Christus St Frances Cabrini Hospital

“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure drugs and biologicals were administered as ordered by the licensed practitioner and according to hospital policy. This deficient practice was evidenced by failure to administer scheduled medications according to hospital policy for 3 (#1, #2, #3) of 3 medical records reviewed for medication administration. Findings: Review of the hospital’s policy titled “Drug Administration”, reviewed 09/2025, revealed in part, “To maintain the integrity of the medication administration process, all non-time critical medications must be given with one (1) hour before or after the scheduled administration time.” Patient #1 Review of Patient #1’s MAR revealed staff failed to administer the following medications according to hospital policy: Date: 11/09/2025 Medication: Ipratopium-Albuterol (Duoneb) Scheduled Time: 7:00 AM Administered Time: 8:47 AM (47 minutes late) Date: 11/09/2025 Medication: Ipratopium-Albuterol (Duoneb) Scheduled Time: 7:00 PM Administered Time: 9:42 PM (1 hour and 42 minutes late) Date: 11/10/2025 Medication: Ipratopium-Albuterol (Duoneb) Scheduled Time: 7:00 AM Administered Time: 9:17 AM (1 hour and 17 minutes late) Date: 11/11/2025 Medication: Ipratopium-Albuterol (Duoneb) Scheduled Time: 7:00 AM Administered Time: 9:12 AM (1 hour and 12 minutes late) Date: 11/12/2025 Medication: Ipratopium-Albuterol (Duoneb) Scheduled Time: 1:00 AM Administered Time: 2:53 AM (53 minutes late) In an interview on 01/07/2026 at 3:46 PM, S2QM confirmed the staff member administering medications has 1 hour before and 1 hour after the scheduled time to administer the medication. In an interview on 01/08/2026 at 10:22 AM, S3CI confirmed if the administration on the MAR is documented as late, the medication was given out of range for the scheduled time. Patient #2 Review of Patient #2’s MAR revealed staff failed to administer the following medications according to hospital policy: Date: 11/20/2025 Medication: Insulin Lispro (HumaLOG) Scheduled Time: 1:00 PM Administered Time: 2:09 PM (9 minutes late) Date: 11/23/2025 Medication: Insulin Lispro (HumaLOG) Scheduled Time: 11:00 AM Administered Time: 1:12 PM (1 hour and 12 minutes late) Date: 11/24/2025 Medication: Insulin Lispro (HumaLOG) Scheduled Time: 4:00 PM Administered Time: 5:12 PM (12 minutes late) In an interview on 01/08/2026 at 2:41 PM, S3CI confirmed the medication administrations that were labeled given late on the MAR were not administered according to hospital policy. Patient #3 Review of Patient #3’s MAR revealed staff failed to administer the following medications according to hospital policy: Date: 12/31/2025 Medication: Budesonide (Pulmicort) Scheduled Time: 8:00 AM Administered Time: 9:31 AM (31 minutes late) Date: 12/31/2025 Medication: Budesonide (Pulmicort) Scheduled Time: 8:00 PM Administered Time: 9:56 PM (56 minutes late) Date: 01/01/2026 Medication: Budesonide (Pulmicort) Scheduled Time: 8:00 AM Administered Time: 2:11 PM (5 hours and 11 minutes late) Date: 01/03/2026 Medication: Budesonide (Pulmicort) Scheduled Time: 8:00 AM Administered Time: 9:16 AM (16 minutes late) Date: 01/04/2026 Medication: Budesonide (Pulmicort) Scheduled Time: 8:00 AM Administered Time: 9:56 AM (56 minutes late) Date: 01/04/2026 Medication: Budesonide (Pulmicort) Scheduled Time: 8:00 PM Administered Time: 9:53 PM (53 minutes late) In an interview on 01/08/2026 at 3:18 PM, S2QM confirmed the medication administrations that were labeled given late were not according to hospital policy.”

“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: 44763 Based on observations, record reviews, and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider’s agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by: 1.) the hospital failed to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department (ED) specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA), with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. This deficient practice was evidenced by failing to post EMTALA signage at the ambulance entrance of the ED (see findings tag A-2402); 2.) the hospital failed to have a working system in place to ensure the effective implementation of hospital policies relating to the responsibilities of on-call physicians. This deficient practice was evidenced by having a protocol in place to not contact on-call surgeons between the hours of 10:00 PM and 7:00 AM (see findings tag A-2404); 3.) the hospital failed to maintain a central log on each individual who comes to the hospital seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by failing to document in the Emergency Department (ED) Transfer log a potential patient transfer to the hospital for 1 (#10) of 20 (#1-#20) sampled patients (see findings tag A-2405); 4.) the hospital failed to provide medical treatment for the patient’s emergency medical condition by failing to admit the patient to the hospital when the hospital had the capability and capacity to treat the patient for 1 (#3) of 20 (#1-#20) sampled patients. The hospital transferred Patient #3 to another acute care hospital with no documented written request for transfer by the patient (see findings tag A-2409); and 5.) the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient’s condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department’s physician who had requested services for 1 (#10) of 20 (#1-#20) sampled patients (see findings tag A-2411).”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 44763 Based on observation and interview, the hospital failed to ensure signs were posted conspicuously in places likely to be noticed by all individuals entering the emergency department (ED) specifying the rights of individuals under section 1867 of the Emergency Medical Treatment and Active Labor Act (EMTALA), with respect to examination and treatment for emergency medical conditions and women in labor, and to post conspicuously information indicating whether or not the hospital participated in the Medicaid program under a State plan approved under Title XIX. This deficient practice was evidenced by failing to post EMTALA signage at the ambulance entrance of the ED. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) and Patient Transfer” reviewed date 12/2024, revealed in part, “EMTALA Signage: Christus St Frances Cabrini Hospital [CH] shall post signs, in English and Spanish in conspicuous locations likely to be noticed by all individuals entering the Emergency Department(s), Labor and Delivery/OB triage areas, and other areas where patients are screened, stating the rights of individuals with emergency medical conditions, and women in labor. Signage will indicate that CH participates in the Medicaid Program.” In an observation on 02/24/2025 at 12:38 PM - 1:07 PM revealed there was no EMTALA signage posted for patients entering the ED from the ambulance entrance. In an interview during the observation S4EDD verified there was no EMTALA signage posted at the ambulance entrance of the ED. S4EDD verified the only EMTALA signage posted in the ED was located at the check-in desk near the main entrance and patients brought in by ambulance were not brought to the check-in desk.”

“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: 44763 Based on record reviews and interview, the hospital failed to have a working system in place to ensure the effective implementation of hospital policies relating to the responsibilities of on-call physicians. This deficient practice was evidenced by having a protocol in place to not contact on-call surgeons between the hours of 10:00 PM and 7:00 AM. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) and Patient Transfer”, reviewed date 12/2024, revealed in part, “List of On-Call Physicians: Christus St Frances Cabrini Hospital [CH] shall maintain a list of physicians who are on-call to consult or provide treatment necessary to stabilize an individual with an emergency medical condition.” Review of the hospital’s Specialty List / Accepting Physicians protocol revealed in part, Surgery: Surgeon does not want to be called between 10:00 PM and 7:00 AM unless it is an emergent case. Hospitalist to call Surgeon on call for any questions/concerns for complicated or non-routine transfer requests after hours. Hospitalist to respond to and admit all transfer requests after 10:00 PM and notify surgeon on call at 7:00 AM. In a phone interview on 02/26/2025 at 3:22 PM S7PTC verified the protocol is not to call for surgery after 10:00 PM unless it is an emergency. S7PTC stated the hospitalist would make the decision rather to call surgery or not.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to maintain a central log on each individual who comes to the hospital seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. This deficient practice was evidenced by failing to document in the Emergency Department (ED) Transfer log a potential patient transfer to the hospital for 1 (#10) of 20 (#1-#20) sampled patients. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) and Patient Transfer”, reviewed date 12/2024, revealed in part, “Central Log: Christus St Frances Cabrini Hospital [CH] shall maintain an EMTALA compliant central log of individuals who come to its emergency department(s) and Labor and Delivery/OB triage areas seeking assistance. The log will indicate whether the individual refused treatment, was refused treatment, was transferred, was admitted to CH and treated, was stabilized and transferred or was discharged.” Review of the hospital’s Transfer log failed to reveal the request for transfer of Patient #10. Review of the hospital’s transfer center’s transfer order dated 12/26/2024 revealed in part, the referring hospital, hospital ‘B’ was requesting transfer of Patient #10 for higher level of care for surgery services with a bed type of medical/surgical. Further review of the document revealed in part, on 12/26/2024 at 10:40 PM, declined to Cabrini [Christus St Frances Cabrini Hospital] due to post op issues from other surgeons being a limitation per protocol. In a phone interview on 02/25/2025 at 1:21 PM S2TCM stated the transfer center is the transfer center for multiple hospitals. S2TCM stated if a patient was accepted at one of their other hospitals, then the patient would not show as a decline on this hospital’s transfer list. S2TCM stated the patient would show on the accepting hospital’s list. In an interview on 02/26/2025 at 3:48 PM S1QD verified Patient #10 was not listed on the hospital’s transfer log.”

“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: 44763 Based on record reviews and interviews, the hospital failed to provide medical treatment for the patient’s emergency medical condition by failing to admit the patient to the hospital when the hospital had the capability and capacity to treat the patient for 1 (#3) of 20 (#1-#20) sampled patients. The hospital transferred Patient #3 to another acute care hospital with no documented written request for transfer by the patient. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) and Patient Transfer”, reviewed date 12/2024, revealed in part, “Patient Transfer for Christus St Frances Cabrini Hospital [CH] (CH Transferring Hospital): 1. If an individual has not been stabilized, CH may not transfer the individual unless: a. The transfer has been certified in writing by a physician that the transfer is deemed appropriate based upon the information available at the time of the transfer and that the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweighs 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. b. If a physician is not physically present at the time of transfer, a qualified medical personnel [QMP] must consult with the physician to determine if the individual with an emergency medical condition is to be transferred to another facility for further stabilizing treatment. The QMP must certify this in writing and the certification must then be countersigned by the physician in a reasonable time period. c. The individual (or a legally responsible person acting on behalf of the individual) requests the transfer, after being informed of CH’s obligations under EMTALA and of the risks of the transfer. This request must be in writing and indicate the reason for the request as well as indicate that the individual is aware of the risks and benefits of the transfer.” Review of Patient #3’s emergency department (ED) record revealed Patient #3 presented to the emergency department (ED) on 01/25/2025 at 10:48 PM with a chief complaint of abdominal pain. Review of the provider note revealed in part, Patient presents with left upper quadrant abdominal pain status post ventral hernia repair using mesh approximately 6 weeks ago. Patient with persistent abdominal pain postoperatively. Patient has had at least 2 other CT [computed tomography] scans which revealed that he has a large hematoma/seroma. Patient presents tonight with severe abdominal pain. Patient also reported subjective fever. White count is normal. Patient is afebrile on presentation. CT scan of the abdomen and pelvis reveals 2 large intra-abdominal fluid collection with a rim enhancement indicating a developing abscess. Patient was operated on at hospital ‘A’ in Baton Rouge. He has been accepted in transfer for further evaluation and management by the operating surgeon. Review of Patient #3’s ED record failed to reveal a written request from Patient #3 (or a legally responsible person acting on behalf of the individual) requesting the transfer. Further review of Patient #3’s ED record revealed there was no documented evidence of the staff requesting an inpatient bed or that an inpatient bed was not available. Review of the Memorandum of Transfer form revealed in part, reason for transfer: medically indicated. Further review of the document revealed in part, obtain level of care/service unavailable at this facility Service: was blank (no documentation). Patient #3 was transferred to hospital ‘A’ on 01/26/2025. In an interview on 02/26/2025 at 2:42 PM S3MD stated Patient #3 had surgery at hospital ‘A’ about 6 weeks prior to coming to the ED. S3MD stated the surgery was a ventral hernia repair with mesh. S3MD stated Patient #3 had multiple doctor visits post-operatively. S3MD stated this was Patient #3’s fourth visit. S3MD stated Patient #3 rated his pain 9 out of 10, severe pain. S3MD stated Patient #3 had no fever, no vomiting, and no chills. S3MD stated Patient #3 had seen the operating surgeon and said it was a seroma and sent Patient #3 home. S3MD stated Patient #3 was having significant pain and Patient #3 was out of pain medication. S3MD stated Patient #3 had two collections, one under the mesh suspicious of abscess and one was somewhere else. S3MD stated he could not remember where the other collection was. S3MD stated this scan was different than the prior scans. S3MD stated he decided to transfer Patient #3 back to the operating surgeon. S3MD stated Patient #3 preferred it. S3MD agreed this hospital could treat Patient #3. S3MD agreed this hospital provides this service. S3MD stated it’s customary for surgical complications to be sent back to the operating surgeon. Review of Patient #3’s emergency department (ED) record from hospital ‘A’ revealed Patient #3 arrived on 01/26/2025 at 7:09 AM. Review of the ED provider note dated 01/26/2025 revealed in part, History: Patient is a male who had what he states is a ventral hernia repair in December. Patient states he has been doing fine but began to have pain and went to the hospital in Alexandria where they did a CT scan and showed a fluid collection just inferior to the mesh. Patient saw his surgeon on Monday (today is Sunday). At that time it was felt that it was a hematoma and it would cause more harm to try and go and drain it then let it resolve on its own. Patient continued to have worsening pain. He has had very little appetite. He finally states he could not stand the pain any longer he went back to the hospital in Alexandria where CT was done and the fluid collection is now being read as a likely abscess. Patient was transferred here for general surgery. Patient has past medical history of CAD [coronary artery disease], A-fib [atrial fibrillation], gastroparesis, HLD [hyperlipidemia- high cholesterol], kidney stones, and seizure disorder. Patient states he has had chills but did not take his temperature. Significant worsening pain and nausea. Further review of the document revealed diagnosis: post-op pain; Disposition and Plan: Admit. On 01/26/2025 Patient #3 was admitted to the surgical unit.”

“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: 44763 Based on record reviews and interviews, the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient’s condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department’s physician who had requested services for 1 (#10) of 20 (#1-#20) sampled patients. Findings: Review of the hospital’s policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) and Patient Transfer” reviewed date 12/2024, revealed in part, “Patient Transfer to Christus St Frances Cabrini Hospital [CH] (CH Receiving Hospital): 1. CH may not refuse to accept from a referring hospital an appropriate transfer of an individual who requires the specialized capabilities or facilities of CH and that CH has the capacity to treat and the transferring hospital does not have the specialized capability to treat. 2. All requests for transfers into CH must be referred immediately to the Transfer Center/Patient Intake Center [PIC]. If the receiving physician is contacted directly by the transferring hospital or physician, the attending physician shall immediately notify the PIC of the request for transfer to CH. The PIC shall, in consultation with the appropriate services, determine whether or not CH has the capacity to accept the individual. 6. The PIC will maintain a record of incoming requests to accept emergency patient transfers.” Review of Patient #10’s ED record from hospital ‘B’ revealed in part, Patient #10 presented to the ED on 12/26/2024 at 4:03 PM. Review of the nurse’s notes revealed in part, Presenting complaint: Patient states: patient had hernia surgery 3 weeks ago in Houston. Patient states surgical incision started bleeding on Sunday. Patient called surgeon’s office and they told him to just “leave it uncovered during the day.” Today patient’s incision is draining and patient states that his abdomen is “hard and hot.” Transition of care: patient was not received from another setting of care. Review of the physician documentation revealed a diagnosis of disruption of external operation (surgical) wound, not elsewhere classified. Review of the nurse’s notes from hospital ‘B’ revealed in part, 12/26/2024 10:24 PM: Called and spoke with transfer center. Cabrini [Christus St Frances Cabrini Hospital] declined because they do not take any complications from post op [post-operative] procedures. Review of the Patient Transfer Out Form from hospital ‘B’ revealed in part, criteria/reason for transfer: for equipment or services not available at this facility: General Surgery with a diagnosis of wound recheck, rule out intra-abdominal abscess. Further review of the document revealed Patient #10 was accepted to hospital ‘C’ on 12/26/2024. Review of the hospital’s transfer center’s transfer order dated 12/26/2024 revealed in part, the referring hospital, hospital ‘B’ was requesting transfer of Patient #10 for higher level of care for surgery services with a bed type of medical/surgical. Further review of the document revealed in part, on 12/26/2024 at 10:40 PM, declined to Cabrini [Christus St Frances Cabrini Hospital] due to post op issues from other surgeons being a limitation per protocol. In a phone interview on 02/26/2025 at 1:32 PM S2TCM stated each of the hospitals they take calls for, each hospital has its own protocol of limitations. S2TCM verified the protocol for post op complication is the patient needs to go back to their surgeon. S2TCM verified Cabrini declined this transfer per protocol. In a phone interview on 02/26/2025 at 3:22 PM S7PTC stated he did not remember Patient #10 in particular. S7PTC verified if there were issues of post op surgical complications, per protocol is to decline the transfer. S7PTC verified the protocol is not to call for surgery after 10:00 PM unless it is an emergency. S7PTC stated the hospitalist would make the decision rather to call surgery or not. Review of the hospital’s Specialty List / Accepting Physicians protocol revealed in part, Surgery: Surgeon does not want to be called between 10:00 PM and 7:00 AM unless it is an emergent case. Hospitalist to call Surgeon on call for any questions/concerns for complicated or non-routine transfer requests after hours. Hospitalist to respond to and admit all transfer requests after 10:00 PM and notify surgeon on call at 7:00 AM. Limitations: No post-operative complications from surgeons not currently on staff; Any patient who is immediately post-op, please make sure the surgeon who performed the procedure was called for transfer to their facility. Hospitalist to call surgeon before accepting: -other surgeons post op patients. Review of the hospital’s Bed Management Report dated 12/26/2024 7:00 PM revealed the hospital had available inpatient beds. In an interview on 02/26/2025 at 4:53 PM while reviewing the Bed Management Report S6ADNO verified the hospital had available beds. Review of Patient #10’s ED record from hospital ‘C’ revealed in part, Patient #10 arrived on 12/27/2024 at 10:51 a.m. Review of the ED provider note revealed in part, In brief, male with past medical history of hypertension [high blood pressure], hyperlipidemia [high cholesterol], small intestine rupture, inguinal and ventral hernia status post multiple repairs presents emergency department as a transfer from outside hospital for evaluation by general surgery after being found to have a large fluid collection within his superficial abdominal wall and intra-abdominal fluid collection. Initially noticed drainage on Sunday that has progressively worsened. Further review of the document revealed in part, Plan: given unknown etiology of patient’s fluid collection he was covered broadly in the event that this is an infection. On repeat lab work patient’s left shift appears to have improved with neutrophil count of 7.10. Patient was consulted to general surgery who evaluated him at bedside and performed a drainage of his large fluid collection with thus far 700 mL [milliliters] of blood output. Clinical Impressions: abscess of postoperative wound of abdominal wall, infected hernioplasty mesh, and abdominal fluid collection. On 12/27/2024 at 5:24 PM Patient #10 was admitted to trauma surgery at hospital ‘C’.”