M Health Fairview Woodwinds 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: 47264 Based on documentation and interview, the facility failed to a medical screen exam (MSE) for 1 of 20 patients (P1) reviewed who presented to the emergency department (ED). P1 was brought to the ED via ambulance and was sent to another facility without an MSE. See tag A2406. Based on documentation and interview, the facility failed to provide safe transfer to 1 of 20 patients (P1) reviewed who presented to the emergency department (ED). P1 was brought to the ED via ambulance and was sent to another facility without an appropriate transfer to an accepting facility or provider. See tag A2409.”

“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: 47264 Based on documentation and interview, the facility failed to a medical screen exam (MSE) for 1 of 20 patients (P1) reviewed who presented to the emergency department (ED). P1 was brought to the ED via ambulance and was sent to another facility without an MSE. Findings Include: A hospital report titled “Power Outage” indicated on 3/4/25 at 9:30 p.m. the hospital’s campus lost power. The report indicated the hospital was fully closed on 3/4/25 at 9:44 p.m. The report indicated the hospital’s MRI and CT were not operational due to this outage. The report indicated the hospital’s power was partially restored on 3/5/25 at 4:44 a.m., and fully restored at 5:10 a.m. P1’s prehospital care report dated 3/5/25 indicated the ambulance service arrived at P1’s home on 2:23 a.m. The report indicated P1 had an infected tooth extracted professionally on 3/4/25. The report indicated P1 was found on the ground at a family member’s home covered in emesis containing blood clots. The report indicated P1 was on blood thinners. The report indicated P1 had uncontrollable bleeding from the mouth and her skin was hot and pale with poor turgor. The report indicated P1’s blood pressure at 2:34 a.m. was 77/33. The report indicated normal saline 500 milliliters and ondansetron 4 milligrams were administered intravenously at 2:36 a.m. The report indicated P1 was initially taken to the ED in question but was diverted to another hospital after presentation. P1 was an 84-year-old female who presented to the ED on 3/5/25 at 2:47 a.m. via ambulance after an unwitnessed fall in the community. P1’s pertinent medical history included aphasia, confusion, atrial flutter, and depression. A provider note written by medical doctor (MD)-A and dated 3/5/25 at 2:56 a.m. indicated P1 was seen in ED during a power crisis, which had caused a loss of the facility’s imaging capabilities. The note indicated P1 was a trauma alert due to her unwitnessed fall, facial bruising, and ongoing blood thinner therapy. The note indicated P1 required a trauma work-up including CT imaging, which could not provide due to the power crisis. The note indicated P1 was transferred to the nearest hospital with imaging capabilities. P1 was discharged from the ED by MD-A on 3/5/25 at 3:02 a.m. P1’s medical record indicated P1’s vitals were not obtained in the ED. During an interview on 5/6/25 at 11:19 a.m., registered nurse (RN)-B stated everyone in the ER has a right to be provided with a medical screening exam and receive emergency medical care. During an interview on 5/6/25 at 11:37 a.m., RN-C stated every patient who presents to the ED needs to have a medical screening exam by a qualified medical professional. During an interview on 5/7/25 at 7:11 a.m., RN-F stated all patients who come to the ED must be seen and medically cleared by a provider prior to leaving. During an interview on 5/7/25 at 7:23 a.m., RN-G stated everyone is entitled to be seen by a provider in the ED. During an interview on 5/7/25 at 8:07 a.m., the paramedic stated she was caring for P1 on the early morning of 3/5/25. The paramedic stated she brought P1 to the hospital ED despite the divert status because they had more resources to care for a P1’s bleeding concerns than she had available in the ambulance. The paramedic stated when she brought P1 into the ED, the providers did not talk to the patient or address her at all. During an interview on 5/7/25 at 9:32 a.m., RN-I stated everyone has the right to be seen and provided with a medical screening exam by a midlevel provider or a doctor. RN-I stated when he saw P1 on 3/5/25, he saw obvious facial bruising. RN-I stated MD-A told the paramedic P1 needed imaging services and needed to be taken to another hospital for care. During an interview on 5/7/25 at 10:22 a.m., MD-A stated any patient in the ED is given a medical screening exam. MD-A stated patients have the right to be treated without any impediment to care. MD-A stated on 3/5/25 P1 came to the emergency room via ambulance for a fall. MD-A stated P1 had bruising on her head. MD-A stated P1 was a stable patient who needed a trauma evaluation due to her unwitnessed fall while on blood thinner therapy. MD-A stated she felt she completed a medical screening exam while at the patient’s bedside. MD-A stated no administrative staff discussed this even with her. During an interview on 5/7/25 at 1:41 p.m., the medical director of the ED stated all everyone in the ED can receive a medical screening exam from their providers. During an interview on 5/7/25 at 2:50 p.m., the nurse manager of the ED stated everyone who comes through the ED doors need to have a medical screening exam to determine if they need care. The nurse manager stated the medical director of the ED reviewed P1’s chart after the event and did not have any concerns with the medical care provided. A hospital policy titled “Emergency Medical Services, EMTALA,” dated 10/19/22 indicated medical screening exams are to be performed on any patient coming into the hospital ED. The policy indicated the medical screening exam is a physical assessment of an individual using ancillary services available to determine if an emergency medical condition exists. The policy indicated a medical screening exam is an ongoing process, and the continued monitoring must be reflected in the medical record. The policy indicated the medical screening exam must include services that would be provided for any other similarly presenting patients.”

“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 documentation and interview, the facility failed to provide safe transfer to 1 of 20 patients (P1) reviewed who presented to the emergency department (ED). P1 was brought to the ED via ambulance and was sent to another facility without an appropriate transfer to an accepting facility or provider. Findings Include: A hospital report titled “Power Outage” indicated on 3/4/25 at 9:30 p.m. the hospital’s campus lost power. The report indicated the hospital was fully closed on 3/4/25 at 9:44 p.m. The report indicated the hospital’s MRI and CT were not operational due to this outage. The report indicated the hospital’s power was partially restored on 3/5/25 at 4:44 a.m., and fully restored at 5:10 a.m. P1’s prehospital care report dated 3/5/25 indicated the ambulance service arrived at P1’s home on 2:23 a.m. P1 had an infected tooth extracted professionally on 3/4/25. P1 was found on the ground at a family member’s home covered in emesis containing blood clots. P1 was on blood thinners. The report indicated P1 was initially taken to the ED in question but was diverted to another hospital after presentation. P1 was an 84-year-old female who presented to the ED on 3/5/25 at 2:47 a.m. via ambulance after an unwitnessed fall in the community. P1’s pertinent medical history included aphasia, confusion, atrial flutter, and depression. A provider notes by medical doctor (MD)-A dated 3/5/25 at 2:56 a.m. indicated P1 was seen in ED during a power crisis, causing loss of the facility’s imaging capabilities. The note indicated P1 was a trauma alert due to her unwitnessed fall, facial bruising, and ongoing blood thinner therapy. P1 required a trauma work-up including CT imaging, which could not provide due to the power crisis. The note indicated P1 was transferred to the nearest hospital with imaging capabilities. P1 was discharged from the ED by MD-A on 3/5/25 at 3:02 a.m. P1’s medical record did not indicate vital signs were obtained, a receiving hospital or receiving physician were determined or contacted prior to discharge. A copy of P1’s medical record from the receiving hospital was requested but was not provided. During an interview on 5/6/25 at 10:56 a.m., registered nurse (RN)-A stated transfers out of the ED to another hospital requires the provider discuss their decision with nursing staff who will then contact an internal placement service. The internal placement service works with the provider to find an accepting provider. Once an accepting provider has accepted the patient and a bed is available, the nursing staff can call report and secure transport according to the patient’s medical needs. RN-A stated the provider completes the EMTALA transfer forms. RN-A stated the hospital no longer goes on divert, however, if a patient presented while the hospital was somehow on a divert, they would still have to provide medical care. During an interview on 5/6/25 at 11:19 a.m., RN-B stated ED transfers to another hospital are done with the decision of a provider. The provider determines if the transfer is appropriate and completes the EMTALA form. The nursing staff then complete a nurse-to-nurse report with the receiving facility. The hospital does not go on divert status. RN-B stated if a patient were to present to the hospital while on divert status, they must provide care. If a patient needs a higher level of care, the hospital must stabilize and then send the patient elsewhere per provider orders. During an interview on 5/6/25 at 11:37 a.m., RN-C stated patients are transferred from the ED if the patient’s care requires, if the hospital does not have an available bed, or if the patient requests transfer. The sending provider and the receiving provider must discuss the patient’s care. There must be an accepting provider at the receiving hospital. The provider completes the EMTALA paperwork, and the patient must sign the form if they are able. RN-C stated the hospital does not go on divert. If a patient presented who needed a service they could not provide, they would medically evaluate, stabilize, and transfer per medical provider. During an interview on 5/7/25 at 7:11 a.m., RN-F stated providers initiate ED transfers to other hospitals they must have an accepting physician prior to transfer. The night of 3/4/25 and into 3/5/25, the hospital lost power and had to go on a hospital-wide divert. Imaging services were inoperable due to the power outage. She was working the early morning of 3/5/25 and remembered when the ambulance came in. She was confused when their provider turned P1 away. They reviewed the hospital’s policy at the time of incident and staff felt they had followed the policy and therefore nothing was wrong. RN-F stated she brought her concerns to the charge nurse, RN-I, who dismissed her concerns. During an interview on 5/7/25 at 7:23 a.m., RN-G stated ED transfers are completed when a patient needs a specific service the hospital cannot provide. There must be an accepting provider at the receiving facility, and this must be documented through EMTALA paperwork in the patient’s chart. RN-G stated during the overnight shift of 3/4/25 into 3/5/25, the hospital lost power, and they did not have access to their imaging department. RN-G stated staff alerted the Minnesota system for Tracking Resources, Alerts and Communication (MNTrac system) so the ambulance companies were aware the hospital was on divert status. If the ED received a patient during the power outage, they would still have to provide care, including transfer if the provider determined it was appropriate. During an interview on 5/7/25 at 7:33 a.m., RN-H stated all transfers must include information about the accepting hospital, provider, and reason for transfer, and must be documented in the EMTALA form. RN-H stated EMTALA still applies if a patient is on their property or in the ambulance bay. During an interview on 5/7/25 at 8:07 a.m., the paramedic stated she was caring for P1 on the early morning of 3/5/25. She called ahead to the ED and was told the hospital was on divert but was unaware of the power outage to the imaging department. A hospital may go on divert; however, this is a suggestion to ambulances. P1 was hypotensive in the ambulance and there was concern for active bleeding from the extraction site, or possible sepsis related to the tooth removal and infection. It would have taken approximately 30-40 minutes to get P1 to the next closest hospital, and therefore took P1 to the hospital’s ED. When she arrived at the ED, she took P1 out of the ambulance bay and brought her to a stabilization room. The providers on site informed her this was an inappropriate transfer because the CT was inoperable. The providers began to discuss an emergent transfer to an outside hospital as they could not provide appropriate imaging in their ED. She offered to take the patient, and the providers gave a suggestion of one or two specific hospitals. The paramedic stated MD-A then brought her hand up in a “stop” motion and stated, “We’re done with this conversation.” The paramedic stated she then took P1 back to the ambulance and transported her to another hospital. During an interview on 5/7/25 at 9:16 a.m., MD-B stated any patient within 200 yards of the hospital who needs care must be given care according to EMTALA regulations. If a patient presented to the hospital while they were on divert, they would receive medica care to ensure they were not having a medical emergency. Providers must stabilize patients the best of their ability prior to transporting. MD-B stated to transfer a patient, the provider must determine if the receiving facility has the capability to accept new patients, and they must determine an accepting provider. During an interview on 5/7/25 at 9:32 a.m., RN-I stated an ED transfer to another facility begins with the provider speaking their internal placement service to find an available bed. Their provider will speak to the provider at the accepting location and must get acceptance prior to transferring the patient. The provider then completes the EMTALA form, and the patient signature is obtained by either the provider or the nurse. RN-I stated the hospital does not go on divert, however there was a recent incident on 3/5/25 when they had to go on divert due to a power outage. They told the ambulance not to bring the patient, however they refused to go to a different hospital. The ambulance containing P1 was on hospital grounds. They told the ambulance not to offload the patient. He was outside the stabilization room while the providers spoke with the paramedic. The provider told the paramedics P1 needed to go to a hospital with imaging capabilities due to the concern for an unwitnessed fall on blood thinners. RN-I stated their provider refused to accept P1 because they did not have the imaging services to rule out a head bleed. RN-I stated after the incident, he did inform the ED manager about what happened. During an interview on 5/7/25 at 10:22 a.m., MD-A stated if an ED patient needs transfer, the provider must find an accepting provider with an available bed. The hospital does not go on divert, and they must care for all patients who come in via ambulance. MD-A stated on 3/5/25 P1 came to the emergency room via ambulance for a fall. Because P1 had an unwitnessed fall and with on blood thinner therapy, she was a trauma alert. P1 stayed on the ambulance cart while she discussed her concerns with the paramedics. She told the paramedics they should take P1 to another hospital where they could complete a trauma evaluation. She did not call a receiving hospital to make arrangements for a transfer. She did not call any other hospitals to find an available bed because she wanted P1 to receive a trauma assessment as soon as possible. She completed a medical screening examination at the bedside. P1 was a stable patient requiring a trauma exam. MD-A stated she felt the paramedics did not relinquish control of P1 to her, and therefore did not need to complete an EMTALA transfer. She does not know why she did not call another hospital to find a receiving provider. MD-A stated P1 did not say much about the situation. During an interview on 5/7/25 at 1:22 p.m., the nursing director of the ED stated any patient who presents to the hospital property is protected by EMTALA. If an ED patient needs to be transferred, the ED provider must contact the accepting provider and complete a handoff. They refer to diverting as a hospital closure. The nursing director of the ED stated when there is a hospital closure and a patient presents in an ambulance, the hospital staff must abide by EMTALA regulations. During an interview on 5/7/25 at 1:41 p.m., the medical director of the ED stated patients transferred out of the ED have EMTALA paperwork completed, which includes the name of the accepting physician, the name of the hospital they are going to, and the patient’s signature. The medical director stated he was unaware of any recent EMTALA violations. During an interview on 5/7/25 at 2:50 p.m., the nurse manager of the ED stated patients who present to the ED must be provided a medical screening exam and stabilized. They must follow the transfer process if their needs surpass the hospital’s capabilities. The transfer process includes the EMTALA forms, which document the accepting provider at the receiving hospital, educating patients on the risks and benefits of transfer, and receiving patient consent for transfer. RN-I informed her of the incident on 3/5/25 after it occurred. The medical director had reviewed P1’s chart and did not have any concerns. The nurse manager of the ED stated in the future, if a patient presents to the ED during a hospital closure, they must provide stabilizing treatment or provide for a safe transfer as needed. A hospital policy titled “Emergency Medical Services, EMTALA” dated 10/19/22 indicated the hospital must provide medical services and transfers according to EMTALA rules and regulations. A hospital policy titled “Diversion of Ambulance Patients,” dated 8/30/2 indicated in the case of a hospital infrastructure failure, the hospital ER waiting room and ambulance arrivals will be closed to new patients. The policy indicated the diversion status of the hospital shall not alter appropriate referral of inbound ambulance to alternative hospitals. A hospital policy titled “Transfer of Care of Patients” dated 8/15/23 indicated the emergency provider will contact the provider at the receiving hospital and provide report. The policy indicated the receiving provider must accept the patient, and there is a bed available for the patient prior to the transfer occurring. The policy indicated all appropriate EMTALA transfer documents are completed by the physician and nurse and documented in the medical record. A hospital form titled “EMTALA TRANSFER FORM” dated 10/24 indicated the provider must document the level of transportation, the name of the accepting physician, the reason for transfer, and if the patient is in a stable or unstable condition.”