University of Michigan Health-Sparrow Carson

“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: 28042 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 (see A-2409) for 2 (P-1 and P-5) patients, resulting in the potential for less than optimal outcomes for all patients seeking emergency care.”

“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: 28042 Based on interview and record review, the facility failed to provide on-call physicians to treat patients with emergency medical conditions in accordance with the resources available at their facility, resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include: During the initial tour of the emergency department on 10/23/2024 at 0930, the surveyor interviewed the Medical Director of the emergency department, Staff E, who stated there were no surgical services available at night or on the weekends. Staff E said during those times, all surgical patients are transferred out. When queried as to whether there were emergency surgical services available during the day Monday through Friday, Staff E said yes. Staff E said there is a concern with ambulance transfers due to the low number of available ambulances in the area and at times a patient can wait up to 16 hours for an ambulance transfer. In an interview on 10/24/2024 at 0910, Staff C (Chief Nursing Officer) stated the facility had 4 (four) surgeons who take “soft call” for general surgery. When the surveyor asked for a document that would define “soft call” Staff C stated she did not have one. Staff C stated soft call was not defined in a policy, the facility rules and regulations or Governing Body. Staff C stated soft call meant the surgeon would provide a telephone consult only and decide if the patient needed to be transferred for surgery or could be admitted for surgery the next day. Staff C stated the surgeons do not come in to see the patients or come in to do surgery after hours or on weekends. Staff C said if a patient presents during the day Monday through Friday with emergent surgical needs, they will be provided emergency surgery at the facility. In an interview on 10/24/2024 at 1310, Staff I (Facility President) stated when surgeons are on soft call, at night and on the weekends, they do not come in to see patients or perform emergency surgeries. All patients who require surgical services are transferred to another facility. On 10/24/2024 at 1145, review of the facility on-call schedule for the emergency department for 06/2024 and 10/01/2024 through 10/21/2024 revealed under Surgeons on call “All surgeons are available by soft calls/phone consult only-none onsite”. On 10/24/2024 at 1100, Review of facility “EMTALA/COBRA Transfer of Patients” policy dated 03/03/2024 revealed, ED Physician Attending Physician or On-Call Physician: The transfer of a patient to another medical facility shall only occur with the Emergency Department Physician, Attending Physician, or On-Call Physician order when indicated by: Patient needs specialty physicians, comprehensive facilities or services not available at their hospital.”

“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: 28042 Based on interview and record review, the facility failed to provide an appropriate transfer to another facility for 2 (P-1 and P-5) of 5 patients reviewed for transfers from a total sample of 11 patients, resulting in the potential for less than optimal outcomes for all patients requiring a transfer to another facility. Findings include: P-1 On 10/23/2024 at 1345, review of P-1’s medical record revealed she was a 49-year-old-female who presented to Facility A’s emergency department via private car on 06/27/2024 at 2000. Emergency department (ED) provider note indicated P-1 reported a chief complaint of having a procedure done earlier that day for urinary incontinence, now was unable to urinate for the last few hours. P-1 reported the surgeon who performed the procedure told her to go to the ED to have a pediatric Foley (urinary catheter) placed no greater than 8-10 French with a leg bag. The provider note indicated P-1 had mild urinary bladder pain. ED provider notes on 06/27/2024 revealed at 2031 the facility did not have pediatric foley catheter but did have femme catheter kit (small single use straight catheter). At 2032 a 700 ml bladder scan was completed. 2039 ED provider consulted with the on-call surgeon from the office who performed P-1’s procedure, who instructed the ED provider to drain P-1’s bladder with a femme catheter kit. 2053: called ED “B” who had needed catheter. 500 ml drained out using femme cath. Registered nurse (RN) note dated 06/27/2024 at 2006 indicated P-1 had called the on-call provider who directed her to go to ER for urinary retention. Surgeon on call stated that P-1 needed to have an 8 or 10 French foley with leg bag placed, nothing larger or it would ruin the procedure that she had that day. The note indicated a bladder scan noted 729ml in bladder. Nursing note at 2056 indicated a straight catheter was performed for P-1 using a femme catheter, with 500 ml (milliliters) of amber colored urine. Nursing note at 2128 indicated P-1 was discharged. At 2105 ED provider documented ED disposition set to discharge. Provider note dated 06/27/2024 at 2105 documented discharge instructions were: Go to “facility B” emergency department to be evaluated and treated and likely to have a Foley catheter placed. After visit summary for P-1 dated 06/27/2024 indicated instructions to go to “facility B” emergency department to be evaluated and treated and likely to have a foley catheter placed. Review of entire Facility A record for P-1 did not reveal any documentation of EMTALA transfer requirements, conversation with Facility B emergency department provider, or copies of medical records sent with P-1 to facility B. On 10/24/2024 at 1645, review of receiving hospital (Facility B) medical record for P-1 revealed she arrived at facility B on 06/27/2024 at 2159 with chief complaint of post operative complications after having Bulkmaid procedure (treatment for urinary incontinence) at 0900 that day. Review of triage note at 2209 indicated P-1 was unable to void, seen at Facility A where she had a straight catheter at 2100 for 400 ml (milliliters) and wants an 8 or 10 French (fr) foley catheter placed. A 10 French Foley catheter was placed by her nurse. Just over 125 mL of urine was drained. P-1 was discharged home with Foley catheter and advised to contact her surgeon in the morning. In an interview on 10/23/2024 at 1625, Staff K (emergency department RN) said she recalled P-1. She had a procedure that morning for urinary incontinence and presented with complaints of not being able to urinate. P-1 had called the on-call surgeon, who told her to come to the ED for a small catheter with a leg bag. Staff K said they did not have a small enough catheter, so a pediatric straight catheter was used to drain about 500 ml of urine from P-1’s bladder. In an interview on 10/23/2024 at 1645, Staff J (ED Physician) said he cared for P-1 when she came to the ED with complaints of urinary retention after having bladder suspension surgery earlier that day. P-1 reported she needed a specific foley catheter per her urologist. Staff J stated they did not have that foley. He called the urologist who said P-1 needed to be drained that night. Staff J said he spoke with the charge nurse at Facility B who indicated they had the speical foley. P-1 was discharged with instructions to go to Facility B emergency department for placement of the foley catheter. Staff J said he did not do the transfer because P-1 was stable, but it would make more sense to do it as a transfer. During the review of P-1’s medical record with Staff B (Manager ED) on 10/23/2024 at 1400, Staff B stated “this should have been a transfer”. She said P-1 should not have been discharged but transferred to Facility B. In an interview on 10/29/2024 at 1045, Facility B ED Physician, Staff R, stated he did not speak with anyone from sending facility (Facility A) and did not know P-1 was coming until she arrived. Staff R said he had to access her records from Facility A electronically in the EMR. On 10/24/2024 at 1100, Review of facility “EMTALA/COBRA Transfer of Patients” policy dated 03/03/2024 revealed, Prior to transfer: The Emergency Department/On-Call Physician/Attending Physician will personally contact the accepting physician and verify that the physician will assume care for the patient and that the facility has appropriate space and personnel to care for the patient...He or she will document the telephone call/communication in the patient ’ s medical record and in the “Physician Documentation” section of the ED EMTALA Transfer Consent in the EMR. P-5: On 10/23/2024 at 1450, review of P-5’s medical record revealed she was an 83-year-old-female who presented to the emergency department on 06/19/2024 at 1243 with complaints of chest pain. Review of ED provider note revealed she had a history of hypertension and was followed by a cardiologist. Due to the new ST depressions, provider discussed with cardiology who wanted P-5 treated for unstable angina with heparin (blood thinner to prevent clots in the heart) as well as aspirin. Nitroglycerin (medication for chest pain) was given, however P-5 did not have much relief with the nitroglycerin and did eventually agree to a very small dose of intravenous (IV) pain medication. P-5 was transported a larger facility for cardiac cath later that day. During review of P-5’s medical record it was revealed the physician documentation portion of EMTALA transfer record indicated P-5 was unstable at the time of transfer and the provider’s name was electronically signed by a registered nurse on 06/19/2024 at 1:45 pm. There was no documentation of the provider’s signature. During an interview on 10/24/2024 at 0950, after thorough review of the record, facility policies, governing body and rules and regulations, Staff C (Chief Nursing Officer) stated the physician should have co-signed the EMTALA transfer document for P-5. On 10/24/2024 at 1100, Review of facility “EMTALA/COBRA Transfer of Patients” policy dated 03/03/2024 revealed, Appropriate trained medical personnel shall conduct all transfers. ED Attending Physician , ED Advanced Practice Providers with oversight by ED Attending Physician. On-Call Physician. Emergency Department Physician/On-Call Physician/Attending Physician will complete all section of the “Physician Documentation” section.”