration is not relevant to this patient’s presentation. The summary of risks and benefits of transfer are not specific for this patient’s presentation.”