Decatur Memorial 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: 39025 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 that an appropriate transfer was performed which included an accepting physician for transfer, lacked documentation of acceptance from (Hospital B), lacked signed consent from Pt #1 for transfer, and lacked required transfer Form. (See A2409)”

“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: 39025 Based on document review and interview, it was determined that for 1 of 6 (Pt. #1) reviewed for transfers, the hospital failed to ensure that an appropriate transfer was performed which included an accepting physician for transfer, lacked documentation of acceptance from (Hospital B), lacked signed consent from Pt #1 for transfer, and lacked required transfer Form. Findings include: 1. The Hospital’s policy titled “Acceptance-Transfer and Referral of Patients to from Other Facilities” dated 12/24 was reviewed and indicated , “ Policy: (Hospital Name) will follow EMTALA (Emergency Medical Treatment and Active Labor Act) and CMS (Centers for Medicare and Medicaid Services) guidelines for transfer and referral of patients ... B. Transfer and referral emergency care and obstetrics patients to other institutions: ... 3. No patient will be transferred until a physician at a receiving institution has consented to accept the patient... 7: Transfer Arrangements: a. The COBRA (Consolidated Omnibus Budget Reconciliation Act) consent for transfer shall be signed by both patient (or guardian) and physician requesting transfers on all transfers to other facilities. b. An Enroute Transfer form (Region 6 form) will be completed for all inter-facility transfers requiring ambulance or helicopter transport. c. Copies of patient’s medical records will accompany the patient including: transfer forms, history and physical, x-ray results and films, treatment records and orders, laboratory reports, ancillary (supportive) service reports, progress notes, discharge summaries. d. The (hospital A) physician shall obtain acceptance from the receiving physician with documentation of acceptance recorded in the medical record. e. Nursing personnel will contact the receiving facility to provide the patient information, ascertain bed availability, and document the exchange of information ... h. A copy of the COBRA consent form and Enroute Transfer form shall be made and placed in the (hospital name) medical records prior to departure.” 2. Pt#1’s medical record was reviewed throughout the survey. The triage form noted, “ ...OB Admission Intake ... performed on: 8/12/25 at 2:04 PM by E#7 ... Chief Complaint: Leaking of fluid ... Pain symptoms: denies pain ...” The OB Admission H&P (History and Physical) stated, “ ... (Pt #1) Gravida (pregnancies) 6, Para (births) 5, presents at approximately 34-weeks (pregnant) with a complaint of loss of fluid since yesterday at noon. Patient denies any bloody show or uterine contractions but does admit to positive but diminished fetal movement ... OB History: Pregnancy History.. Pregnancy #1. Outcome Date: 11/20/2000. Outcome Result: Cesarean Birth. Gestational Age: 25 weeks. Outcome: Live Birth. Birth Sex: Female ... Past medical history is significant for one preterm delivery (delivery of baby before 40 weeks gestation) at approximately 36 weeks via C-section (cesarean section, a surgical procedure in which a baby is delivered through incisions in the abdomen and uterus) followed by three vaginal births after cesarean section. Secondary to history of preterm delivery, likely secondary to cervical incompetence (weakness), the patient has a cerclage (the use of a stitch to encircle the opening of a malfunctioning cervix) in place. Additionally, the patient is on Suboxone (an oral dissolvable film prescribed to treat dependence on opioid drugs. It works to reduce withdrawal symptoms when stopping opioids and for an extended period of time afterward) to treat narcotic dependence ...” History and Physical note dated 9/12/25 3:05 PM by OB physician (E#5) indicated, “...Assessment: 1.) preterm IUP (intrauterine pregnancy) at 34 weeks ...Plan 1.) EFM (external fetal monitor) -FWBR (fetal wellbeing reassuring, a fetal monitor is placed on the mother to document fetal heart tones) 2.) Discussed with MFM 3.) Secondary to patient’s desire to deliver in (hospital B) and staffing issues ambulance service will be set up for safe transport ...” The Fetal Link (a program for documentation of external fetal monitor and mother and baby vital signs) documentation was reviewed for Pt#1. Vital signs (blood pressure, pulse, temperature, and respirations) were within normal limits during this visit. No concerns were noted with Fetal Link documentation. Lab work ordered during the visit included CBC (complete blood count that shows anemia or infection), routine chemistry and enzymes (electrolyte levels that would show dehydration), glucose level (sugar level), and a urine protein level (to check for preeclampsia, a high blood pressure disorder of pregnancy). A rupture of Fetal Membranes Screen was positive on 8/12/25 at 2:29 PM. No other concerns wee noted with lab work. Pt #1’s record lacked the name of accepting physician for transfer, lacked documentation of acceptance from (Hospital B), lacked signed consent from Pt #1 for transfer, and lacked required Region 6 Transfer Form. 3. A review of Pt #1’s record from Hospital B was reviewed on 9/25/25 at approximately 3:00 PM. The record contained a History and Physical MD note dated 8/12/25 and noted “ ... (Pt #1) is a 40 year-old gravida 6 para 5 at 34 weeks 2 days who is being in admitted for induction of labor due to PPROM (premature rupture of membranes; refers to the rupture of the amniotic sac before 37 weeks of gestation). (Pt #1) reports loss of fluid yesterday afternoon around dinner ...reports continuing to leak with squatting and movement but thought it was urine. (Pt #1) presented to (hospital A) and ROM plus was positive, (Pt #1) was then transported here ...General: NAD (no acute distress) ...Respiratory: Respirations non-labored, CTAB (clear to auscultation bilaterally), Abdomen: Gravid (pregnant), non-tender, Extremities: Warm, well-perfused. No edema. FHT: (fetal heart tones) Baseline 120, moderate variability (fluctuation in fetal heart rate)Added, +accelerations, - decelerations ...” Discharge summary (hospital B) dated 8/14/25 at 2:14 PM noted “ ... Diagnosis: 1. Singleton intrauterine pregnancy at 34 weeks 3 days gestation 2. Vacuum assisted vaginal delivery ...3 Routine postpartum care after vaginal delivery ...Discharge disposition: stable, discharged to home ...Indication for Admission: patient was admitted from for PPROM. ..Procedure performed: vacuum assisted vaginal delivery ...” Pt #1 was discharged from (Hospital B) on 8/14/25. 4. An interview was completed with Medical Doctor (E #5) on 9/23/25 at approximately 2:25 PM. E #5 did recall caring for Pt #1 and stated “ ...I didn’t even know that there was such a thing as nurse practitioners that practice neonatology (a specialist who care for pre term babies or high risk babies) ...so anyway I didn’t know that existed at this hospital and so my information was that another patient had gotten transferred and (Pt #1) came in stating (Pt #1) thought (they) were ruptured and was supposed to deliver in (hospital B) and basically was saying that (Pt #1) didn’t want to be separated from (Pt #1’s) child ...and the fact that (Pt #1) was on Suboxone and ruptured at 34 weeks I’m thinking surely this baby is going to get transferred and ...I talked to the MFM and I told the scenario and the MFM MD said ’(Pt #1) has been here for a while not contracting, not showing signs of infection’ and an idea was that I could discharge (Pt #1) and have (Pt #1) just show up at (hospital B) and I think that might be an EMTALA (Emergency Medical Treatment and Labor Act) violation... I’m not sure because what I understand is that if they’re unstable, contracting or for whatever reason they may have an increased risk for fetal demise or some sort of problem you’re obligated, especially if you have the means, to take care of them. I don’t know if I can just discharge (Pt #1) ... I didn’t know exactly what to do ...because at the same time I’m still not knowing that I have nurse practitioners that do neonatology ... then I was telling the nurses that I was going to probably discharge (Pt #1) and they said ’ ...no, you can’t do that ...’ and I decided to get (Pt #1) transferred ...up to (hospital B) via ambulance ...and at that point I had already talked to the MFM ...they were aware of (Pt #1) but we hadn’t talked about it as a transfer...” 5. Physician employee records were reviewed. OB physician (E#5) did not have EMTALA training or orientation information in the employee file. Patient Safety Coordinator (E#1) stated “ ...the orientation was done at (outside organization) and we do not have access to that information ...” 6. An interview was conducted with the OB (obstetrics) and Pediatric Nurse Manager (E#10) on 9/24/25 at 11:10 AM. (E#10) stated, “I went thru the chart with a fine tooth comb ...I could not find the Enroute Transfer form/Region 6 form in (Pt #1’s) medical record ...””