Mymichigan Medical Center Clare

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 48030 Based on record review and interview, the facility failed to provide a face-to-face evaluation within one hour of restraint or seclusion for 2 (P-17, P-19) of 3 patients reviewed for restraint/seclusion resulting in the potential for violation of patient rights and poor patient outcomes. Findings include: P-17 On 3/11/2025 review of the medical record for P-17 revealed he was placed into restraints multiple times from 12/16/24 through 12/17/2024. Face-to-face evaluations were not competed for 5 out of 5 episodes. Review of Restraint Orders reveals violent restraints were ordered on the following dates: 12/16/2024 0917 - No Face-to Face evaluation documented 12/16/2024 1236 - No Face-to-Face evaluation documented 12/16/2024 2001 - No Face-to-Face evaluation documented 12/17/2024 0003 - No Face-to Face evaluation documented 12/17/2024 0324 - No Face-to-Face evaluation documented Nursing documentation from 12/16/24 0917 and 12/16/24 1614 reveals Face-to-Face evaluation: “yes” however, no note from the provider was found in documentation. P-19 On 3/11/2025 review of the medical record for P-19 revealed she had been placed in restraints on two separate occasions. Face-to-face evaluations were not completed on 11/16/2024 at 0810 or 11/16/2024 at 0843. The documentation revealed the following: 11/16/2024 0810 No Face-to-Face evaluation 11/16/2024 0843 No Face-to-Face evaluation 11/16/2024 1532 Face-to-face evaluation documented On 3/11/225 at 1200, an interview with the Emergency Department Medical Director (Staff X) was conducted and reveals he was aware that ED providers are required to document a Face-to-Face assessment within an hour of placing an order and providers have been made aware that this is a requirement and he will continue to educate providers at staff meetings. Facility policy #17088390 titled “General Nursing-Restraint of Patients on Non-Behavioral Health Units Policy and Procedure” last revised 11/2024 states, “The physician must conduct a face-to-face assessment of the patient within one hour of the initiation of restraints. The face-to-face assessment must be documented and must include: 1. An evaluation of the patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition and 4. The need to continue or terminate the restraint.””

“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, 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 log the arrival of 1(P-1) patient presenting to the Emergency Department and failed to provide a medical screening exam (MSE) for 1 (P-1) patient of 20 patients reviewed for medical screening exams, resulting in the potential for less than optimal outcomes for all patients seeking emergency care. Findings include: See tags: 2405: Failure to keep a central log 2406: Failure to provide a medical screening exam.”

“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: 48030 Based on document review and interview, the facility failed to log 1 of 20 (P-1) patients presenting to the Emergency Department (ED) seeking emergency services resulting in the failure to identify patients leaving the facility without being seen and the potential for less than optimal outcomes. Findings include: On 3/10/2025 at 1300 review of the facility Emergency Department (ED) Discharge Log from November 2024 through March 10, 2025 was conducted. P-1 was not found on the log for the date of service 2/22/2025. Review of facility policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure”, policy #17636849, last revised 2/2025 reveals under the Procedure, Section I, “...will maintain a log listing each individual who comes to the dedicated emergency department seeking medical care, including patients presenting to the Emergency Department”, “The log entry will take place at the first point of contact and may be in a “log book”, on a census sheet, or on a computer, depending upon the area involved.” and “The log will contain the following information: The name or a description of the individual requesting emergency medical services; The location where the patient presented for emergency medical services or receives a medical screening examination; The disposition of the individual.””

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 48030 Based on interview and record review, the facility failed to provide an appropriate medical screening exam for 1 (P-1) of 20 patients reviewed for emergency medical treatment and labor act (EMTALA) requirements, resulting in the potential for an untreated emergency medical condition and poor outcomes. Findings include: On 3/10/2025 at 1608 review of video footage from Facility-A from 2/22/2025 was conducted with the Lead Security Officer (Staff N) and revealed at 1207 two adults (older male and younger female) presented to the Emergency Department (ED) registration window (the ED Manager (Staff D) and the Director of Nursing (Staff C) identified the admitting representative at the window as Staff P). At 1208, Staff P is observed interacting with them and then leaving the registration window. At 1210 Staff P is observed returning to the registration window and interacting again with the two adults who then walked away from the registration window, sat down at a table near the registration window and walked out of the ED at 1229. On 3/11/2025 at 0915 an interview with Staff P, the Admitting Registration Clerk working when P-1 and his daughter presented on 2/22/2025 at 1207 to the Emergency Department (ED). Staff P revealed she remembered speaking with P-1 and his daughter and that he came in complaining that his drainage tube from a recent gallbladder surgery had decreased output and he was having “pain” related to the surgery. Staff P reported she went back to the ED treatment area and spoke with staff about whether she should register P-1 to be seen. P-1 explained she could not remember who she spoke with when she went to the treatment area but did remember that the staff asked her if P-1 called his surgeon and then instructed her that to tell them that “if he had surgery somewhere else they are not going to be able to do anything” for him. Staff P revealed after this conversation she went back to the registration window and told the patient that “if he had surgery somewhere else, they should go back to where he had surgery” for treatment. Staff P recalled P-1 and his daughter sat at a table near the registration window and attempted to call someone on the phone, who she thought was the doctor s office. When queried why she did not register the patient and chose to ask whether he should be seen, Staff P stated, “I am not sure why I didn’t just register him”. When queried if she was familiar with EMTALA and if she has received EMTALA education, Staff P responded, “yes, we are not to refused patient care regardless of anything”. During an interview on 3/11/2025 at 1045 the nurse practitioner (Staff Y) revealed she did not remember discussing P-1 with Staff P but if she were asked, she would have told her to “register him so he can be seen”. When queried if she received EMTALA training, Staff Y stated, “yes, anybody that presents to the facility should be seen and nobody is turned away.” In an interview on 3/11/2025 at 0938 the ED provider (Staff K) revealed he did not remember talking with Staff P about P-1 but if he were asked about whether the patient should be registered to be seen he would have said yes. Staff K added, “I would never want anybody to go out without an evaluation.” On 3/11/2025 interviews were conducted with all staff members working in the Emergency Department (ED) with Staff P on 2/22/2025 at 1207. The staff nurses (Staff S, Staff BB, Staff Z) and the clerk/assistant (Staff CC) revealed they did not remember speaking with Staff P about P-1 and were not aware a patient left the ED without a medical screening. All staff added they receive EMTALA education and are aware that all patients are entitled to a medical screening. On 3/11/2025 at 1200 an interview with the Emergency Department (ED) Director (Staff X) was conducted and revealed he was not aware of the incident involving P-1. Staff X explained that P-1 “should have been registered and we can figure out what needs to be done”. Staff X added all ED providers receive EMTALA education and are aware all patients must have a medical screening when they present requesting treatment. Review of facility policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA) Policy and Procedure”, policy #17636849, last revised 2/2025 reveals under the Policy section, “Any individual who comes to the Medical Centers or any of the facilities where the Medical Centers provider emergency services, who is in need of or request emergency services, will be treated in accordance with the law. The individual is entitled to and will receive, regardless of diagnosis, race, color, nationality, handicap, or financial status, an appropriate: Medical screening examination by a qualified medical personnel* to determine whether an emergency medical condition exists”.”

“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: 45246 Based on a review of medical records, hospital policies, observation, and interviews, 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] for two of twenty-one sampled patients who presented at the hospital’s dedicated emergency department. The hospital failed to ensure that Patient #6 received an appropriate medical screening examination (MSE) that made use of the hospital’s capabilities (including the ancillary services routinely available to the emergency department) to determine whether an emergency medical condition (EMC) existed. The hospital also failed to provide, within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize an identified emergency medical condition for Patient #1 and failed to provide her an appropriate transfer. Failure to provide an appropriate MSE, stabilizing treatment, and an appropriate transfer to patients with an emergency medical condition has the potential to result in deterioration of the patient’s health or bodily functions (including, but not limited to, risk of fetal distress, preterm labor, organ failure, infection, coagulopathy, sepsis, severe bleeding, risk of future infertility, poor fetal outcomes, and death).”

“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: 28042 Based on observation and interview, the facility failed to post Emergency Medical Treatment and Labor Act (EMTALA) signs in areas likely to be noticed by all individuals that visit the emergency department (ED) resulting in the potential for all emergency patients to be uninformed of their rights. Findings include: On 08/13/2024 at 0945 entrance to the facility occurred through the designated Emergency Room Department entrance. During the observational tour of the ED, on 08/13/2024 at 0950, it was noted that there was only one Emergency Medical Treatment and Labor Act (EMTALA) sign posted in the patient waiting area, which was only written in Spanish. There was no English language EMTALA signage observed in the patient triage area or patient hallway in the emergency department. In an interview with Staff A (Emergency Department Manager), on 08/13/2024 at 0950, she stated there was no EMTALA sign in English posted in the patient waiting area. The only EMTALA sign in English was posted in the Ambulance entrance area. Staff A stated they would need to get more signs ordered.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 45246 Based on interview and document review, the facility failed to provide an appropriate medical screening examination (MSE) that made use of the hospital’s capabilities (including the ancillary services routinely available to the emergency department) to determine whether an emergency medical condition (EMC) existed for one of twenty-one (Patient #6) patients reviewed. Failure to provide an appropriate MSE placed patients at risk for an undiagnosed emergency medical condition, which has the potential to result in deterioration of the patient’s health or bodily functions (including, but not limited to, risk of fetal distress, preterm labor, organ failure, infection, coagulopathy, sepsis, severe bleeding, risk of future infertility, poor fetal outcomes, and death). Findings include: Review of the facility’s policy entitled “Maternal Child-Admission and OB Medical Screening Exam Procedure When Presenting with an Emergency Medical Condition,” dated 05/2024 and “applicability: MyMichigan Health and all its wholly owned subsidiaries” revealed the policy purpose was to “To provide appropriate assessment, care and disposition of all patients (greater than 20 weeks gestation) presenting to the Maternity Center/Emergency Department (ED) for evaluation/admission.” The policy stated, “All patients greater than 20 weeks gestation who present to the Maternity Center/ED for unscheduled exams/procedures/admission with obstetric complaints will be seen in the OB department. 1. Patients 20 weeks or greater with pregnancy related signs/symptoms or issues will be seen in the OB department... 4. If a patient presents to the ED and delivery is imminent and the patient is not stable for transfer to the OB unit, the ED staff will call the OB unit and an OB nurse, OB provider, and shift supervisor will be called to the ED to assist with delivery... B. RN’s [sic] will perform the triage assessment and consult with a physician after the assessment and cervical exam, if necessary, and prior to the patient’s discharge. The physicians will refer to the OB triage index. The OB provider is responsible for ruling out false labor, obtaining pertinent information from the nurse, ordering appropriate diagnostic tests, analyzing the results of those tests and determining the appropriate disposition of the patient. The nurse will wait until all lab tests are interpreted by the OB provider to discharge the patient...C. Patients 23 weeks or greater gestation being evaluated on an outpatient basis should receive a 20-minute fetal monitor strip to determine fetal well-being. Patients less than 23 weeks gestation will have fetal heart tones dopplered. The attending OB provider will be notified of the patient’s status by either resident or nurse. After observation, the patient will be re-evaluated at which time the attending OB provider will make a decision to admit the patient or send her home undelivered.” Review of the facility’s “Emergency Medical Treatment and Active [sic] Labor Act (EMTALA) Policy and Procedure, dated 11/2023 and applicability : Medical Center Clare revealed the policy purpose was “To assure that all MyMichigan Medical Centers, their associates and medical staff members, comply with the rules and regulations of the federal Emergency Medical Treatment and Active Labor Act (EMTALA). Under “Procedure, 1. Presenting for Care and Medical Screening Examination...G. The purpose of the medical screening examination is to determine if an individual is experiencing an emergency medical condition. The medical screening examination is more than providing triage; triage is a process used to determine the presence or absence of an emergency medical condition. The medical screening examination represents a spectrum ranging from a simple process that involves performing ancillary studies and procedures. It is an on-going process, not an isolated event... 1. An “emergency medical condition” is a condition manifesting symptoms (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) which, in the absence of immediate medical attention, is likely to cause serious dysfunction of impairment to a bodily organ or function or serious jeopardy to the health of the individual or unborn child. 2. A pregnant woman who is having contractions is considered to be an “emergency medical condition” if there is not enough time to safely transfer the woman prior to delivery or a transfer would pose a threat to the woman or her unborn child. Review of Patient #6’s medical record revealed that Patient #6 presented to the hospital’s emergency department (ED) 6/30/2024 at 2315 complaining of “possible decreased fetal movement” and “possible UTI” (urinary tract infection). Documentation by ED physician Q, dated 6/30/2024 at 2315, said, “Patient presents with possible UTI [and] possible decreased fetal movement...33-year-old female with symptoms of urinary tract infection. Patient [states] symptoms have been going on for the last 2 days[;] no dysuria [painful urination] but positive odor noted[,] consistent with prior urinary tract infections. Patient denies any fevers or chills[;] patient denies any abdominal pain[,] vaginal bleeding[,] or vaginal discharge[;] patient denies any current back pain. Patient is currently 30-ish weeks pregnant at this time. Seeing OB/GYN doctor for prenatal care.” Physician Q documented Patient 6’s past medical history as including gestational diabetes, placenta previa (when the placenta attaches low in the uterus and covers all or part of the cervix, which can result in heavy bleeding), and spontaneous abortion (miscarriage) complicated by need for dilation and curettage (a surgical procedure to remove abnormal tissue from the uterus after a miscarriage complication). The “Medical Decision Making” documented by Physician Q included only “Labs: ordered” and incorporation of urinalysis results showing bacteria and 5-10 white blood cells per high power field in the urine (an indication of possible inflammation in the urinary tract.” Documentation by Staff R described that Patient #6 “thinks she might have less fetal movement today” and documented assessment of “fetal heart rate 141” (normal) on 6/30/2024 at 2338. Patient #6 was discharged on 7/1/2024 at 0013 with a prescription for antibiotics and discharge instructions to “please notify your OB/GYN doctor.” The medical record did not contain documentation that Patient #6 was evaluated in the “OB department,” as required by hospital policy, nor that her screening included further evaluation of fetal status described by hospital policy, including ongoing fetal monitoring or attending OB provider notification. The hospital’s on-call obstetrical physician, Staff N was available and on-call when Patient #6 presented to the hospital’s emergency department but did not participate in the evaluation or management of Patient #6.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45246 Based on document review, interview, and policy review, the facility failed to provide, within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize an identified emergency medical condition for one (Patient #1) of twenty-one patients reviewed. Failure to provide stabilizing treatment has the potential to result in deterioration of the patient’s health or bodily functions (including, but not limited to organ failure, infection, coagulopathy, sepsis, severe bleeding, risk of future infertility, and death). Findings include: Cross-refer to A-2406 for hospital policies Review of Patient #1’s medical records revealed that Patient #1 presented to the hospital’s ED on 6/26/2024 at 0839 with “Chief Complaints” of “Abdominal Pain” and “Vaginal Bleeding - Pregnant.” Documentation by Physician I, dated 6/26/2024 0839, said, “This is a 31 y.o. [year old] female with a history of POTS [postural orthostatic tachycardia syndrome, a condition that can cause symptoms when transitioning from lying down to standing up, such as a fast heart rate, dizziness and fatigue] and a DVT [deep vein thrombosis, a blood clot generally treated with blood-thinning medications] who presents today to the Emergency Department for evaluation of abdominal pain onset 2 hours ago. Patient is currently 16 weeks pregnant and states that last night, she began to have some vaginal bleeding[,] and this morning she was having abdominal pain and spotting. She notes that she feels as though she is having contractions that are minutes apart. Patient mentions that this is her fifth pregnancy and that she only had complications after her first pregnancy in which she had developed a DVT[,] and her child was born at 32 weeks. She states that she is currently on Lovenox [brand name for a blood thinning medication used to prevent or treat blood clots] but did not take any of it due to it possibly causing her nausea and abdominal pain.” Physician I documented the “onset” of both the abdominal pain and vaginal bleeding as “sudden” and Patient #1’s “Physician Exam” as including “Gravid [pregnant] uterus” but no other genitourinary examination or characterization of bleeding, cervical dilation, or presentation of fetal parts. ED nurse Staff K documented on 6/26/2024 at 1015 “Bleeding Amount: Gush” and then at 1216 “Pt [patient] expelled fetus [at] approximately 0950 am. Pt proceeded to expel several blood clots. At [approximately] 11 am[,] pt became dizzy and reported blurry vision and vomiting. Pt noted to have soft [low] blood pressures at this time.” At 1032, Staff S documented, “Transfer Initiation” and “passed infant in ED- no placenta, on lovenox [sic] for clots...recommended admit to OB under oncall.” Between arrival and 1145, the record indicated that Patient #1’s blood pressure dropped from 125/77 (normal) at 0845 to 102/58 at 1045, 94/44 at 1100, 90/51 at 1115, 90/54 at 1130, and 81/68 at 1145. At 1129, Physician I documented, “Patient with episode of hypotension [low blood pressure] but also had vomiting and then syncope [loss of consciousness]. Concern for vagal episode as well as potential severe bleeding.” At 1203, Physician I documented, “Hemoglobin [blood count] decreased slightly from 12.3 [to] 9.7. This likely represents dilution after 2 L normal saline. Last BP 100/60.” At 1207, Physician I documented, “Shortly after arrival[,] patient had passed the fetus. It appears deceased, pale and with no movement.” The medical record did not contain evidence that Patient #1 delivered both the fetus and placenta prior to being transferred on 6/26/2024 at 1212 (cross-refer to A-2409). There was no evidence the hospital considered or attempted spontaneous delivery of the placenta prior to transfer, nor that the hospital considered the potential benefits of delivery of the placenta, including minimizing the risk of post-partum hemorrhage. In an interview on 08/13/2024 at 1505, Physician I stated he was a board-certified emergency physician and had been doing approximately two shifts per month at this facility for 5 years. He said that after Patient #1 delivered the fetus, he “walked in her room” but “did not physically assess [her] for bleeding” and “did not deliver the placenta.” During interview with ED nurse, Staff K, on 8/14/2024 at approximately 1010, she stated that she recalled that sometime after arrival, Patient 1 activated her call light and notified Staff K that her “water just broke.” Staff K went in the room and helped patient change in the gown. Staff K left the room to notify Physician I. While speaking to the physician at the nurses’ station, the call light was activated by Patient #1, who notified staff that she “delivered the baby.” Staff K, Physician I, and triage nurse Staff E all went to patient’s room. Staff K recalled observing Patient #1 sitting in bed with the fetus between her legs. When asked to describe the fetus, Staff K stated it was about the size of her hand, with short, thin umbilical cord, like a “dry thin noodle.” When asked if a physician assessed for placenta delivery and bleeding, Staff K stated “no.” Staff K said that the triage nurse, Staff E, left the room to call OB services for fetus care instructions. Staff K stayed in the room to take care of the patient and fetus. Staff K said she remembered assisting patient to a bedside commode and inspecting discharge for placenta tissue. Review of the hospital’s on-call schedule revealed that an OB/GYN physician, Staff N, was available and on-call when Patient #1 presented to the hospital’s emergency department and was credentialed to perform spontaneous deliveries, including delivery of the placenta. Review of hospital credentialing information for Physician I revealed that he was also credentialed to perform spontaneous deliveries, including delivery of the placenta. Review of the hospital’s public website revealed the facility holds itself out to the public as offering “a full range of services in specialty areas, including...gynecology,” “surgical services,” and “women’s health.” Cross refer to tag A-2409.”

“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: 45246 Based on document review, interview, and policy review, the facility failed to appropriately transfer one (Patient #1) of twenty-one patients reviewed when it identified Patient #1 as having an emergency medical condition as a “pregnant woman who is having contractions...that there is inadequate time to effect a safe transfer to another hospital before delivery” because they had knowledge that her delivery was already in progress, so it would have been impossible for her to be transferred “before” delivery. The hospital expressly listed “deterioration” and “worsening condition” as risks of the transfer, which also indicate the hospital’s knowledge of an unstabilized emergency medical condition. The hospital erroneously represented her emergency medical condition in the medical record and in transfer documentation as “stabilized” at the time of transfer. Failure to provide appropriate transfer has the potential to result in deterioration of the patient’s health or bodily functions (including, but not limited to, organ failure, infection, coagulopathy, sepsis, severe bleeding, risk of future infertility, and death). Findings include: Cross-refer to A-2406 for hospital policies . Cross-refer to A-2407. Briefly, review of Patient #1’s medical records revealed that Patient #1 presented to the hospital’s ED on 6/26/2024 at 0839 with “Chief Complaints” of “Abdominal Pain” and “Vaginal Bleeding - Pregnant.” Documentation by Physician I, dated 6/26/2024 0839, included, “Patient is currently 16 weeks pregnant and states that last night, she began to have some vaginal bleeding[,] and this morning she was having abdominal pain and spotting. She notes that she feels as though she is having contractions that are minutes apart.” ED nurse Staff K documented on 6/26/2024 at 1015 “Bleeding Amount: Gush” and then at 1216 “Pt [patient] expelled fetus [at] approximately 0950 am. Pt proceeded to expel several blood clots. At [approximately] 11 am[,] pt became dizzy and reported blurry vision and vomiting. Pt noted to have soft [low] blood pressures at this time.” At 1032, Staff S documented, “Transfer Initiation” and “passed infant in ED- no placenta, on lovenox [sic] for clots...recommended admit to OB under oncall.” Between arrival and 1145, the record indicated that Patient #1’s blood pressure dropped from 125/77 (normal) at 0845 to 102/58 at 1045, 94/44 at 1100, 90/51 at 1115, 90/54 at 1130, and 81/68 at 1145. At 1129, Physician I documented, “Patient with episode of hypotension [low blood pressure] but also had vomiting and then syncope [loss of consciousness]. Concern for vagal episode as well as potential severe bleeding.” At 1137, Physician I documented on the electronic “EMTALA Transfer Form” “Patient stabilized.” Physician I documented the “Risks of Transfer” to include “deterioration” and “worsening condition.” There was no evidence the hospital considered or attempted spontaneous delivery of the placenta prior to transfer, nor that the hospital considered the potential benefits of delivery of the placenta, including minimizing the risk of post-partum hemorrhage. The medical record also contained evidence that the hospital knew that Patient #1 had yet to deliver the placenta prior to being transferred on 6/26/2024 at 1212 and, therefore, could not have had her EMC “stabilized,” as defined in 42 CFR 489.24(b) (cross-refer to A-2407).”