Baptist Health Louisville

“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: 35627 Based on interview, review of medical records, transfer center notes, Emergency Medical Services (EMS) run sheet and EMTALA (Emergency Medical Treatment and Labor Act) policy review, it was determined facility (F)2 failed to accept an appropriate transfer from F1 for 1 (one) of twenty (20) sampled patients, Patient (P)1. The findings include: On 01/13/2026 P1 presented to the F1’s Emergency Department (ED) for worsening left hip pain and immobility following femur fracture repair and hip prosthesis placement surgery performed at F3 on 12/14/2025. P1 received a Medical Screening Exam (MSE) including Computed Tomography Scan (CT) of the left hip which was suggestive of periprosthetic abscess and osteomyelitis. Medical Doctor (MD)1, the attending ED physician discussed the case with F1’s on-call Orthopedist who advised P1 was a complex case and would require multiple surgical revisions indicating it was not viable to keep the patient at F1. MD1 requested transfer to F2, a facility in the same network as F3 and approved by P1 and family. F2 had the capability and capacity to admit P1, however the admission was declined. Cross Refer to A-2411.”

“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: 35627 Based on interview, review of medical records, transfer center notes, and EMTALA (Emergency Medical Treatment and Labor Act) policy review, it was determined facility (F)2 failed to accept an appropriate transfer from F1 for 1 (one) of twenty (20) sampled patients, Patient (P)1. The findings include: Review of F2’s policy #11600.9, “Emergency Medical Treatment and Labor Act (EMTALA),” created 11/10/2003 and last reviewed 08/02/2024 revealed F2 facilities would comply with the Emergency Medical Treatment and Labor Act [EMTALA], 42 USC §1395 and all federal regulations and interpretive guidelines promulgated thereunder. Continued review of policy #11600.9 demonstrated ... receiving hospitals have a duty to accept transfers if the hospital has specialized capabilities or facilities (e.g., neonatal intensive care units, psychiatric units or with respect to rural areas, regional referral centers) and may not refuse to accept from a referring hospital an appropriate transfer of an individual requiring such specialized capabilities or facilities if the receiving or recipient hospital has the capacity to treat the individual. Review of F1’s ED Medical Doctor, (MD)1’s “Physician’s note” from 01/13/2026 at 8:01 PM revealed P1 was 74 years old and had hypertension and diabetes. P1 had a hip replacement on 12/14/2025 at F3, had gone to rehab after surgery was unable to participate in physical therapy and discharged home on 12/31/2025. Home health made an initial visit on 01/13/2026. Patient 1 had not had any physical therapy, was immobile and complained of leg pain. Additionally, the 01/13/2026 “Physician’s note” note stated, family reported P1 is unable to see F3’s Orthopedic Surgeon, MD3, who performed the hip replacement procedure, as P1’s insurance had changed (per family P1 had an appointment 01/14/2026 that was canceled due to lack of insurance). Review of the 01/13/2026 CT scan completed at 10:33 PM of P1’s left hip revealed, the prosthesis was present (hip hardware in place and intact) and a large elongated hypodense fluid collection with mild peripheral enhancement surrounding the left hip joint and proximal aspect of the left hip prosthesis, suspicious for abscess (infection). There was osteolysis and bony destruction surrounding the proximal aspect of the left hip prosthesis suggestive for osteomyelitis (bone infection). Correlate clinically. Follow-up recommended. Enlarged inferior abdominal and bilateral inguinal lymph nodes. Review of the “Physician’s note” written at 01/14/2026 at 12:38 AM revealed since the CT scan imaging showed likely osteomyelitis (bone infection), abscess associated w/ prosthesis (related to the hip replacement procedure and hardware) they paged F2 to request a transfer. P1 did not want to return to F3. MD1 discussed case with F1’s on-call Orthopedist and summarized “this would be a complex case with multiple revisions, not viable to keep P1 here [at F1].” On 1/14/2026 at 12:55 AM a “Physician’s note” recorded by MD1 documented the discussion of P1’s case with F2’s MD2, who declined transfer. MD2 reported P1 needed to be seen at F3, where the hip replacement occurred. MD1 explained, P1 and family had refused transfer to F3. P1 and family had attempted to see the Surgeon and were told P1’s insurance was not accepted in the office. Continued review showed MD1 stated there was no option to reach out directly to Surgeon (MD3) at F3 and had directly contacted F2’s transfer center to facilitate care of P1, based on the prior relationship (F2 and F3 are part of the same hospital system). On 01/14/2026 at 1:12 AM, MD1 recorded in a “physician’s note” they had spoken with F2’s transfer center and were told by F2’s House Manager Registered Nurse (RN1) if the MD2 was unwilling to accept P1’s care, F2 could not accept the patient, again MD1 clearly explained this would be a decline in acceptance of a patient requiring an increase in care. Review of F2’s transfer center notes from 01/14/2026 revealed MD1 spoke by phone with F2’s MD2 at 12:56 AM. MD1 stated P1 had a hip replacement at F3 and based on CT results likely had a post-operative infection. P1 was currently non-weight bearing, with left hip/knee pain and ankle weakness. P1 was scheduled to follow up with MD3 but the office would not accept insurance. MD2 recommended P1 return to MD3 at F3. MD1 stated P1 refused to return to F3. MD2 repeated the recommendation. MD1 again stated P1 had refused. Call ended. Interview with MD1 on 02/27/2026 at 10:25 AM revealed they worked at F1, a 40-bed hospital with 14 ED beds and 5 fast track rooms. MD1 stated they cared for P1 in the F1 ED on 01/13/2026 and 01/14/2026. They remembered P1 had hip surgery at F3, went to rehab but didn’t participate and had been sleeping on the couch with a family member for a couple weeks. P1’s family shared they were told MD3 did not take their insurance the day before P1’s follow-up appointment. P1 had a substantial abscess and was in a lot of pain. P1 preferred not to return to F3. MD1 was not sure how to reach the MD3, nor did MD1 know if MD3 saw patients at F2. MD1 stated MD2 did not want to take P1 and refused the transfer. MD1 explained to MD2 they needed to accept because it was a higher level of care. MD1 also stated F2’s House Manager (RN1) had called F1 back and said P1 could come to F2 after returning to the F3 first. An interview on 02/26/2026 at 4:56 PM with F2’s On Call Orthopedic Medical Doctor (MD2) revealed they (MD2) were taking calls for direct admissions to F2 on 01/13/2026 and 01/14/2026. MD2 stated the transfer center called and then connected them to MD1. MD2 remembered MD1 told them F1 had a patient who had hip surgery within the month at F3 and MD1 had concerns about infection. MD2 recommended P1 return to F3 for continuity of care. MD1 responded P1 had an issue with insurance not being accepted and MD2 shared F2 and F3 were under the same financial umbrella so the insurance issues would likely be the same. MD1 quickly responded P1 did not want to go to F3, which confused MD2 as MD1 had not taken any time to consult P1 with the information offered. MD2 stated they had recently attended EMTALA training, which was helpful as they do take transfers frequently. MD2 described EMTALA from the standpoint of an on-call MD was, if an ED calls with a patient they cannot care for and it is an emergent situation for which they are seeking admission, and we can care for them we will take them. MD2 stated hospital capacity would not be a concern as the transfer center would not reach out if there was no bed available. MD2 stated they did not refuse the transfer of P1, just recommended better continuity of care. An interview with RN1, the House Manager who worked 01/13/2026 and 01/14/2026, revealed they remembered P1 because they spoke with the transfer call center after MD1 got really upset. RN1 stated, normally F2’s Hospitalists do direct admissions but since this case was related to a surgical complication, they called MD2, the orthopedic specialist on call. MD2 recommended P1 go to the location of the original surgery. RN1 went on, if P1 had sepsis or a new diagnosis admission would not have been a problem, but this case was only about surgical complications from a very recent surgery. So, MD2 recommended they return to their surgeon. Patient 1 was transferred from F1’s ED to F6 on 01/14/2026 and admitted at 1:52 PM to the care of MD5, an internist. On 01/16/2026 P1 had an abscess aspiration while under conscious sedation (testing for infection around joints). On 01/20/2026, MD6 removed P1’s original Left Hip prosthesis, and replaced it with another prosthesis and an antibiotic spacer to treat infection. While hospitalized at F6, P1 was treated for a urinary tract infection, hypertension, diabetes mellitus, hypokalemia (low potassium level), osteomyelitis (bone infection), encephalopathy (brain infection) and an episode of anxiety accompanied by chest pain. P1 was discharged to another facility for orthopedic rehabilitation on 01/30/2026.”

“DISCHARGE PLANNING- TRANSMISSION INFORMATION CFR(s): Discharge of the patient and the provision and transmission of the patient’s necessary medical information. (b) The hospital must discharge the patient , and also transfer or refer the patient where applicable, along with all necessary medical information pertaining to the patient’s current course of illness and treatment, post-discharge goals of care, and treatment preferences, at the time of discharge, to the appropriate post-acute care service providers and suppliers, facilities, agencies, and other outpatient service providers and practitioners responsible for the patient’s follow-up or ancillary care. This Standard is not met as evidenced by: 29137 Based on interview, record review, and facility policy review, the facility failed to ensure an individual’s emergency department (ED) records were transmitted upon discharge for one (1) of ten (10) sampled patients, Patient #2 (P2). Patient #2 (P2) was transported to the facility’s ED, via emergency medical services (EMS), on 01/10/2022, from the long term care (LTC) facility that he/she resided in. However, the facility’s ED Physician documented P2 seemed competent, and the patient was discharged from the ED in a cab to return “home,” which was the LTC facility he/she resided at. The findings include: Review of the facility’s policy entitled, “ED-Discharge/Follow-up Care Instructions for Emergency Department Patients”, last reviewed 04/2021, revealed the purpose was to instruct patients of their discharge instructions and ensure the patient had a a Physician for his/her follow-up care. Review of the EMS run sheet dated 01/10/2022, revealed P2 was transported from the LTC facility in which he/she resided at 11:00 PM. Continued review revealed documentation noting P2 had fallen, hitting his/her head; however, without reported loss of consciousness. Per review of the EMS run sheet, P2 was assessed as alert and oriented “x4” (oriented to person, place, time, and situation). Further review of the EMS run sheet revealed Patient #2 arrived at the facility’s ED via EMS on 01/10/2022, at 11:13 PM, related to a fall at the LTC where he/she resided. Review of P2’s hospital ED record revealed the ED Physician noted P2 seemed to be competent, and as stable at the time of discharge. Review of the ED Patient Care Timeline dated 01/10/2022, at 11:28 PM through 01/11/2022, at 9:21 AM, revealed P2 arrived to the facility on 01/10/2022, at 11:28 PM, from a LTC facility. Continued review revealed triage (process of quickly examining sick or injured people) was initiated at 11:30 PM, and the chief complaint (CC) for P2 was updated to include Fall and Hyperglycemia (high blood sugar). Further review revealed at 12:33 AM, on 01/11/2022, orders for laboratory work (labs) and imaging (computerized tomography [CT] of the head/spine) were placed. Review further revealed P2 allowed the CT imaging to be performed, and the CT of his/her head/spine were both negative for injury. In addition, review revealed multiple attempts were made to draw P2’s ordered labs, vital signs and blood sugar checks with the patient refusing all attempts. Additional review of the ED Patient Care Timeline dated 01/10/2022 through 01/11/2022 at 9:21 AM, revealed at 9:16 AM, on 01/11/2022, P2 was discharged from the ED in stable condition, and he/she left in a cab, alone. Review of the ED Provider Notes dated 01/11/2022, revealed P2 reported “kids and toys” caused him/her to fall at home. Continued review of the ED Provider Notes revealed P2 was alert and oriented; however, declined to allow a full medical screening exam (MSE). Further review revealed the Medical Provider documented P2 “vehemently” crossed his/her arms and stated he/she wanted to go home and had money to do so. Review of the ED Key Information revealed the “home” P2 was referring to was the LTC facility. During an interview on 04/10/2024 at 2:10 PM, the ED Charge Nurse stated she was familiar with the incident that occurred on 01/10/2022; however, did not know anything about P2’s discharge. The Charge Nurse stated there had been “immediate” education provided to ensure patients were discharged appropriately. She stated her expectation was if an individual arrived via EMS from an outside facility, such as a long term care (LTC) facility, the individual was to be returned to the facility via EMS, and not per cab. (The facility declined to provide a copy of the incident report and Root Cause Analysis (RCA) for the State Survey Agency [SSA] Surveyor’s review). In interview on 04/10/2024 at 3:03 PM, Registered Nurse (RN) #4 stated she was “fairly new” to the ED, but had received education on appropriate patient disposition in her orientation. RN #4 further stated she would review a patient’s EMS run sheet and consult with the patient’s guardian, as applicable. In an interview on 04/11/2024 at 9:14 AM, RN #5, stated there were “checks and balances” to utilize, related to disposition of a patient from an outside facility. He stated phone reports, the EMS run sheet, and patient transfer sheets were options to use to ensure patients were discharged appropriately. During an interview with the Director of Emergency Services (DES) on 04/11/2024 at 9:27 AM, she stated she had reviewed the incident report involving P2 and met with the ED Leadership as the facility determined there had been a failure in the discharge process, and education was provided. The DES stated based on P2’s recollection of events leading to the fall, the focus of the facility’s staff education became recognizing dementia patients and following the proper processes for discharge of patients. She stated the facility’s internal investigation regarding the incident revealed a failure to follow its discharge process, compounded by “inaccurate” patient information.”