Covenant Medical Center

“DELIVERY OF DRUGS CFR(s): 482.25(b) §482.25(b) Standard: Delivery of Services In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law. This Standard is not met as evidenced by: 53399 Based on interview and record review, the facility failed to follow policy and procedure related to follow up of significant clinical findings with patients and/or their attending physicians for 1 (P1) of 12 patients reviewed, resulting in P-1’s return to the Emergency Department. Findings include: A review of P-1’s medical record revealed that P-1 presented to the Emergency Department (ED) on 10/04/2025 at 2016 after being transported by Emergency Medical Services (EMS) from a Skilled Nursing Facility (SNF). P-1 arrived with an indwelling urinary catheter and a chief complaint of urinary retention and cloudy urine. Vital signs revealed: blood pressure (B/P) 122/79, pulse (P) 83, respirations (R) 16, pulse oximetry (Sp02) 96% on room air, temperature (T) 98.4 F. P-1 identified a urinary/bladder associated pain score of 8 on a 1-10 scale. P-1 has allergies to Bactrim DS, Tylenol and Zithromax. On 10/04/2025 at 2337 Emergency Physician Staff B documented in the emergency medical record, “History and physical are consistent with urinary retention likely due to Foley obstruction possibly secondary to yeast or other infection.” Differential diagnosis includes developing sepsis.” “Urinalysis did show strong evidence of urine tract infection with positive nitrates, large leukocyte esterase, 20-30 white blood cells and bacteria present.” “I do believe (P-1’s) urinary retention and cloudy urine was secondary to urinary tract infection.” Ciprofloxacin (Cipro) was ordered and P-1 was discharged from the Emergency Department back to the SNF. On 10/06/2025 at 1008 a urinalysis organism sensitivities report resulted which identified the prescribed Ciprofloxacin (Antibiotic) as being resistant to the identified organism (Proteus Mirabilis). On 10/06/2025 at 1650 Pharmacy Resident Staff C documented in the Emergency Medical Record (EMR). “spoke to nurse at SNF (P-1) is not complaining of urinary symptoms and is improving. will continue with ciprofloxacin. All questions answered.” On 03/17/2026 at 1430 Pharmacy Resident Staff C was queried about the culture and sensitivity report results, any consultations that occurred regarding those results, and the process for notifying P-1. Staff C identified that clinicians, including pharmacists, monitor an EMR queue that alerts clinicians to positive culture and sensitivity reports. Staff C revealed, pharmacists work under an “Emergency Department Culture follow up Collaborative Agreement” which allows Pharmacists to independently reconcile antibiotics found to be resistant to identified organisms and, if deemed necessary, prescribe an appropriate antibiotic under the agreement.” Staff C was queried further if they had notified and consulted the prescribing physician, Staff B, about the prescribed antibiotic being organism resistant? Staff C stated, “They did not recall speaking to the ED Physician (Staff B) about the culture and sensitivity report”. On 03/18/2025 an Information Technology (IT) request was made to determine if P-1’s culture and sensitivity report had been reviewed by the assigned ED physician Staff B. The report provided indicated that the culture and sensitivity report was never accessed in the EMR by ED Physician Staff B. A request was made to interview the assigned Emergency Department Physician Staff B. Physician Director of ED Staff F stated, “Staff B was no longer on staff at (Facility) and has since moved out of State.” On 03/17/2026 at 1353 an interview with the Emergency Department Physician Director Staff F, was conducted. When queried about the decision to continue a prescribed antibiotic after determined to be resistant, Staff F revealed, “considering (P-1’s) comorbidities including lymphoma, I would have discontinued the resistant antibiotic and selected an appropriate antibiotic.” On 03/17/2026 at 1353 during an interview with the Director of Pharmacy Staff G revealed, “with the patient’s allergies (Bactrim DS and Zithromax), (P-1) did not have any other oral options, however I would have recommended to the provider to “find a match for the bug.” During record review on 03/17/2026 at 1256 it was revealed on 10/14/2025 at 1712 P-1 accompanied by family, returned to the ED with a chief complaint of urinary retention, pressure in his lower abdomen, white sediment in urine, fever and diaphoresis. During record review on 03/17/2026 at 1256 it was revealed on 10/14/2025 at 2005 Emergency Physician Staff Y documented in the EMR (medical record), “A code sepsis was initiated after (P-1’s) blood pressure dropped to 89/53, temperature was 99.9.” “This patient has sepsis and evidence of end organ failure (hypotension). Therefore, a code sepsis was activated. The source of infection is most likely kidney or bladder. Blood cultures will be drawn, a lactate level will be checked, and the patient’s suspected infection will be treated with IV antibiotics. If their systolic blood pressure drops below 90mmHg or their lactate is greater than or equal to 4, they will be given an IV fluid bolus of 30 cc/kg.” 2g Meropenem IV was ordered for antibiotic treatment of the patient’s acute cystitis. A review of the facility’s policy “Emergency Department Culture follow up Collaborative Agreement: Pharmacist Prescribed Outpatient Infectious Disease Treatment Protocol (no date) “ Revealed “ED/ID pharmacists may participate in the practice of reviewing positive cultures for all specimens submitted and prescribing appropriate drug therapy according to the ID treatment protocol. Positive blood cultures will not be treated according to ID protocols but will be brought to the attention of an available ED physician for review, the charge physician for that day.” A review of the facility’s policy “Revision of Treatment Policy” dated September 2023, revealed, “The revision of treatment policy outlines the steps taken in addressing the Revision of Treatment process in the Emergency Care Center (ECC). To assure that all significant clinical findings will be addressed and followed up with patients and/or their attending physicians.””

“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: 45245 Based on interview and record review, 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 for 1 (P-1) of 20 patients reviewed, to another facility resulting in the potential for less than optimal outcomes for all emergency patients who require transfer. Findings include: See A-2409 - Failure to conduct 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: 45245 Based on interview and record review, the facility failed to confirm acceptance of transfer for 1 (P-1) of 20 patients reviewed, resulting in an inappropriate Emergency Medical Treatment and Labor Act (EMTALA) transfer. Findings include: Review of “History of Present Illness (facility B),” dated 10/12/25 at 1912 revealed, “(P-1) is a 16-year-old female with no pertinent past medical history, who presents to our ER as a transfer from (facility A) hospital in Saginaw, for pulmonary embolism (blood clot) and pneumonia. She notes that she has been having a fever for a week and for the past couple of days coughed up streaks of blood. (P-1) also endorse [SIC] for the past 2 days she has been having shortness of breath and worsening. She notes that last night she was not feeling well and had episode of emesis (vomiting). She denies any personal history of blood clots but notes that family on her mother side has a history of blood clots though she does not know if there is a blood clotting disorder. Patient is a non-smoker. She denies pregnancy. She has a (birth control device) in place. She came to our ER (emergency room) via EMS (emergency medical response) from (facility A) in Saginaw.” Review of “ED Provider Notes (facility B),” dated 10/12/25 at 1934 revealed, “Patient’s arrival was unanticipated. Per chart review, it appears that the emergency department physician at (facility A) gave instructions to transfer to (facility B) Children’s Emergency Department under the acceptance of a physician that was actually at a Detroit (facility C) Medical Center. Patient arrived to emergency department and records were limited. I did call (facility A’s) emergency department and asked for records to be sent over I explained to them that the patient was transferred to our facility (facility B) unbeknownst to us. I also followed up with Detroit (facility C) Medical Center to let them know that their patient is not going to arrive there and will stay at our Children’s Hospital. Patient’s (blood thinner) drip was restarted for suspected pulmonary embolism...She was admitted to the pediatric intensive care team in stable condition.” Review of “ED Notes,” dated 10/12/25 at 1925 and authored by facility A attending ED physician (Staff S ) revealed, “I was informed that the patient was transferred to (facility B), but was actually accepted at (facility C) by Dr. (Staff R). I discussed patient care with (facility B ’ s) Emergency Department. The patient will be admitted to (facility B) and will not be transferred to (facility C). (Facility C) has been notified to not expect the patient.” During interview with (facility A) ED Chief Medical Officer (Staff E) and Director of Quality (Staff B) on 12/02/25 at 1130, Staff E stated that multiple calls were made to multiple “Children’s Hospitals” requesting transfer and acceptance. The resident (Staff Q) believed she was speaking with facility B, when she was actually speaking with facility C. Staff E added that the ED is always very busy and chaotic at shift change, and that may have been a factor in the miscommunication. The patient was transferred to facility B without facility B’s prior acceptance or the provision of patient report being provided to physicians and nurses (hand-off reporting), preceding the transfer.”