Munson Healthcare Manistee Hospital

“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: 29955 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 facilitate an appropriate transfer to another facility for 1 patient (P-14) of 20 patients reviewed, resulting in the potential for less than optimal outcomes during transportation to another facility. 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: 29955 Based on interview and record review, the facility failed to provide an appropriate transfer for 1 (P-14) of 20 patients reviewed, resulting in the potential for adverse outcomes for P-14 during transport to another facility. Findings include: On 11/19/2024 at 1515 a record review of P-14’s medical record revealed P-14 was a 59-year-old female who presented to the ED on 7/26/2023 at 1339 with severe abdominal pain. P-14 had a history of hypertension, hypercholesteremia, diabetes mellitus, chronic kidney disease stage IV, coronary artery bypass graft X 4, myocardial infarction with 4 stents. P-14 stated her pain level was 12/10 within the past hour and her pain was located in her upper abdominal area. P-14 also stated she was short of breath without chest pain. CT scan resulted as pneumoperitoneum (air inside the abdominal cavity, which often is the result of a perforated internal organ). Labs indicated leukocytosis 11.4. According to the medical record, a consult with the general surgeon and the ED physician (Staff R) took place, and a decision was made to transfer the patient due to the inability to support P-14 if she were to go into renal failure. The physician’s note revealed, “He [accepting physician at receiving facility] understands that we are short on ambulances and advised we treat her pain, administer Zosyn (antibiotic), and send her by POV (private vehicle) as soon as possible to (accepting facility) ED.” On the Authorization Transfer Form, the reason for transfer was documented as “beds”. The mode of transportation for P-14 was “ALS/Ambulance”, but was crossed out and private vehicle was checked. Documentation revealed P-14 left facility A via private vehicle driven by spouse (husband) at 1535 on 07/26/2023. P-14 arrived at the accepting facility on 07/26/2023 at 1700. According to the documentation, the transfer request was not made by P-14 or a legal guardian. There was no evidence P-14 refused to go by ambulance. P-14 arrived at facility B on 07/26/2023 at 1700, was taken to surgery (diagnostic laproscopy, repair gastrojejunal perforation) at 1750 and was diagnosed with a perforated viscus and infection post operation. On 11/20/2024 at 1115, during record review of P-14 medical record, Staff A was asked if there was an exception when an emergent transfer was waiting for an ambulance. Staff A responded, “Yes. Staff can tell the ambulance that the transfer is STAT (medical terminology to express urgent need and immediacy).” Review of the medical record failed to have documentation of a “STAT” order being made for P-14. On 11/20/2024 at 1145 a record review occurred of the policy titled, “Munson Healthcare EMTALA / Physician On Call Policy,” policy ID15194754, dated 8/14/2024. According to the document under the subtitle “policy,” it reads as follows, “b. Emergency medical condition is a condition manifesting itself by acute and severe symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in (1) placing the health of the individual (including the health of an unborn child) in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part;” and, “2. Stabilizing Treatment. If the medical screening examination indicates that the person has an emergency medical condition, the hospital will provide:... b. An appropriate discharge or transfer as described below.” Further it reads, “3. Appropriate Discharge or Transfer. a. Stabilized person. If the person is stabilized, the hospital may discharge or transfer the person as appropriate. The person’s stabilized condition should be documented in the medical records. A person is deemed stabilized under the following circumstances: i. For discharge: if the person does not need continued care, or no material deterioration is likely to result if the patient receives continued care as an outpatient or later as an inpatient and the patient is given a plan for appropriate follow-up care.””