Advocate Lutheran General Hospital

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 32741 Based on document review and interview, for 1 of 1 transfer clinical record reviewed for a pregnant patient needing higher level of care (Pt. #1), the hospital refused to accept the transfer of Pt #1 from a referring hospital. Findings include: 1.On 2/4/2026, the Hospital’s “EMTALA” policy (dated 9/22/2025) was reviewed and indicated, “Emergency Medical Condition - A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse such that the absence of immediate medical attention could reasonably be expected wot result in either: a. placing the health of the patient (or, with respect to a pregnant patient, the health of the woman or her unborn child) in serious jeopardy. b. serious impairment to bodily functions; or c. serious dysfunction of any bodily organ or part ...Obligations to Accept Certain Transfers - If the recipient hospital has specialized capabilities that are not available at the transferring hospital, the recipient hospital should not refuse to accept the transfer of a patient needing those capabilities if the hospital has the capacity to treat the patient.” 2.Pt #1’s ED clinical record (dated 12/28/2025) from Hospital A (transferring hospital) was reviewed on 2/5/2026 and indicated that Pt. #1 arrived as a walk-in at 2:28 PM. Vital signs on arrival were blood pressure 114/77 (normal blood pressure is 120/80), pulse 100 (normal range is 60 to 100), respirations 23 (normal range is 16 to 20) and oxygen saturation 100%. Labs (complete blood count, comprehensive metabolic panel and troponin) were drawn. ED provider (Z1) notes dated 12/28/2025 included, “Triage Chief Complaint: Abdominal pain. Patient arrived via ambulatory. [Pt #1] presents to ED with generalized abdominal pain, suprapubic pain and vaginal spotting ... reportedly 6 weeks pregnant ... G P4P1A2 [4 pregnancies, 1 live birth, 2 abortions] history left-sided ruptured ectopic with left salpingectomy [removal of fallopian tube] presents to the ED for evaluation with concern for miscarriage, Patient reports had been doing well, last hCG [pregnancy test] checked several days ago at her PCP [primary care physician] office with hCG of 4000 [anything above 25 mlU/mL is positive for pregnancy]. Today went to lunch and had sudden onset generalized abdominal pain with nausea and vomiting especially bad with lower abdominal cramping. Some vaginal spotting ... Given severity of symptoms came in ... bedside ultrasound was performed immediately once patient was roomed showing positive free fluid in the right upper quadrant and suprapubic region. Immediately called Advocate transfer line as patient sees all her care at [Hospital B] reportedly. Patient has a history of previous ectopic pregnancy with rupture. After [Hospital B] physician OB refused patient. Shared that this hospital has general surgeon recently not comfortable with emergent laparotomy, No OB here [at Hosptial A]. Will send with blood products. On record was still refused. Transfer center personnel attempted reach [Hospital D], while I reach out to [Hospital C] OB to prevent further delay in care. Accepted by local OB spoke to [MD at Hospital C] who is mobilizing the OR [operating room] for the patient. Communicated also [accepted] to [Hospital D] at the same time ... The quicker transfer would be to [Hospital C] with traffic and ambulance ETA with critical care ...” The ED Course/Timeline included: 2:30 PM: Positive fast (focused assessment with sonography for trauma- means an ultrasound has detected free fluid - usually blood in the abdominal cavity, pelvic, or chest cavity of a patient, typically after trauma) on exam. RUQ (right upper quadrant) on exam, RUQ and pelvic free fluid concerning for ruptured ectopic and immediate transfer initiated. 2:50 PM: [BP] now 80/55. Ordering more blood. OB hospitalist on line with [Luth Gen]. Formally refused transfer. 2:54 PM: Refused by [Lutheran Gen OB] reportedly for instability despite shared concerns of hemorrhagic shock due to ruptured ectopic with inability to care for patient here due to lack of OB and minimal blood here. [Luth Gen OB] requesting surgery here with laparotomy by general surgery. 2:57 PM: 2 gm txa [medicine that controls bleeding] ordered 2:58 PM: In setting of active bleeding, anticipate actively decreasing hemoglobin: 12.9 [normal range 12.0-15.3 g/dL] 3:05 PM: MTP [massive transfusion protocol] activated, d/w [discussed with] blood bank 3:08 PM: Accepted by [OB/GYN MD] at Masonic. Transfer center arranging emergent transfer. 3:10 PM: [OB/GYN MD] Loyola accepting 3:19 PM: General Surgery would not recommend they intervene when transfer with ob/gyn possible. 3:37 PM: [RN] Report given to RN at Loyola Hospital OR. Patient accepted by [OB/GYN MD at Loyola]. Superior Ambulance transport ETA [estimated time of arrival] 20 minutes. 3. Hospital B’s patient communication center (transfer center) documentation (dated 12/28/2025 at 2:34 PM) regarding the request from Hospital A to transfer Pt. #1 to Hospital B included the following: “Initial information - request type - labor and delivery from Z1 at Hospital A - reason -higher level of care. [ MD #2 from Hospital B] - decline reason - Pt. #1’s condition not suitable for transfer. Accepting Physician at Hospital C and Hospital D. Time of canceled request - request began on 12/28 at 2:34 PM. Reason for transfer - higher level of care - OB, Diagnosis - ruptured ectopic pregnancy. On 12/28 at 2:47 PM - [MD #2 from Hospital B] declined transfer for obstetrics - decline reason - Pt. #1’s condition not suitable for transfer. MD #2 discussed case at length with Z1, questions answered, recommendations given. [MD #2] does not believe Pt. #1 should not be transferred due to stabilization and is declining transfer. Patient care center RN offering Hospital D, Z1 agreeable. At 2:51PM, Pt. #1 got accepted at Hospital C.” 4. Pt #1’s clinical record from Hospital C (dated 12/28/2025 at 3:44 PM) was reviewed on 2/5/2026 and included, “[Pt. #1] presented with suspected ectopic. Pt. #1 presented to [Hospital A] and found to have a ruptured ectopic pregnancy with hemorrhagic shock. Blood pressure 95/53, heart rate 92. Pt. #1 is 6 weeks by last menstrual period. Given hemodynamic instability, Pt. #1 was given 2 units pRBC (packed red blood cells) and transferred to [Hospital C] for higher level of care. History is limited given Pt. #1’s instability. Assessment and plan - Ruptured ectopic pregnancy. Given ruptured ectopic with hemodynamic instability, plan to proceed to the OR immediately for diagnostic laparoscopy, removal of ectopic pregnancy, possible unilateral salpingectomy (surgical removal of one or both fallopian tubes, typically in the context of ectopic pregnancy), possible unilateral salpingo-oophorectomy (removal one ovary and fallopian tube), possible laparotomy (major open surgery involving a large incision in the abdominal wall to access, examine, and treat abdominal organs). Pt. #1 consented for diagnostic laparoscopy, removal of ectopic pregnancy, possible unilateral salpingectomy, possible unilateral salpingo-oophorectomy, possible laparotomy. Risk including but not limited to risks of anesthesia, bleeding, infection, injury to surrounding organs (bowel, bladder, blood vessels, nerves) and venous thrombosis were discussed. All questions answered. Pre-operative diagnosis - ruptured ectopic pregnancy. Post-operative diagnosis - ruptured left cornual pregnancy (a rare, high-risk type of ectopic pregnancy -2-4% of cases, where the embryo implants in the upper, outer corner of the uterus. It can lead to severe life-threatening hemorrhage due to delayed diagnosis and potential rupture). Findings - on laparoscopy, there was over a liter of hemoperitoneum. Once this was sufficiently cleared to allow for visualization of the uterus, we noted that the ectopic was at the left cornua and ruptured with the sac aborting. The uterus, right fallopian tube, and both ovaries appeared grossly normal. Pt. #1 was admitted to Hospital C and was discharged home on 12/31/2025.” 5. On 2/5/2026 at 10:00 AM, an interview was conducted with the OB Physician (MD #2 from Hospital B) MD #2 stated that MD #2 refused Pt. #1’s transfer from Hospital A to Hospital B not because Hospital B did not have the capability to take Pt #1 but because Pt. #1 was not stable. MD #2 stated that the report MD #2 received from Z1 at Hospital A was that Pt. #1’s blood pressure was 80/55. MD #2 stated that Z1 reported that Pt. #1’s blood pressure had been 140 systolic and then 110 systolic. MD #2 stated that MD #2 told Z1 that Pt. #1 was not stable for transfer. MD #2 stated that MD #2 told Z1 that Pt. #1 needed to go to surgery immediately. MD #2 stated that Hospital A has general surgery, and any general surgeon should have been able to perform the surgery. MD #2 stated that Hospital A had general surgeons who had the capability to perform Pt. #1’s surgery. MD #2 stated that Z1 was threatening MD #2 stating that the conversation was being recorded. MD #2 stated that there was no follow up call from Z1.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 50411 Based on document review and interview, for 1 of 4 patients (Pt. #1) clinical records reviewed for pre-surgical informed consents, the hospital failed to ensure that informed consent was obtained from the appropriate individual. Findings include: 1. On 9/2/2025, the Hospital’s Policy titled “IL Informed Consent for Procedures, Interventions or Medical Care That Require Consent for Adults” (Effective Date 3/19/2025), was reviewed and included, “ ... Informed Consent ... A patient and/or substitute decision maker (SDM) must be apprised of the purpose, nature, risks and benefits of the procedure, alternatives to the procedure ... After receiving this information, the patient and/or substitute decision maker (SDM) then either consents to or refuses such a procedure or treatment ... Substitute Decision Maker (SDM) ... The SDM can be a legal guardian of the person; an agent appointed pursuant to a power of attorney for health care; or a Surrogate identified by the Attending Physician pursuant to the Illinois Health Care Surrogate Act if the patient lacks decision-making capacity ... Informed Consent Documentation ... 2. The following information is noted or documented on the consent form ... d. Patient/SDM signature with the corresponding date and time noted ... C. Telephone Consent - 1. Telephone Consent may be given by the representative or substitute decision-maker of the patient if they cannot be present to sign the consent form ...” 2. On 9/2/2025, the clinical record for Pt.#1 was reviewed. On 7/18/2025, Pt.#1 was brought to the Emergency Department (ED) after suffering a mechanical fall. Diagnostic Tests were performed and it was determined that Pt.#1 had suffered a left hip fracture and needed surgical intervention. - The ED Nurses Note by Registered Nurse (RN-E#9) on 7/18/2025 at 9:52 PM included, “RN spoke with [Name-Guardian], representative from [Name of County] Public Guardian; [Name-Guardian]. [Guardian] verbalized confirmation that the nursing and medical team received the legal documents of pt’s guardianship. Pt.#1’s son is not allowed to visit [Pt.#1] nor is he entitled to medical information and updates from the medical team. He is allowed to speak with the pt via phone call if pt accept his call. [Guardian] is the on-call public guardian for this pt... if after hours alert them to your need and they will fwd (forward) to 24 hour answering service. SON MAY NOT VISIT OR RECEIVE MEDICAL UPDATES/INFO FROM STAFF. HE MAY TALK TO PT VIA PHONE CALL ONLY.” - The Illinois Consent for Anesthesia Services form dated 7/21/2025 and signed at 3:43 PM was reviewed and indicated that phone consent was given by Pt. #1’s son. This was witnessed by RN (E#8) and signed by anesthesia provider (MD#2). - The Illinois Consent to Surgical/Invasive Procedure form dated 7/21/2025 and signed at 3:43 PM, was reviewed and indicated that phone consent was given by Pt. #1’s son. This was witnessed by RN (E#8) and signed by surgeon (MD#1). 3. On 9/3/2025 at 8:55 AM, an interview was conducted with Registered Nurse on 8 West inpatient unit (E#7). E#7 stated that E#7 recalls Pt.#1 was scheduled for surgery on 7/21/2025. E#7 stated that E#7 was not aware that Pt.#1 had a state appointed guardian. E#7 stated that E#7 received a call from the pre-op unit and informed to update Pt.#1 contact information to include the state appointed guardian. E#7 stated that E#7 updated Pt.#1’s information to include the state appointed guardian’s contact information. E#7 stated that Pt.#1’s son had been listed as the primary contact. E#7 stated that E#7 would expect any update regarding a patient guardian to be included in the nurse handover report. This is done during shift changes. E#7 stated that when a patient is admitted to their unit, patient’s primary contact information should be reviewed and updated. E#7 stated that if E#7 was aware of any change in patient’s primary contact information, E#7 will immediately update the patient’s information. E#7 stated that generally, consent for procedure is obtained in pre-surgery. 4. On 9/3/2025 at 9:50 AM, an interview was conducted with Operating Room Registered Nurse (E#8). E#8 stated that consents for procedures are obtained by the pre-op unit. E#8 stated that the pre-op unit charge nurse receives a report from the unit where the patient came from. E#8 stated that with regards to consent, E#8 will verify in the patient’s medical record or with the patient’s nurse as to who may give consent for procedures. E#8 stated that E#8 will mainly rely on the patient’s medical record or the report received from the nursing unit. E#8 stated that consent for Pt.#1’s procedure was obtained from the patient’s brother or son (could not recall relation). E#8 stated that E#8 was made aware that Pt.#1 had a state guardian by another nurse on their unit. E#8 stated that Pt.#1 was already in the OR (Operating Room) when E#8 found out that Pt.#1 had a state guardian. E#8 stated that the state guardian was listed as the third contact option in Pt.#1’s medical record. E#8 stated that it was wrong that the state guardian was not called to obtain the consent for Pt.#1’s procedure. 5. On 9/3/2025, interviews were conducted with the Orthopedic Surgeon (MD#1) at 9:34 AM and the Anesthesiologist (MD#2) at 10:20 AM. Both indicated that they were not aware that Pt.#1 had a state appointed guardian and that informed consent for the procedure was obtained from an individual who had no authority to do so.”

“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: 39802 Based on document review and interview, it was determined that the hospital failed to ensure compliance with 42 CFR 489.24. Findings include: 1. The Hospital failed to ensure that the receiving hospital had agreed to accept the patient and had space and qualified personnel available for the treatment of the individual. See deficiency at A-2409 A. 2. The Hospital failed to ensure that the physician completed a written certification for transfer, including the reason for transfer and the risks and benefits associated with the transfer. See deficiency at A-2409 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: 39802 A. Based on document review and interview, it was determined that for 1 of 5 behavioral health patient (Pt. #1) transfer records reviewed, Hospital A failed to ensure that the receiving hospital [Hospital B] had agreed to accept the patient and had space and qualified personnel available for the treatment of the patient. Findings include: 1. Hospital A’s policy titled, “MW [Midwest] Region EMTALA (Emergency Medical Treatment and Labor Act)” (revised 12/09/2024), was reviewed and required, “ ...patient may be transferred if hospital staff provide stabilizing treatment for the patient’s EMC [emergency medical condition] within the Capacity and Capabilities of the Hospital and sections a-d below are met: ....b) Recipient Hospital: A representative of the Recipient Hospital must confirm prior to Transfer that: (1) The Recipient Hospital has available space and qualified personnel to treat the patient and agrees to accept the Transfer and to provide appropriate medical treatment; and (2) Hospital staff should document any communication with the Recipient Hospital, including date and time of the Transfer request and the name of the person accepting the Transfer in the patient’s medical record ...” 2. Hospital A’s clinical record of Pt. #1’s ED visit on 04/18/2025 was reviewed on 06/03/2025. Pt. #1 presented to the ED on 04/18/2025 at 3:12 PM with a chief complaint of suicidal ideation/SI. - The Triage Note, dated 04/18/2025 at 3:37 PM included “[Pt. #1] arrived ambulatory through triage with c/o [complaint of] suicidal ideation, with plans to use service weapon. No hx [history] of SI ... Accompanied by fellow officers.” - The Medical Screening Examination/MSE completed by ED Physician (MD#1) on 04/18/202 at 4:35 PM, included “...Patient presents to the emergency room with suicidal ideations. Patient has access to weapons. No acute medical complaints at this time, routine lab work shows no acute medical issues. No indication for any further medical workup at this time. Central access as well as the fellow officers have arranged for inpatient treatment. Patient to be transferred with a certificate via ambulance.” - The Suicide Risk Score completed on 04/18/2025 at 3:38 PM indicated that Pt. #1 was at high risk for suicide. The record indicated that Pt. #1’s belongings were secured (Pt. #1 changed into hospital clothes) and a sitter was assigned to monitor Pt. #1 for safety. - The record indicated that labs were drawn and completed which included: CBC (complete blood count), drug screen, blood alcohol level, comprehensive metabolic panel, pregnancy test. Results were within normal range. - The Central Access Licensed Clinical Professional Counselor/LCPC (E#1) note, dated 04/18/2025 at 7:02 PM, included “Patient in need of transfer due to on-site BH [behavioral health] unit - no appropriate bed [Hospital Bed Report dated 04/18/2025 indicated the BH units were not at capacity, see interview with E#1 for reason for transfer]. Patient Site Preference 1) [Hospital B] ... EAP [Pt. #1’s Employer’s Employee Assistance Program] Team Lead [Z#1] requested patient be sent to this facility as this is a facility they use for active duty police, [Z#1 stated that they] called and confirmed patient can be sent there without referral packet being done or RN to RN. PCS (Physician Certification Statement) form completed and placed on chart, called [Ambulance Service] ... scheduled BLS [basic life support] transport.” - Another note by E#1, dated 04/18/2025 at 7:11 PM, included “[Pt. #1] presenting to the emergency room with [Pt. #1’s] EAP support team after calling their crisis line and endorsing having suicidal thoughts with a plan to use service gun. Patient was medically cleared and central access evaluated patient. Patient gave consent for EAP team to be in assessment as well as Peer support officer. Also gave verbal consent to provide information to friend at bedside ... Patient reports today everything came to a head, [Pt. #1] reports being in a ‘dark place’ and stated [Pt. #1] sat with [Pt. #1’s] gun in front of [Pt. #1] on bed for a couple hours and eventually called the EAP crisis line. Patient stated prior to today, [Pt. #1] never had suicidal thoughts that were active, only passive death wishes when going through separation and random other points in [Pt. #1’s] life. Patient has never attempted suicide, reports unknown mental health history in family. Patient reports reasons to live are daughter. [Pt. #1] reports knowing the impending death of mother from cancer is hard, [Pt. #1] reports great support around [Pt. #1] with EAP and police coworkers ... Above contacts at bedside during whole assessment and vouched for patient’s safety. Informed writer [Pt. #1] will be with someone at all times and escorted to the facility, informed writer they took [Pt. #1’s] gun and have it secured. EAP reports the facility [Hospital B] patient is transfer[ing] to is the facility they use in these situations, the reason [Pt. #1] came to [this] ED was ‘lack of knowledge’ [by the officers who brought Pt. #1 here] and usually they transport people in patient’s situation directly to the facility [Hospital B] but stated there were many cops at [Pt. #1’s] home and [Pt. #1’s child] was witnessing this and they felt best situation was to take [Pt. #1] to [this] ED. Informed above [Pt. #1] will need to go via ambulance per protocol as the above mentioned taking [Pt. #1] would be a discharge and it is not safe nor protocol with a suicidal patient, above named all in agreement with ambulance transport and thankful for the help provided in making sure patient is taken care of ... Pt does meet criteria for psychiatric inpatient hospitalization as evidenced by SI with a plan to shoot self with service gun. ED attending notified of treatment plan and is in agreement ... Involuntary petition and certificate were completed ...” - The record lacked documentation that any contact with Hospital B was made regarding acceptance of transfer of Pt. #1 and/or capacity/capability. - A Nurse’s (E#2) note, dated 04/18/2025 at 7:21 PM, included “Per [E#1] (central access) no report necessary to [Hospital B]. [Ambulance] here - given PCS and face sheet; awaiting belongings.” - Nursing Discharge Note, dated 04/18/2025 at 7:39 PM, included “Patient discharged in the care of ambulance. Transfer charge completed by [E#2]. Patient vitals stable upon transfer. Public Safety has returned personal belongings to patient and they are in the care of [Ambulance Service] for transport. Patient stable upon discharge.” - E#1’s Note, dated 04/18/2025 at 7:43 PM, included, “At 9:13 PM and 9:19 PM Writer spoke with staff at [Hospital B], medical director [Z#2] and crisis worker [Z#3], at different times. [Z#2] called asking clarification on the situation as they do not have an inpatient psychiatric unit at their facility. Writer informed [Z#2] we were unaware of this matter, writer was informed via patient’s EAP team lead, this is the facility they send their team members to in these situations. [Z#2] asked if an accepting physician was established or called, writer informed [Z#2] no, due to this situation being new and the protocols for police officers being different, writer took the advice of the EAP counselor as [Z#1] best knew their protocols ... Writer also clarified with [Z#3], they are able to send [Pt. #1] back [to Hospital A] and [MD#1] communicated this to [Z#2] as the intention was to be helpful to the patient ...11:15 PM: Received called from [Z#1], indicating [Pt. #1] was being hospitalized in WI (Wisconsin) and writer informed [Z#1] that [E#1] was told the patient is coming back to [Hospital A] and will be hospitalized here ... 11:20 PM: Received call from [Z#3] ... asked when patient would be coming back as it was informed to us by [ED Medical Director MD#2] they called and were sending [Pt. #1] back to [Hospital A]. [Z#3] stated [Z#3] is working on placement in WI as this is patient’s wish to stay in WI and is unaware of patient coming back [to Hospital A] ...” 3. Hospital B’s clinical record of Pt. #1’s ED visit on 04/18/2025 was reviewed on 06/05/2025. Pt. #1 presented to Hospital B’s ED by ambulance on 04/18/2025 at 9:22 PM with a chief complaint of suicidal ideation. - ED Triage Note, dated 04/18/2025 at 9:25 PM, included “Pt arrived to the ED from ambulance with complaints of suicidal ideation. Pt is a [police] officer and wanted to shot self with service weapon. Pt came here from [Hospital A] with no notice of pt coming here. Pt was an involuntary petition in IL (Illinois), pt is voluntary here at this time...” - The MSE by ED Physician (Z#2), dated 04/18/2025 at 9:27 PM, included “We did notify our emergency department social worker. In addition our staff are working on psychiatric placement for this patient... Patient is agreeable to voluntary psychiatric hospitalization. We are currently pending acceptance at a psychiatric facility. Patient was also accompanied to the hospital by a police officer who reported that they had removed the patient’s firearms and that EAP program is involved ... History of Present Illness: [Pt. #1] is a law enforcement officer in Illinois arrived by ambulance to our facility for psychiatric placement transferred from [Hospital A]. Patient has suicidal ideation therefore it was determined [Pt. #1] would need psychiatric hospitalization. I did contact physician [MD#1] after the patient arrived. [MD#1] stated the patient had suicidal ideation and thoughts of killing self with handgun. It was unclear why the patient was transferred to our facility...” - Crisis Worker (Z#3’s) Note, dated 04/18/2025 at 10:48 PM, included “...[Z#3] consulted to assess pt and assist with Mental Health placement ... Patient presented to ED on an involuntary petition hold from Illinois. Due to patient being over state lines and is now in Wisconsin, Illinois involuntary petition documentation does not apply. At this time, patient is voluntary seeking behavioral health treatment in Wisconsin. ED charge nurse and MD spoke with hospital staff at [Hospital A] and was informed that the patient is an active duty police officer in [city name]. [Z#3] was connected with [E#1] who reported that per the [PD-police department] ‘employee assistance program’, it is their protocol to either bring the patient to a Wisconsin hospital or an Indiana hospital... Social worker informed [E#1] that regardless of [PD] protocol, Wisconsin has different mental health laws than Illinois and cannot accept involuntary petition paperwork ... Patient continues to be voluntary at this time and is willing to seek inpatient treatment in Wisconsin ... 11:30 PM: Social Worker initiated referral at [Hospital C] per pt request to stay in WI but also be ‘close to Illinois border.’ ... Patient has been accepted ...” - ED Provider Note, dated 04/19/2025 at 12:12 AM, included “Discussed with psychiatry at [Hospital C] ... [Pt. #1] is agreeable ... Patient accepted for transfer to [Hospital C]. - The record indicated that Pt. #1 was transferred by ambulance to Hospital C on 04/19/2025 at 2:00 AM. 4. The clinical record from Hospital C was reviewed and indicated that Pt #1 arrived via ambulance on 4/19/2025 at 2:45 AM for voluntary psychiatric inpatient admission/treatment. The record indicated that Hospital C accepted the transfer of Pt #1 and included all records from Hospital B were sent to Hospital C. Pt #1 was directly admitted to Hospital C. 5. An interview was conducted with the Central Access LCPC (E#1) on 6/3/2025, at approximately 2:25 PM. E#1 stated that E#1 and MD#1 agreed that Pt. #1 needed inpatient psychiatric hospitalization. E#1 stated that in Pt. #1’s case, when the patient and EAP team were notified of the plan, they immediately requested to transfer Pt. #1 to Hospital B in Wisconsin, or a hospital in Indiana (no name was given). E#1 stated that E#1 was not familiar with Hospital B and had never heard of them prior to this encounter. E#1 stated that they have a list of hospitals they typically attempt first and go down the line when trying to find placement. E#1 stated that typically the other hospital will tell us who is the accepting physician and this is usually arranged with conversations with the other hospital’s crisis/central access team. E#1 stated that E#1 did not reach out to anyone at Hospital B before sending Pt. #1 there. E#1 stated that after sending Pt. #1 to Hospital B, they received a call from their ED staff at Hospital B asking why the patient was sent to them. E#1 stated that Hospital B stated that they didn’t have inpatient psychiatric services. E#1 stated that this was the first time E#1 had a patient that was an active duty police officer, and didn’t know what their protocols were. E#1 stated that in all other instances E#1 has reached out to the recipient facility to ensure they accepted the patient and had the capabilities to treat the patient before sending them. E#1 stated that E#1 admits that it was an EMTALA violation. 6. An interview was conducted with the ED Medical Director (MD#2) on 06/05/2025, at approximately 9:00 AM. MD#2 stated that MD#2 was made aware of the case with Pt .#1 the day after it occurred. MD#2 stated that they discussed the missed opportunity to communicate with the other facility. MD#2 stated that it should be a collaborative effort between the provider, nursing, and central access to ensure that a transfer is appropriately arranged. B. Based on document review and interview, it was determined that for 1 of 5 behavioral health patient (Pt. #1) transfer records reviewed, Hospital A failed to ensure that the physician completed a written certification for transfer, including the reason for transfer and the risks and benefits associated with the transfer. Findings include: 1. Hospital A’s policy titled, “MW [Midwest] Region EMTALA (Emergency Medical Treatment and Labor Act)” (revised 12/09/2024), was reviewed and required, “ ...patient may be transferred if hospital staff provide stabilizing treatment for the patient’s EMC [emergency medical condition] within the Capacity and Capabilities of the Hospital and sections a-d below are met: ....a) A physician certifies the Transfer, or the Transfer occurs upon the request of the patient or a legally responsible person acting on the patient’s behalf, as documented on the Patient Transfer Form... (1) Transfer with Certification: A physician must certify that the medical benefits expected from Transfer outweigh the risks and describe the reasons for and potential risks and benefits of the Transfer by completing the applicable areas on the Patient Transfer Form...” 2. Hospital A’s clinical record of Pt. #1’s ED visit on 04/18/2025 was reviewed on 06/03/2025. Pt. #1 presented to the ED on 04/18/2025 at 3:12 PM with a chief complaint of suicidal ideation/SI. - The Triage Note, dated 04/18/2025 at 3:37 PM included “[Pt. #1] arrived ambulatory through triage with c/o [complaint of] suicidal ideation, with plans to use service weapon. No hx [history] of SI ... Accompanied by fellow officers.” - The Medical Screening Examination/MSE completed by ED Physician (MD#1) on 04/18/202 at 4:35 PM, included “...Patient presents to the emergency room with suicidal ideations. Patient has access to weapons. No acute medical complaints at this time, routine lab work shows no acute medical issues. No indication for any further medical workup at this time. Central access as well as the fellow officers have arranged for inpatient treatment. Patient to be transferred with a certificate via ambulance.” - The Central Access Licensed Clinical Professional Counselor/LCPC (E#1) note, dated 04/18/2025 at 7:02 PM, included “Patient in need of transfer due to on-site BH [behavioral health] unit - no appropriate bed [Hospital Bed Report dated 04/18/2025 indicated the BH units were not at capacity, see interview with E#1 for reason for transfer]. Patient Site Preference 1) [Hospital B] ... EAP [Pt. #1’s Employer’s Employee Assistance Program] Team Lead [Z#1] requested patient be sent to this facility as this is a facility they use for active duty police, [Z#1 stated that they] called and confirmed patient can be sent there without referral packet being done or RN to RN. PCS (Physician Certification Statement) form completed and placed on chart, called [Ambulance Service] ... scheduled BLS [basic life support] transport.” - Another note by E#1, dated 04/18/2025 at 7:11 PM, included “[Pt. #1] presenting to the emergency room with [Pt. #1’s] EAP support team after calling their crisis line and endorsing having suicidal thoughts with a plan to use service gun. Patient was medically cleared and central access evaluated patient. Patient gave consent for EAP team to be in assessment as well as Peer support officer. Also gave verbal consent to provide information to friend at bedside ... Patient reports today everything came to a head, [Pt. #1] reports being in a ‘dark place’ and stated [Pt. #1] sat with [Pt. #1’s] gun in front of [Pt. #1] on bed for a couple hours and eventually called the EAP crisis line. Patient stated prior to today, [Pt. #1] never had suicidal thoughts that were active, only passive death wishes when going through separation and random other points in [Pt. #1’s] life. Patient has never attempted suicide, reports unknown mental health history in family. Patient reports reasons to live are daughter. [Pt. #1] reports knowing the impending death of mother from cancer is hard, [Pt. #1] reports great support around [Pt. #1] with EAP and police coworkers ... Above contacts at bedside during whole assessment and vouched for patient’s safety. Informed writer [Pt. #1] will be with someone at all times and escorted to the facility, informed writer they took [Pt. #1’s] gun and have it secured. EAP reports the facility [Hospital B] patient is transfer[ing] to is the facility they use in these situations, the reason [Pt. #1] came to [this] ED was ‘lack of knowledge’ [by the officers who brought Pt. #1 here] and usually they transport people in patient’s situation directly to the facility [Hospital B] but stated there were many cops at [Pt. #1’s] home and [Pt. #1’s child] was witnessing this and they felt best situation was to take [Pt. #1] to [this] ED. Informed above [Pt. #1] will need to go via ambulance per protocol as the above mentioned taking [Pt. #1] would be a discharge and it is not safe nor protocol with a suicidal patient, above named all in agreement with ambulance transport and thankful for the help provided in making sure patient is taken care of ... Pt does meet criteria for psychiatric inpatient hospitalization as evidenced by SI with a plan to shoot self with service gun. ED attending notified of treatment plan and is in agreement ... Involuntary petition and certificate were completed ...” - The record lacked documentation that any contact with Hospital B was made regarding acceptance of transfer of Pt. #1 and/or capacity/capability. - A Nurse’s (E#2) note, dated 04/18/2025 at 7:21 PM, included “Per [E#1] (central access) no report necessary to [Hospital B]. [Ambulance] here - given PCS and face sheet; awaiting belongings.” - Nursing Discharge Note, dated 04/18/2025 at 7:39 PM, included “Patient discharged in the care of ambulance. Transfer charge completed by [E#2]. Patient vitals stable upon transfer. Public Safety has returned personal belongings to patient and they are in the care of [Ambulance Service] for transport. Patient stable upon discharge.” Hospital A’s record lacked the physician’s written certification for transfer form, including the risks and benefits of transfer, for Pt. #1. 3. Hospital B’s clinical record of Pt. #1’s ED visit on 04/18/2025 was reviewed on 06/05/2025. Pt. #1 presented to Hospital B’s ED by ambulance on 04/18/2025 at 9:22 PM with a chief complaint of suicidal ideation. -ED Triage Note, dated 04/18/2025 at 9:25 PM, included “Pt arrived to the ED from ambulance with complaints of suicidal ideation. Pt is a [police] officer and wanted to shoot self with service weapon. Pt came here from [Hospital A] with no notice of pt coming here. Pt was an involuntary petition in IL (Illinois), pt is voluntary here at this time. Pt is A&O [alert and oriented] x4 and appears to be in no distress.” 4. An interview was conducted with the ED Medical Director (MD#2) on 06/05/2025, at approximately 9:00 AM. MD#2 stated that it should be a collaborative effort between the provider, nursing, and central access to ensure that a transfer is appropriately arranged. MD#2 stated that they are working on education for the staff to ensure that transfer forms are being completed, contain all the necessary components (i.e. accepting facility), and are included in the patient’s medical record.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 2 of 3 patients’ (Pt. #1 and Pt. #10) clinical records reviewed for restraint use, the hospital failed to ensure that least restrictive measures/alternatives were attempted prior to placing the patient in restraints. Findings include: 1. On 3/25/2025, the hospital’s policy titled, “Restraint and Seclusion” (Last Revision 04/23/2024), was reviewed and required, “...Use of Restraints for Acute Medical and Post-Surgical Care - Nonviolent/Non-self-destructive...Restraint Orders...Be implemented at the least restrictive level possible while maintaining the patient’s safety and well-being...Documentation. The RN (registered nurse) documents in the patient’s EHR (electronic health record)...” 2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that least restrictive measure was attempted prior to application of restraints. 3. The clinical record of Pt. #10 was reviewed on 03/25/2025 at 10:30 AM. The ED (Emergency Department) Progress Note by ED Physician (MD#3) on 10/13/2024 at 11:51 PM, indicated that Pt.#10 presented to the ED with delirium, vomiting and yawning and diagnosed with Acute Hyperactive Opioid Withdrawal Delirium. Pt.#10 was found restless on the ground by Pt.#10’s child. The ED Triage Note by ED Registered Nurse (E#9) on 10/13/2024 at 11:23 PM, included - “Patient arrives via EMS (Emergency Medical Service) from home for drug withdrawal...[Pt.#10’s child] called 911 when patient was thrashing around & vomiting...” A physician’s order was placed on 10/13/2024 at 11:56 PM for non-violent or non-self destructive restraints. Restraint flowsheets indicated that Pt. #10 was placed in violent/locked restraints on 10/13/2024 at 11:56 PM. The record lacked documentation that the least restrictive measures/alternatives were attempted prior to using restraints as required. 4. On 3/25/2025 at approximately 12:03 PM, an interview was conducted with Registered Nurse (E#7). E#7 stated that prior to using restraints on a patient, attempts should be made at utilizing less restrictive interventions and such attempts should be documented. E#7 stated that prior to application of restraints, a physician’s order should be obtained. 5. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1’s RN). Regarding application of restraints, E #6 stated, “I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(4)(i) The use of restraint or seclusion must be-- (i) in accordance with a written modification to the patient’s plan of care. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #1) clinical records used regarding use of restraints, the hospital failed to ensure that the care plan was modified. Findings include: 1. On 3/25/2025, the hospital’s policy titled, “Restraint and Seclusion” (4/23/2024) was reviewed and included, “... Use of Restraints for Acute Medical and Post-Surgical Care... Be accompanied by modification to the patient’s plan of care...” 2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that the care plan was modified when restraints were used. 3. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1’s RN). Regarding application of restraints, E #6 stated, “I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes.” E #6 stated that the care plan is modified when restraints are used.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #1) clinical records used regarding use of restraints, the hospital failed to ensure that a physician’s order was obtained. Findings include: 1. On 3/25/2025, the hospital’s policy titled, “Restraint and Seclusion” (4/23/2024) was reviewed and included, “... Use of Restraints for Acute Medical and Post-Surgical Care... Restraints orders are documented in the EHR (electronic health record)... “ 2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that a physician’s order was obtained when restraints were used. 3. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1’s RN). Regarding application of restraints, E #6 stated, “I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes.” E #6 stated that a physician’s order should be obtained when restraints are used.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #1) clinical records used regarding use of restraints, the hospital failed to document that the patient was monitored while in restraints. Findings include: 1. On 3/25/2025, the hospital’s policy titled, “Restraint and Seclusion” (4/23/2024) was reviewed and included, “... Use of Restraints for Acute Medical and Post-Surgical Care... The following monitoring and activities are performed... Every 2 hours: Signs of injury... Adequate nutrition and hydration. Circulation, skin integrity and range of motion...” 2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that Pt. #1 was monitored while in restraints, as required. 3. On 3/25/2025 3:01 PM, a telephone interview was conducted with E #6 (ICU RN/Pt. #1’s RN). Regarding application of restraints, E #6 stated, “I placed soft wrist restraints on (Pt. #1) because (Pt. #1) was pulling tubes.” E #6 stated that when in restraints, patients should be monitored every two hours for signs of injury, hydration, type of restraint use, and range of motion.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 36774 Based on document review and interview, it was determined that for 1 of 3 patients’ (Pt. #1) clinical records reviewed for nursing assessment/reassessment, the hospital failed to ensure that reassessment was documented, as required. Findings include: 1. On 3/25/2025, the hospital’s document titled, “Attachment A: Nursing Assessment Standards by Patient Venue” (3/4/2024) was reviewed and indicated, “ ... ICU (Intensive Care Unit) ... Reassessment: Head to Toe reassessments will be completed/documented every 4 hours ...” 2. On 3/25/2025, the clinical record for Pt. #1 was reviewed. On 10/13/2024, Pt. #1 was admitted to the ICU (intensive care unit) due to hypotension (low blood pressure). While in the ICU from 10/13/2024 through 10/24/2024, there was no documentation that Pt. #1 was monitored while in restraints, as required. 3. On 3/25/2025 at approximately 10:45 AM, interviews were conducted with E #10 (ICU Assistant Manager) and E #11 (ICU Manager). E #10 and E #11 stated a head to toe nursing assessment should be completed every four hours.”