Range Regional Health Services

“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: 47264 Based on interview and document review, the hospital failed to ensure safe transfer for one of eight patients (P1) reviewed for transfers when P1 was sent to the receiving hospital pending bed availability. Findings Include: P1 was a 49-year-old male who presented to the emergency department (ED) on 3/9/26 at 5:50 a.m. via ambulance for chest pain. P1’s relevant medical diagnoses included diabetes mellitus, type 2. An EKG obtained on 3/9/26 at 5:55 a.m. and resulted at 8:22 a.m. indicated P1 was questionable for myocardial infarction (MI) and was not exhibiting ST elevation. A troponin laboratory value was collected on 3/9/26 at 6:05 a.m. and resulted in a high value at 6:36 a.m. A triage note dated 3/9/26 at 6:30 a.m. indicated P1’s chest pain began approximately 6 hours prior. P1’s pain radiated to his left jaw and left shoulder. A provider note dated 3/9/26 at 6:35 a.m. had a time stamped addition at 7:23 a.m. and indicated the hospitalist at the receiving hospital had accepted P1 for transfer. P1’s destination within the hospital was unknown due to internal factors. An addition at 7:33 a.m. indicated the receiving hospital called the facility and requested a pause on the transfer due to concerns of capacity. Emergency medical services (EMS) were at P1’s bedside at the time of the call. A recorded phone call dated 3/9/26 at approximately 6:52 a.m. between patient flow staff and the provider indicated P1 needed transfer to a higher level of care. The patient flow representative indicated they would identify an appropriate provider and connect them via telephone when able. A recorded phone call dated 3/9/26 at approximately 7:25 a.m. between patient flow staff, medical doctor (MD)-A, and the accepting provider indicated P1 was experiencing an NSTEMI. The providers discussed P1’s presentation, pertinent laboratory values, and stabilizing care provided in the ED. The accepting provider and the patient flow staff determined P1 could potentially go to the cardiac catheterization lab. If the cardiac catheterization lab were full, P1 would need to be admitted to inpatient due to the cardiac drips being inappropriate for observation care. They determined a plan would need to be established after morning rounds at the receiving hospital were completed, and the call was ended. A recorded phone call dated 3/9/26 at approximately 7:25 a.m. indicated the sending hospital’s ED staff called the patient flow staff to request a room number or destination for P1. The patient flow staff stated they did not have yet have space for P1. It was determined P1 needed to be held in the sending hospital’s ED until a space was secured. The patient flow staff indicated they would call the sending hospital back with a plan as soon as they could. A recorded phone call dated 3/9/26 at approximately 7:30 a.m. indicated the sending hospital’s ED staff called the patient flow staff again to request a room number or destination for P1. The patient flow staff indicated they did not have a plan yet, and the receiving hospital’s provider were in their meeting to discuss a plan. The tentative plan was to send P1 to the cardiac catheterization lab but was not yet confirmed. A nursing note dated 3/9/26 at 7:36 a.m. indicated P1’s care was transferred to EMS. A transfer checklist dated 3/9/26 at 7:40 a.m. indicated P1 was sent to the receiving hospital. P1’s bed assignment was the cardiac ICU/catheterization lab. P1 was discharged from the hospital on 3/9/26 at 7:41 a.m. An EMS Care Report dated 3/9/26 at 7:24 a.m. indicated the EMS care team was at the patient’s bedside at 7:30 a.m. The EMS team left the hospital at 7:40 a.m., and P1 arrived at the receiving hospital at 8:59 a.m. A recorded phone call dated 3/9/26 at 8:01 a.m. between the patient flow team and the sending nurse indicated there was no available bed at the receiving hospital’s cardiac catheterization lab. The plan was to make room for P1 by moving another patient off the inpatient cardiac floor. Once the move was completed and the room was cleaned, the receiving hospital would be ready for P1, and patient flow would call the sending hospital with the confirmed bed number. The sending nurse then indicated P1 had already been sent via ambulance approximately 10 minutes prior because the provider “wanted him to go.” The patient flow staff stated P1 did not have a space actively available at the receiving hospital, and the sending nurse verbalized she was aware. The patient flow staff stated this was “bad,” and the sending nurse stated, “I know.” During an interview on 4/15/26 at 9:31 a.m., registered nurse (RN)-A stated when transferring an ED patient to another hospital for care, she must wait until given a bed number at the receiving hospital to call report. To complete a proper EMTALA transfer, she must record the unit/department and the assigned room number at the receiving facility. RN-A stated if she believed there was a concern for an EMTALA violation, she would escalate the concern to the house supervisor and file an internal report. During an interview on 4/15/26 at 9:50 a.m., RN-B stated if they need to transfer a patient from the ED, they must have an accepting provider who is able to receive another patient. If a receiving hospital did not have space and they needed to care for a patient with an NSTEMI, the patient would go on a waiting list because “they cannot force [another hospital] to take a patient.” Typically, staff will call other hospitals and attempt to find an accepting provider with space to take the patient. During an interview on 4/15/26 at 10:05 a.m., RN-C stated patients who have an NSTEMI must be kept in the ER until there is space available at another hospital. During an interview on 4/15/26 at 2:03 p.m., RN-F stated if they are transferring a patient, they must have both an accepting provider and room number for the patient. RN-F stated she did not remember the exact order of events but believed she called the receiving hospital’s to give report prior to P1 leaving the hospital. She did not believe she needed a room number for the patient because he was going to the catheterization lab. RN-F stated she called the receiving hospital’s patient flow service as EMS was departing the facility. RN-F stated the provider told her P1 needed to transfer, and because a provider told her this, they were “obviously good to go.” During an interview on 4/15/26 at 2:18 p.m., the complainant stated the receiving hospital’s patient flow service contacted the complainant to disclose a potential violation of EMTALA. The patient flow team was contacted by the sending hospital to request an emergent transfer of care for a patient with an NSTEMI. The patient flow team assisted with connecting the providers. Acceptance was established; however, they needed a plan because they were unsure whether the catheterization lab was at full capacity. After this phone call, the sending hospital called back twice to request a room number to give report and were told the receiving hospital did not have a plan at the moment and could not accept the transfer yet. Once the patient flow team had established a plan and space for P1, they called the sending hospital and spoke with RN-F, who informed them P1 had been sent by ambulance approximately 10 minutes prior. During an interview on 4/15/26 at 3:14 p.m., MD-A stated when he was providing care to P1, the patient was experiencing an NSTEMI. Once P1 was accepted by a provider, they filled out paperwork and requested EMS for transfer. As P1 was being loaded into the ambulance, he received notification the receiving hospital wanted them to pause the transfer because they did not know where in the hospital they would care for the patient.MD-A stated he believed it was not medically appropriate to keep P1 at their hospital. If they were delayed any further, it could have been hours before another ambulance team was available and made the decision to send him despite the request to pause the transfer. MD-A stated the receiving hospital “had an hour and half to figure out beds on their end.” During an interview on 4/16/26 at 2:29 p.m. the ED nurse manager stated if a patient needed transfer and was still on hospital grounds when the receiving hospital told them the transfer needed to be paused, they would keep the patient at the hospital. The nurse manager stated he had heard rumors a receiving hospital had informed them the transfer of a patient needed to pause while the patient was in the ambulance garage. An internal report was filed on the situation. He was unaware if the staff attempted to stop the ambulance. Staff were not interviewed. The receiving hospital was not contacted regarding the event. The nurse manager stated the ambulance bay is considered hospital property. During an interview on 4/16/26 at 2:43 p.m. the nursing services director stated the hospital property is considered approximately 100 feet past the front and back doors and everywhere in between. She stated once there is an accepting provider, they must receive a room number or destination from the patient flow team. If a patient were accepted but did not have a determined space or bed, the provider would not continue the transfer and complete coordination of care to continue stabilizing treatment at their facility until a plan was made. The nursing services director stated an internal report was filed for P1 regarding the lack of nurse-to-nurse reports from the ED to the receiving hospital. Their internal review determined they must have had an accepting provider and a bed because they had a phone number documented to call report to. A facility policy titled “Transfer of Care of Patients,” dated 8/15/23, patients transferring to another hospital must ensure there is a bed space available and ready for the patient prior to initiating a transfer.”