Mymichigan Medical Center Alpena

“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: 48030 Based on interview and record review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide an appropriate transfer to another facility for 1 patient (P-1) of 6 patients reviewed for transfers from a total sample of 20 patients, resulting in the potential for less than optimal outcomes for all patients requiring transfer from the facility’s Emergency Department. Findings include: See tag 2409: Failure to provide an appropriate transfer.”

“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: 48030 Based on interview and record review, the facility failed to provide an appropriate transfer to another facility for 1 (P-1) of 6 patients reviewed for transfer from a total of 20 patients, resulting in the potential for less than optimal outcomes for all patients requiring transfer to another facility. Findings include: On 12/4/2024 at 0800 record review from Facility-A was conducted and revealed P-1 arrived in the Obstetrics Department (OB) on 10/19/2024 at 0941. A procedure note dated 10/19/2024 at 1120 from the on-call OB/GYN (Staff S) revealed P-1 was pregnant and 34 weeks/3 days gestation who presented with leaking vaginal fluid, which began on 10/19/2024 at 0830. P-1 was evaluated by Staff S who recommended transfer to Facility-B due to the early gestation and documentation reveals under “Orders received to: Discharge home (Pt going by private car to (Facility-B) for treatment.” A note from the OB nurse (Staff P) under procedures reveals, “Pt seen in triage and checked. Grossly ruptured and leaking clear fluid. Cx (cervical) exam: Posterior 1 cm/50%-2. Pt given IV fluid and repositioned with good Fetal tracing noted after that.” A note from Staff P dated 10/19/2024 at 1100 reveals, “Pt and spouse aware of need to transfer to a level 2 nursery for delivery of less than 35 weeks. Mother denies further contractions, states only felt mild cramping before. (Staff S) is agreeable to discharge patient and for her to go by private car to (Facility-B). IV discontinued and patient discharged via wheelchair.” Review of the After Visit Summary from Facility-A dated 10/19/2024 reveals under Instructions, “Go to (Facility-B) immediately!” and a signed document that reveals, “I have read or had the instructions reviewed with me and understand the instructions given to me by my caregivers” on 10/19/2024 at 1150. Review of the entire Facility-A record for P-1 did not reveal any documentation of EMTALA transfer requirements or conversations with either Facility-B’s Emergency Department or Obstetrics Department providers. During record review on 12/5/2024 at 1530 of the receiving facilities (Facility-B) medical record for P-1, the History and Physical with dated 10/19/2024 at 1556 reveals P-1 had “presented to the hospital (Facility-A) and was diagnosed with preterm premature rupture of membranes (PPROM) and was checked. She was then sent via private vehicle to (Facility-B). She reports minimal cramping prior to PPROM; however, while driving here she reports worsening contractions occurring about every 5 minutes.” On 12/4/2024 at 0952 an interview with the Obstetrics (OB) nurse (Staff P) that provided care for P-1 at Facility-A was conducted. Staff P explained she worked at the facility in the OB Department for 20 years and remembers P-1 and that “her water had broke” at 34 weeks. Staff P revealed the facility transfers all patients that are less than 35 weeks gestation to a higher level of care. Staff P explained the locum OB physician (Staff S) checked P-1 and determined she was “remote from delivery” but needed to be transferred to a higher level of care. Staff P revealed the locum OB/GYN (Staff S) that was on call does not normally work at the facility, so she was assisting with the transfer. Staff S revealed P-1 did not want to be transferred by ambulance and requested to go by private vehicle and Staff S agreed this would be acceptable since P-1 had previously had a c-section and had never been in labor before and which made it more likely that she would have enough time to get to the facility, which was 2.5 hours away. Staff P explained she copied the clinical notes to bring with her and told her to go to Facility-B immediately. When queried what the process for transferring a patient to another facility by ambulance, Staff P revealed the staff would normally call report and get an accepting provider and fill out transfer paperwork. When queried if she had done this for P-1, Staff P replied, “I didn ’ t call report, I thought she would go to the ER” and transfer paperwork was not completed. On 12/3/2024 at 1628 an interview with Obstetrics (OB) Department Manager (Staff N) revealed she was aware of P-1 and had been asked to investigate the circumstances behind the transfer when she received a call from a Case Reviewer from Facility-B. Staff N explained when P-1 arrived to the OB Department, a Locum (temporary) OB/GYN was covering call for the department and this provider had never covered at the facility prior to that weekend and has not been back since. Staff N explained when she reviewed the case, she found that P-1 declined transfer by ambulance and requested to go to Facility-B by private vehicle with her husband due to the expense of an ambulance. Staff N explained based on her record review and an interview conducted with the OB nurse (Staff P) that was present for the decision to transfer, P-1 was stable to be transferred but did not want to go by ambulance. When queried if it was standard practice for patients that require a higher level of care to go by private vehicle, Staff N responded that “was not a normal practice”. When queried if patients that are transferred to another facility and decide to go by private vehicle should have transfer paperwork completed and for the sending facility to call report and get an accepting provider to the receiving facility is still required, Staff N responded, “Nursing and/or the provider should have called report and completed better documentation of the incident”. During an interview with the Obstetrics Department Chair (Staff R) on 12/4/2024 at 1215 it was revealed he had “heard about the case” involving P-1 and the transfer. Staff R explained it is standard practice for a provider to call a receiving facility prior to transfer and get an accepting provider and discuss the reason for transfer. Staff R revealed this did not occur with P-1 and that the OB physician was a locum OB/GYN that was covering the facility for the weekend. Staff R explained the provider had never worked at the facility before and has not been back since. Staff R revealed when a transfer occurs by ambulance or private vehicle the transfer paperwork should always be completed and signed and report should be called to notify the facility that the patient will be coming via private vehicle. Staff R revealed that they could not find the required transfer paperwork or evidence of report being called to the receiving facility after reviewing P-1’s records. On 12/4/2024 at 0924 an interview with the System Director for Maternal Child Health (Staff O) was conducted. Staff O explained she oversees all of the OB Departments within the Healthcare Facility Network and was notified by Staff N (OB Manager) about the transfer for P-1. Staff O revealed this case was “different because it was a locum” but that the provider should have called the receiving facility and given report that P-1 was coming and completed the transfer paperwork. On 12/4/2024 at 1730 review of policy #17102042, Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure, last revised on 11/2024 was conducted and revealed, “Patients 20 weeks or greater with pregnancy related signs/symptoms or issues will be seen in the OB department and receive an OB MSE when directed by OB provider”. Paragraph II. Patient Transfers to a Medical Facility, Section A, reveals, “1. after being informed of the risks of transfer and of the Medical Center’s treatment obligations, the individual requests to be transferred - complete form ER-074” and “2. based on the information available at the time of transfer, the physician determines that the medical benefits to be received at another medical facility outweigh the risk to the patient of being transferred (including, in the case of a woman in labor, the risks to the unborn child) and a certification to this effect is signed by the physician-complete form ER-074.” and Section E, reveals, “In all cases of patient transfer, consent of the receiving Medical Center must be obtained and documented in the patient’s medical record before the transfer.””