Saint Francis Medical Center

“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: 48359 Based on interview, record review and policy review the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#29 and #33); ensure that an emergency medical condition (EMC) was stabilized for two patients (#33 and #35); and arrange an appropriate transfer for one patient (#1), of 35 ED records reviewed from 05/01/25 through 11/03/25. These failed practices had the potential to cause harm to all patients who present to the ED seeking care for an EMC. The hospital’s ED average monthly census over the past six months was 3,533, and the average monthly transfer of patients over the past six months was 74. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” reviewed 11/01/22, showed - A MSE will include, as appropriate, the full capabilities of the ED including all ancillary services routinely available to the ED and the services of staff specialists and sub specialists on-call to the ED as may be necessary to determine with reasonable clinical confidence whether an EMC exists. - All patients presenting to the ED requesting an examination or treatment for a medical condition, or has such a request made on their behalf, must be given a MSE and, if that exam reveals that the patient has an EMC, the patient must be provided medical care and treatment to stabilize their condition. - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy; serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part. - Medical care and treatment required to stabilize an EMC is that which, to a reasonable medical probability, will assure that no material deterioration of the patient’s condition is likely to result during transfer to another facility or if the patient is discharged, before follow-up outpatient care can be provided. - All available records of the patient’s screening exam, care and treatment of the EMC shall accompany the patient. This will include all x-rays (test that creates pictures of the structures inside the body-particularly bones), lab tests and other diagnostic test results. Records not available at the time of transfer shall be sent to the receiving hospital as soon as practicable. Review of the hospital’s document titled, “Saint Francis Medical Center Medical Staff Rules and Regulations,” approved 06/04/19, showed: - EMTALA requires all patients who present to the ED, the hospital must provide for an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists. - If the operative report is not immediately available, a brief operative note must be entered in the medical record by the performing practitioner prior to transfer of the patient to the next level of care. - The brief operative notes will include the name of the licensed independent practitioner(s) who performed the procedure and any assistants, the name of the procedure performed, findings of the procedure, any estimated blood loss, any specimen(s) removed and the post-operative/procedure diagnosis. - An ED record must be completed by the responsible practitioner prior to transfer for all transferred patients. Review of the hospital’s policy titled, “Triage,” reviewed 06/2025, showed: - The RN will evaluate and categorize each patient upon arrival to the ED according to the Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients). - An ESI Level Two is a high-risk situation. - Genitourinary (organs of both the reproductive and urinary systems) symptoms of a testicular torsion indicate an ESI Level Two acuity. Please refer to 2406, 2407 and 2409 for further details.”

“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: 48359 Based on interview, record review and policy review, the hospital failed to provide, within its capability and capacity, an ongoing assessment and reassessment during a medical screening exam (MSE) sufficient to determine the presence of an Emergency Medical Condition (EMC) for two patients (#29 and #33) of 35 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” reviewed 11/01/22, showed a MSE will include, as appropriate, the full capabilities of the ED including all ancillary services routinely available to the ED and the services of staff specialists and sub specialists on-call to the ED as may be necessary to determine with reasonable clinical confidence whether an EMC exists. Review of the hospital’s document titled, “Saint Francis Medical Center, Medical Staff Rules and Regulations,” approved 06/04/19, showed EMTALA requires that for all patients who present to the ED, the hospital must provide for an appropriate MSE within the capability of the hospital’s ED, including ancillary services routinely available to the ED, to determine whether or not an EMC exists. Review of Patient #29’s medical record dated 08/02/25, showed: - At 11:00 AM, he was a 69-year-old who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) with abdominal pain. - He was discharged from an in-patient hospital stay on 08/01/25. The discharge diagnoses included an acute (sudden onset) kidney injury, elevated troponin (a type of blood test that measures whether or not a person is experiencing a heart attack), chronic (long-term, ongoing) low blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80), anemia (low amounts of oxygen rich blood, causes paleness and weakness), dehydration, shock liver (a condition where the liver receives inadequate blood flow, leading to damaged liver cells) and acute on chronic systolic heart failure (a condition where a sudden worsening of symptoms occurs in a person with systolic heart failure [a condition where the heart muscle is weakened and cannot pump blood effectively]). - His past medical history included atrial fibrillation (A-fib, an irregular, often rapid heart rate that commonly causes poor blood flow), coronary artery disease (CAD, the narrowing or blockage of the coronary arteries usually caused by the buildup of cholesterol and fatty deposits on the inner walls of the arteries), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing), high BP, heart attack, aortic stenosis (narrowing of the valve in the large blood vessel branched off of the heart) and asthma (a chronic lung disease which makes breathing difficult). - His past surgical history included an aortic valve replacement (AVR, replacement of the heart’s aortic valve with a new valve) and cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions). - His review of systems (ROS) showed he had abdominal pain, diarrhea, nausea and vomiting. - At 11:01 AM, his vital signs (VS, measurements of the body’s most basic functions BP; heartrate (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8o to 99o Fahrenheit (F)) were BP 134/75, HR 97, RR 18 and T 98.7o F. His oxygen saturation (SAO2, measure of how much oxygen is in blood, normal is between 95% and 100) was 94%. - At 11:08 AM, his complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) showed no significant changes from 07/31/25. - At 11:08 AM, his comprehensive metabolic panel (CMP, a blood test performed to determine a variety of diseases and conditions) showed carbon dioxide (CO2, a gas produced by exhaling, normal is 20 to 23) of 18 and an anion gap (a measure for electrolyte imbalances and acid-base imbalances in your blood, normal is 8 to 16) was 18. - On 08/01/25 at 3:41 AM, a CMP drawn during his inpatient stay showed his CO2 was 20 and anion gap was 11. - At 11:16 AM, his VS were BP 132/82, RR 16, HR 95 and SAO2 96%. - At 11:31 AM, his VS were BP 137/78, RR 17, HR 93 and SAO2 94%. - At 11:38 AM, intravenous (IV, in the vein) morphine (an opioid pain medication) and zofran (medication for the treatment of nausea) were administered. - At 11:46 AM, his VS were BP 124/74, RR 19, HR 93 and SAO2 92%. - At 12:11 PM, an abdominal and pelvis computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed a small left pleural effusion (a buildup of fluid between the tissues that line the lungs and the chest due to poor pumping by the heart) and trace right effusion. bibasilar infiltrates (accumulation of a foreign substance, typically within the lungs of the lower lobes of both lungs) were moderate possibly representing edema (swelling) or pneumonia (infection in the lungs) and slight excess fecal retention throughout the colon. - On 07/30/25 at 6:07 PM, a chest CT scan performed during his inpatient stay, showed asymmetry (difference in size, shape, and relative position of body parts, on opposite sides), pulmonary (related to the lungs) edema versus left-sided pneumonitis (inflammation of the lungs,) bilateral (both left and right side) effusions, cardiomegaly (an enlarged heart), mediastinal lymphadenopathy (enlargement of lymph nodes [small bean shaped structures thar are part of the immune system]) of the chest cavity between the lungs of indeterminate significance. - At 12:01 PM, his VS were BP 107/70, RR 20, HR 97 and SAO2 84%. - At 12:16 PM, his VS were BP 108/73, RR 23 and HR 101 and SAO2 88%. - At 12:31 PM, his VS were RR 16 and HR 99 and SAO2 was 95%. - At 2:01 PM, IV zofran was administered. - At 2:14 PM, his VS were BP 139/80, RR 18, HR 98 and SAO2 97%. - The ED provider note showed the patient’s pain improved with pain medication. The ED provider discussed the patient with the hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients) and was advised to discharge home with pain medication because everything improved since his recent admission, and he did not meet admission criteria. - At 2:37 PM, he was discharged home with a prescription for oral morphine, zofran and colace (stool softener). Fluids and rest were encouraged. - A brain natriuretic peptide (BNP, blood tests that measures levels of protein made by the heart and blood vessels that indicate heart failure, normal is 0 to 125) and chest CT scan were not performed. Review of Patient #29’s medical record dated 08/03/25, showed: - At 10:27 PM, he arrived at the ED via EMS with nausea and vomiting. - At 11:05 PM, his BNP was 18,237. - Medical decision making showed Patient #29 had hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) suspected likely secondary to pulmonary edema. - On 08/04/25 at 1:59 AM, he was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for). During a telephone interview on 11/10/25 at 9:00 AM, Staff U, Physician, stated that Patient #29 presented with nausea, vomiting and diarrhea. He had no shortness of breath. He had a low concern for congestive heart failure (CHF, a weakness of the heart that causes it to not pump blood like it should leading to a buildup of fluid in the lungs and surrounding body tissues) because his BUN and creatinine improved. The abdominal and pelvis CT scan ruled out gastroenteritis (inflammation of the stomach and intestines) and diverticulitis (an infection or inflammation of small pouches that form on the wall of the colon) which was his concern because of the complaint of diarrhea. He felt the negative CT scan indicated a gastrointestinal (GI, the stomach and intestines) viral infection. He consulted the hospitalist and reviewed his blood work. The blood work improved, the patient felt better, and he want to be discharged. Discharge instructions were to return to the ED if he got worse. In hindsight, he could have delved into a cardiac assessment to “rule anything cardiac out,” but the average patient with his symptoms and ED work up indicated a viral infection. During a telephone interview on 11/10/25 at 1:00 PM, Staff Q, Registered Nurse (RN), stated that Patient #29 presented with nausea, vomiting and diarrhea and he wanted relief of those symptoms. He believed the SAO2 of 84% and 88% could have been related to the morphine administration or laying in a flat position during the CT scan. The patient did not display any symptoms of distress during this ED visit. Review of Patient #33’s medical record dated 09/08/25, showed: - At 11:18 AM, he was a 62-year-old who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) with a fever and altered mental status (AMS, mental functioning ranging from slight confusion to coma). - His past medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and kidney transplant. He was confirmed positive for COVID-19 (highly contagious, and sometimes fatal, virus) and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) on 09/02/25. - His home medications included mycophenolate and tacrolimus (immune suppressant medications that cause the body’s immune system to be unable to fight infections and other diseases). - The ED provider was unable to perform a ROS due to mental status changes. - His physical examination showed he was ill-appearing, had a high HR and was disoriented. - At 11:18 AM, his VS were BP 138/76, HR 131, RR 20, T 103.9 F and SAO2 97%. - At 11:23 AM, his lactic acid (LA, an acid produced in muscle tissues during strenuous exercise, normal is 5.7 to 17.9) was 22.0. - At 11:24 AM, his urinalysis (a laboratory examination of a person’s urine) showed cloudy urine, leukocytes (substance that suggests there are white blood cells in the urine, normal is zero) were 500, white blood cell count (WBC, the number of white cells [infection-fighting cells],normal is 0 to 5) was greater than 100, red blood cell count (RBC, cells in your blood that carry oxygen from your lungs to the tissues and organs in your body, normal is 0 to 2) was 51-100 and bacteria (normal is none) was trace. - At 11:23 AM, his complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) showed his white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4.2 to 10.2) was 9.36. - At 11:31 AM, intravenous (IV, in the vein) tylenol (medication that treats minor pains and fever) was administered. - At 11:53 AM, 500 milliliters (mL) of IV fluids were administered. - At 11:54 AM, IV antibiotics were administered. - At 12:00 PM, his VS were BP 127/66, HR 123 and RR 22. - At 12:15 PM, his VS were BP 100/58, HR 116 and RR 23. - At 12:30 PM, his VS were BP 98/60, HR 115 and RR 23. - At 12:43 PM, 500 mL of IV fluids were administered. - At 12:45 PM, his VS were BP 92/59, HR 112 and RR 23. - At 12:53 PM, his chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed right lower lobe infiltrates (accumulation of a foreign substance, typically within the lungs) may have been developing. - At 1:00 PM, his VS were BP 97/61 and HR 104. - At 1:15 PM, his BP was 91/57. - At 1:30 PM, his VS were BP 90/59 and RR 21. - At 1:31 PM, his T was 99.6 F. - At 1:36 PM, 1,000 mL of IV fluids were administered. - At 1:45 PM, his BP was 100/55. - At 2:00 PM, his BP was 112/60. - At 2:15 PM, his BP was 98/59. - At 2:30 PM, his BP was 89/58. - At 2:43 PM, his repeat LA was 24.8. - At 2:45 PM, his BP was 98/58. - At 3:00 PM, his BP was 99/61. - The medical decision making showed his VS improved with fluid resuscitation and antipyretics (a medication used to reduce fever). He no longer had a high HR. He had some soft blood BPs which trended up with IV fluids. His labs improved since his last ED visit CRP and procalcitonin down trended. He had a normal WBC. He continued to have evidence of a UTI. Review of his records showed he was treated with Levaquin (antibiotic) which he did not receive a full course of but that was also not effective against the bacteria culture (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection) from his urine. He was given oral antibiotics based on the previous urine culture and was discharged home. - At 3:21 PM, he was discharged home via EMS. - The patient was not provided any oral intake while in the ED. Review of Patient 33’s second medical record dated 09/08/25, showed: - At 9:21 PM, he presented to the ED via EMS with AMS and inability to swallow pills due to difficulty swallowing and confusion in response to a fever. - He was unable to tolerate oral intake, and the nursing home reported a low BP of 90/50. The family stated the patient was able to converse and make jokes at baseline. - The ROS showed he had fatigue (weakness or tiredness), weakness and fever. - At 9:22 PM, his VS were BP 149/69, HR 101, RR 22, T 100.3 F and SAO2 93%. - The physical exam showed he was ill-appearing, had a high HR, was confused, unable to converse and made incomprehensible noises. - At 10:24 PM, a respiratory panel was negative for acute (sudden onset) illness. - At 10:24 PM, his LA was 8.1. - At 11:08 PM, a head computed tomography (CT, a combination of x-ray and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed acute sinusitis (inflammation of the tissues in your sinuses [spaces in your forehead, cheeks and nose usually filled with air]). - At 10:39 PM, his CBC showed his WBC was 13.41 - At 1:19 AM, a consult was placed for a hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients). - The medical decision making showed the ED provider spoke to the patient’s primary nephrologist (medical doctor who specializes in the care of kidneys), and he recommended to transfer the patient to monitor his tacrolimus levels, hold the mycophenolate for at least 10 days and continue the prednisone (a steroid medication used to decrease inflammation). There was concern for sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) with the patient’s high HR and fever. The patient failed an oral challenge, and the ED physician suspected that he would continue to worsen, there was a developing acute kidney injury due to infection. - The patient was accepted for transfer with a bed assignment pending. - A bed assignment was not obtained, and the patient remained in the ED. - On 09/11/25 at 10:50 AM, a hospitalist’s daily progress note showed the patient continued to improve. He was without a fever for greater than 24 hours. He was more awake and tolerated his diet and pills. His blood cultures (a laboratory test to check for bacteria or other germs in a blood sample) were negative. Urine cultures were sensitive to oral antibiotics. - At 2:47 PM, he was discharged via EMS. During a telephone interview on 11/06/25 at 8:30 AM, Staff O, Physician, stated that he did not recall the increased repeat LA, he did not recall addressing the LA. He was “okay” with the lower BPs because it trended up. He stated that the fever was treated appropriately with tylenol and agreed the patient remained febrile after treatment with tylenol. The patient was not short of breath, his SAO2 was within normal limits and his lung assessment was negative. He was not concerned with the possible lung infiltrates; he felt the infection source was the previously diagnosed UTI. He did not recall if the patient was orally challenged. He cared for Patient #33 previously and he believed his mentation was similar to previous visits. The rationale for discharge was based on the wrong antibiotics were previously prescribed, a dose of IV antibiotics was administered with a plan to prescribe oral antibiotics with close observation at the patient’s nursing home. The patient was not a typical patient with a history of a kidney transplant, but he felt the patient was stable at discharge and did not require transfer because the hospital did not admit kidney transplant patients. During a telephone interview on 11/06/25 at 9:15 AM, Staff P, RN, stated that the patient’s wife and mother were present with him in the ED. The family informed her the patient had difficulty swallowing when he was sick and she informed Staff O, Physician. Staff O prescribed IV antibiotics at that time and “hoped” the patient was able to tolerate the oral antibiotics at the nursing home. The patient was not given any oral intake during that ED visit. She spoke with the nursing home and was told the patient was typically capable of swallowing medication. The nursing home stated that the patient did not normally speak, “he may talk with his eyes a little bit.””

“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: 48359 Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#33 and #35) of 35 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition),” reviewed 11/01/22, showed: - All patients presenting to the ED requesting an examination or treatment for a medical condition, or has such a request made on their behalf, must be given a medical screening examination (MSE) and, if that exam reveals that the patient has an EMC, the patient must be provided medical care and treatment to stabilize their condition. - An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual in serious jeopardy; serious impairment to any bodily functions and/or serious dysfunction of any bodily organ or part. - Medical care and treatment required to stabilize an EMC is that which, to a reasonable medical probability, will assure that no material deterioration of the patient’s condition is likely to result during transfer to another facility or if the patient is discharged, before follow-up outpatient care can be provided. Review of the hospital’s policy titled, “Triage (process of determining the priority of a patient’s treatment based on the severity of their condition),” reviewed 06/2025, showed: - The Registered Nurse (RN) will evaluate and categorize each patient upon arrival to the ED according to the Emergency Severity Index (ESI, a numerical value one [most urgent] to five [least urgent], that shows priority of medical evaluations, as well as resources needed to treat patients). - Genitourinary (organs of both the reproductive and urinary systems) symptoms of a testicle torsion (when a testicle rotates, twisting the spermatic cord that brings blood to the scrotum) indicate an ESI Level Two acuity. - An ESI Level Two is a high-risk situation. Review of the hospital’s document titled, “Physician On-Call Roster, dated 10/28/25, showed Staff Staff X, Urologist (a physician who specializes in diseases of the urinary system) was on ED call for urology (medical specialty concerned with the function and disorders of the urinary system). Review of the hospital’s document titled, “MD-Staff Record Urology Privilege Delineation Form Privileges for Staff X, Urologist,” dated 08/01/25, showed Staff X, had privileges to admit, evaluate, diagnose, consult and provide non-surgical and surgical care to patients of all ages. Surgical privileges included scrotal (part of the male’s genitals) exploration, orchiopexy (surgical procedure used to treat a testicle that doesn’t move down into its proper place in the scrotum before birth or a testicular torsion) and orchiectomy (surgical procedure to remove a testicle). Review of Patient #35’s medical record, dated 10/28/25, showed: - At 5:35 PM, he was a three-year-old who presented to the ED with intermittent abdominal pain since 11:00 AM. He was evaluated at an urgent care, an x-ray (test that creates pictures of the structures inside the body-particularly bones) was performed and he was advised to seek further evaluation. - His review of systems (ROS) showed abdominal pain and vomiting. - His physical examination showed left lower abdominal quadrant pain with tenderness to his left testicle with slight swelling. - At 5:40 PM, his Vital signs (VS, measurements of the body’s most basic functions blood pressure (BP) normal between 90/60 and 120/80; heartrate (HR) normal 60 to 100 per minute; respiration rate (RR) normal 12 to 20 breaths per minute; and body temperature (T) normal 97.8 to 99 Fahrenheit (F)) were HR 100, RR 25 and T 97.8 F. His oxygen saturation (SAO2, measure of how much oxygen is in blood, a normal is between 95% and 100%) was 98%. His Wong-Baker Faces Pain Scale ( a self-assessment tool that helps communication about physical pain) score was four-moderate pain. - At 5:41 PM, his ESI level was three. - At 7:36 PM, the patient’s father stated the Patient’s pain was increasing and his breathing became labored. - At 7:56 PM, he was placed in an ED room. - At 8:00 PM, his Head-to-Toe Assessment (complete assessment of all patient body systems, including heart, lung, skin, VS, etc.) showed his respiratory effort was grunting, abdominal tenderness and guarding with hypoactive bowel sounds. His Wong-Baker Faces Pain Scale score was eight-severe pain. - At 8:06 PM, Staff R, Physician, performed the first provider evaluation. - At 8:11 PM, a scrotal/testicle ultrasound (a test that uses sound waves to create images of structures within the body) was ordered. - At 8:23 PM, registration was completed. - At 8:27 PM, tylenol (medication that treats minor pains and fever) was administered. - From 8:45 PM to 9:31 PM, the scrotal/testicle ultrasound was performed. - At 9:57 PM, the scrotal/testicle ultrasound with doppler (high-frequency sound wave that measure the amount of blood flowing through blood vessels) showed suspicious for left testicular torsion and recommended an urgent urology consult. - At 10:12 PM, urology was consulted and Staff W, Nurse Practitioner, (NP, a nurse with advanced clinical education and training), recommended transfer to Hospital D. - At 10:23 PM, the patient was accepted for transfer to Hospital D and the family requested transfer by private vehicle. - A private vehicle transportation acknowledgement of risk, signed by Patient #35’s parents at 10:30 PM, showed their acknowledgement that Patient #1 needed to be transported to another location for continued treatment, and that it was not emergent but should be accomplished without delay. - At 10:40 PM, the EMTALA documents were completed, sent with the patient and showed the reason for transfer was qualified clinical personnel or service unavailable. Provider to provider report and nurse to nurse reports were given. His VS were BP 114/98, HR 98, RR 20 and T 98.8 F. His Wong-Baker Faces Pain Scale score was zero-no pain. - At 10:48 PM, a comment showed waiting on imaging disc. - At 11:31 PM, his VS were BP 108/62, HR 95, RR 18 and T 99.0 F. His SAO2 was 100%. - At 11:32 PM, he was discharged. Review of Patient #35’s Hospital D medical record dated 10/29/25, showed: - On 10/28/25 at 11:30 PM, the ED team was notified Patient #35 was enroute, his T was 99.0 F and urology was aware. - At 1:03 AM, he arrived via a transfer from an outside hospital. - At 2:52 AM, Patient #35 was taken to the operating room and minimal return of blood flow was noted after a detorsion (a procedure to untwist the testicle and restore blood supply) of his left testicle and a left orchiectomy was performed. During a telephone interview on 11/12/25 at 5:50 PM, Staff R, Physician, stated that he was not aware the patient was seen at Facility E for a possible torsion. He felt Patient #35 was triaged incorrectly because of the assigned ESI level three. The prolonged waiting room time did not meet his expectations, the ED was “slammed” that day. The expectation for the completion time of the ultrasound was as soon as possible. He spoke with Staff W, NP, who spoke with Staff X, Urologists, and made the recommendation to transfer Patient #35 because he was too young and needed to be seen by a pediatric urologist. Staff X called after the fact and wondered why it was taking so long to transfer Patient #35. He responded they were working to transfer as soon as possible. He was not aware Staff X had privileges for all ages. The decision to transfer via private vehicle was a shared decision because it was the “fastest” route, there was no wait for transport to arrive. He and the family agreed private vehicle was the fastest route. The delay in discharge was due to a miscommunication between himself and the nurse. He completed the paperwork and “pushed” the ultrasound to Hospital D. The nurse waited on the ultrasound to be burned to a disc without his knowledge. A hardcopy of an ultrasound could be useful for a receiving hospital, but he did not care about that disc because patient #35’s condition was so time sensitive. During a telephone interview on 11/13/25 at 12:00 PM, Staff X, Urologist, stated that he was the urologist on call when Patient #35 presented to the ED. He received report from Staff W, NP, reviewed the medical record and imaging. He called Staff R, Physician, and recommended to transfer the patient to Hospital D. He acknowledged that his privileges included care for patients of all ages. It had been “many many” years since he operated on a patient of that age, and he was not comfortable. The expected timeline for care of a testicular torsion from symptom onset was six hours to intervention. He agreed transport via a private vehicle was appropriate. He would have discharged the patient without the ultrasound disc due to the time sensitivity of the diagnosis. During a telephone interview on 11/13/25 at 9:15 AM, Staff W, NP, stated that he received a call from the ED provider regarding Patient #35. He contacted Staff X, Urologist, and was told he would review the medical record. Staff X stated he thought the patient may require transfer due to his age. Staff W called the ED and informed them of Staff X’s plan to review the medical record and plan to follow up with the ED provider. Staff W had no experience with a pediatric torsion. He stated that his group did care for pediatric patients in the office. He stated a testicular torsion was time critical and the delays in care while in the waiting room and the disc were wasted time. He stated that children were hard to evaluate. It was not the parent’s responsibility to explain Facility E’s concern for a testicular torsion, they were not clinical. During a telephone interview on 11/13/25 at 7:00 AM, Staff S, RN, stated that she had no thoughts on the waiting room time for Patient #35. When she assumed care of the patient he was in a “little bit” of distress, he was grunting and holding his mother. He did not want her to “mess” with him. She did not know the expected timeframe for an ultrasound order to completion for a testicular torsion, that was the first patient with a testicular torsion she cared for. She was aware his condition was time sensitive. She stated that the delay in discharge was due to obtaining the ultrasound disc. The burning of a disc typically took between 30 and 45 minutes. When she was told the patient needed to be discharged, she called radiology (a variety of medical imaging/x-ray techniques used to diagnose or treat diseases) and they met the patient at the exit door with the disc. She was not aware Staff R, Physician “pushed” the ultrasound to Hospital D. During a telephone interview on 11/10/25 at 10:00 AM, Staff T, RN stated that she was not provided a report from Facility E and the patient’s family did not report the concern for a testicular torsion. She did not assess Patient #35’s testicles because there was no complaint of difficulty urinating or referred pain. The triage acuity assignment was based on the report she received from the parents because the patient was three years old. A Wong Baker Faces Pain Scale score of four and VS within normal limits indicated a level four acuity. If the family had reported the suspected torsion she would have placed him at a higher acuity level, placed him in a room “pretty fast” and ordered an ultrasound that would have been performed within 10 minutes. In hindsight, the only thing she could have done differently was to directly ask about the patient’s testicles. Review of Patient #33’s medical record dated 09/08/25, showed: - At 11:18 AM, he was a 62-year-old who presented to the ED via Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) with a fever and altered mental status (AMS, mental functioning ranging from slight confusion to coma). - His past medical history included chronic kidney disease (CKD, ongoing, gradual loss of kidney function), diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing) and kidney transplant. He was confirmed positive for COVID-19 (highly contagious, and sometimes fatal, virus) and a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) on 09/02/25. - His home medications included mycophenolate and tacrolimus (immune suppressant medications that cause the body’s immune system to be unable to fight infections and other diseases). - The ED provider was unable to perform a ROS due to mental status changes. - His physical examination showed he was ill-appearing, had a high HR and was disoriented. - At 11:18 AM, his VS were BP 138/76, HR 131, RR 20, T 103.9 F and SAO2 97%. - At 11:23 AM, his lactic acid (LA, an acid produced in muscle tissues during strenuous exercise, normal is 5.7 to 17.9) was 22.0. - At 11:24 AM, his urinalysis (a laboratory examination of a person’s urine) showed cloudy urine, leukocytes (substance that suggests there are white blood cells in the urine, normal is zero) were 500, white blood cell count (WBC, the number of white cells [infection-fighting cells],normal is 0 to 5) was greater than 100, red blood cell count (RBC, cells in your blood that carry oxygen from your lungs to the tissues and organs in your body, normal is 0 to 2) was 51-100 and bacteria (normal is none) was trace. - At 11:23 AM, his complete blood count (CBC, a blood test performed to determine overall health including inflammation or infection) showed his white blood cell count (WBC, the number of white cells [infection-fighting cells] in the blood, normal is 4.2 to 10.2) was 9.36. - At 11:31 AM, intravenous (IV, in the vein) tylenol (medication that treats minor pains and fever) was administered. - At 11:53 AM, 500 milliliters (mL) of IV fluids were administered. - At 11:54 AM, IV antibiotics were administered. - At 12:00 PM, his VS were BP 127/66, HR 123 and RR 22. - At 12:15 PM, his VS were BP 100/58, HR 116 and RR 23. - At 12:30 PM, his VS were BP 98/60, HR 115 and RR 23. - At 12:43 PM, 500 mL of IV fluids were administered. - At 12:45 PM, his VS were BP 92/59, HR 112 and RR 23. - At 12:53 PM, his chest x-ray (test that creates pictures of the structures inside the body-particularly bones) showed right lower lobe infiltrates (accumulation of a foreign substance, typically within the lungs) may have been developing. - At 1:00 PM, his VS were BP 97/61 and HR 104. - At 1:15 PM, his BP was 91/57. - At 1:30 PM, his VS were BP 90/59 and RR 21. - At 1:31 PM, his T was 99.6 F. - At 1:36 PM, 1,000 mL of IV fluids were administered. - At 1:45 PM, his BP was 100/55. - At 2:00 PM, his BP was 112/60. - At 2:15 PM, his BP was 98/59. - At 2:30 PM, his BP was 89/58. - At 2:43 PM, his repeat LA was 24.8. - At 2:45 PM, his BP was 98/58. - At 3:00 PM, his BP was 99/61. - The medical decision making showed his VS improved with fluid resuscitation and antipyretics (a medication used to reduce fever). He no longer had a high HR. He had some soft blood BPs which trended up with IV fluids. His labs improved since his last ED visit CRP and procalcitonin down trended. He had a normal WBC. He continued to have evidence of a UTI. Review of his records showed he was treated with Levaquin (antibiotic) which he did not receive a full course of but that was also not effective against the bacteria culture (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection) from his urine. He was given oral antibiotics based on the previous urine culture and was discharged home. - At 3:21 PM, he was discharged home via EMS. - The patient was not provided any oral intake while in the ED. Review of Patient 33’s second medical record dated 09/08/25, showed: - At 9:21 PM, he presented to the ED via EMS with AMS and inability to swallow pills due to difficulty swallowing and confusion in response to a fever. - He was unable to tolerate oral intake, and the nursing home reported a low BP of 90/50. The family stated the patient was able to converse and make jokes at baseline. - The ROS showed he had fatigue (weakness or tiredness), weakness and fever. - At 9:22 PM, his VS were BP 149/69, HR 101, RR 22, T 100.3 F and SAO2 93%. - The physical exam showed he was ill-appearing, had a high HR, was confused, unable to converse and made incomprehensible noises. - At 10:24 PM, a respiratory panel was negative for acute (sudden onset) illness. - At 10:24 PM, his LA was 8.1. - At 11:08 PM, a head computed tomography (CT, a combination of x-ray and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) scan showed acute sinusitis (inflammation of the tissues in your sinuses [spaces in your forehead, cheeks and nose usually filled with air]). - At 10:39 PM, his CBC showed his WBC was 13.41 - At 1:19 AM, a consult was placed for a hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients). - The medical decision making showed the ED provider spoke to the patient’s primary nephrologist (medical doctor who specializes in the care of kidneys), and he recommended to transfer the patient to monitor his tacrolimus levels, hold the mycophenolate for at least 10 days and continue the prednisone (a steroid medication used to decrease inflammation). There was concern for sepsis (life threatening condition when the body’s response to infection injures its own tissues and organs) with the patient’s high HR and fever. The patient failed an oral challenge, and the ED physician suspected that he would continue to worsen, there was a developing acute kidney injury due to infection. - The patient was accepted for transfer with a bed assignment pending. - A bed assignment was not obtained, and the patient remained in the ED. - On 09/11/25 at 10:50 AM, a hospitalist’s daily progress note showed the patient continued to improve. He was without a fever for greater than 24 hours. He was more awake and tolerated his diet and pills. His blood cultures (a laboratory test to check for bacteria or other germs in a blood sample) were negative. Urine cultures were sensitive to oral antibiotics. - At 2:47 PM, he was discharged via EMS. During a telephone interview on 11/06/25 at 8:30 AM, Staff O, Physician, stated that he did not recall the increased repeat LA, he did not recall addressing the LA. He was “okay” with the lower BPs because it trended up. He stated that the fever was treated appropriately with tylenol and agreed the patient remained febrile after treatment with tylenol. The patient was not short of breath, his SAO2 was within normal limits and his lung assessment was negative. He was not concerned with the possible lung infiltrates; he felt the infection source was the previously diagnosed UTI. He did not recall if the patient was orally challenged. He cared for Patient #33 previously and he believed his mentation was similar to previous visits. The rationale for discharge was based on the wrong antibiotics were previously prescribed, a dose of IV antibiotics was administered with a plan to prescribe oral antibiotics with close observation at the patient’s nursing home. The patient was not a typical patient with a history of a kidney transplant, but he felt the patient was stable at discharge and did not require transfer because the hospital did not admit kidney transplant patients. During a telephone interview on 11/06/25 at 9:15 AM, Staff P, RN, stated that the patient’s wife and mother were present with him in the ED. The family informed her the patient had difficulty swallowing when he was sick and she informed Staff O, Physician. Staff O prescribed IV antibiotics at that time and “hoped” the patient was able to tolerate the oral antibiotics at the nursing home. The patient was not given any oral intake during that ED visit. She spoke with the nursing home and was told the patient was typically capable of swallowing medication. The nursing home stated that the patient did not normally speak, “he may talk with his eyes a little bit.””

“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: 48359 Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#1) of 35 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented seeking care at the ED. Findings included: Review of the hospital’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an emergency medical condition (EMC),” reviewed 11/01/22, showed all available records of the patient’s screening exam, care and treatment of the EMC shall accompany the patient. This will include all x-rays (test that creates pictures of the structures inside the body-particularly bones), lab tests and other diagnostic test results. Records not available at the time of transfer shall be sent to the receiving hospital as soon as practicable. Review of the hospital’s document titled, “Saint Francis Medical Center Medical Staff Rules and Regulations,” approved 06/04/19, showed: - If the operative report is not immediately available, a brief operative note must be entered in the medical record by the performing practitioner prior to transfer of the patient to the next level of care. - The brief operative notes will include the name of the licensed independent practitioner(s) who performed the procedure and any assistants, the name of the procedure performed, findings of the procedure, any estimated blood loss, any specimen(s) removed and the post-operative/procedure diagnosis. - An ED record must be completed by the responsible practitioner prior to transfer for all transferred patients. Review of Facility B’s document titled, “EMS Patient Care Report,” dated 07/21/25, showed an interventional radiology (IR, a medical specialty that uses imaging techniques to guide minimally invasive procedures to diagnose and treat a wide range of conditions) embolization (a medical procedure that uses tiny particles, coils or a special glue to intentionally block off blood flow to a specific artery or vein) and ultrasound (a test that uses sound waves to create images of structures within the body) guided vascular access device (a flexible, sterile plastic tube inserted into a blood vessel to allow blood to be drawn from or medication to be delivered into a patient’s bloodstream) placement were in process. Review of Patient #1’s medical record, dated 07/21/25, showed: - At 10:37 AM, Patient #1 was a 71-year-old who arrived at the ED via Air Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) following a motor vehicle crash (MVC), he was an unrestrained passenger in a transportation shuttle. - His injuries included a left hip fracture, bilateral (right and left side) subarachnoid hemorrhages (SAH, a medical emergency where there is bleeding in the space between the brain and the tissue covering the brain), hemorrhagic shock (a condition of reduced tissue perfusion due to inadequate delivery of oxygenated blood), middle and lower backbone fractures (break in a bone), rib fractures, pneumothorax (the presence of air or gas in the cavity between the lungs and the chest wall, causing collapse of the lung), pelvic fractures, pelvis hematoma (collection of blood below the surface of the skin) and breast bone fracture. - At 1:45 PM, the patient was taken to IR for an embolization. - At 2:30 PM, an arterial line (thin, flexible tube placed into an artery) was placed in IR. - At 3:00 PM, he was discharged via an air evacuation transfer to Hospital B. - At 3:08 PM, Staff J, Physician Assistant (PA, a type of mid-level health care that can serve as a principal healthcare provider), wrote a note that showed the patient was persistently unstable despite fluid and blood product resuscitating, he was subsequently sent to IR where he had an angiogram (a medical imaging test that uses x-rays and a special dye to create pictures of your arteries) and embolization of his pelvic vessels. He became more hemodynamically (how your blood flows through your blood vessels) stable and was subsequently transferred to Hospital B, for management of his pelvic fractures. - There was no brief operative note. - At 5:40 PM, the pelvic angiogram and embolization report was filed by Staff K, Physician, and showed an active hemorrhage in the setting of a right pubic bone fracture. A pelvic angiogram demonstrated an active hemorrhage from the right obturator branches (nerves that carry messages for movement and sensation) and left sacral artery branches (arteries that supply blood to the tailbone and surrounding muscles). An embolization of the right obturator and left sacral artery branches was performed. There was no active pelvic arterial bleeding at the conclusion of the procedure. Levophed (medication used to treat low blood pressure and heart failure) was initiated in the IR suite in order to maintain a systolic pressure (the pressure against the artery during the heartbeat, when the heart is pushing blood out) of 90. Blood product resuscitation continued. The patient’s blood pressure stabilized following embolization of two areas of bleeding. A second pelvic binder was placed to provide compression over the pelvis. The arterial line was left in place to provide arterial line blood pressure monitoring. Air evacuation was available for transportation and the patient was discharged to Hospital B. Review of Patient #1’s Hospital B medical record dated 07/21/25, showed Patient #1 presented as a level one trauma from Hospital A. It was reported he underwent an IR embolization of the sacral or pelvic branch vessels, there was no documentation at that time. The Hospital B physician called Hospital A, and the trauma team was unable to tell him what procedure IR performed. During a telephone interview on 11/05/25 at 3:00 PM, Staff K, Physician, stated that he did not know who talked to Hospital B regarding the details of the embolization procedure for Patient #1. He spoke in detail to the medical evacuation team, who was present during the procedure. It was not typical for there to be a delay in the creation of an operative report, he had a full schedule the day of Patient #1’s injuries and that “threw a wrinkle in the day.” He was not aware the provider from Hospital B called and requested details of the embolization procedure. On a normal day he provided verbal report to the ED provider, but in the case of Patient #1 he transferred directly from the IR suite. He had never experienced a patient transferred directly from IR when medical evacuation was waiting. He did not call the ED provider with the report, he spoke with the medical evacuation team. During a telephone interview on 11/05/25 at 2:10 PM Staff L, Trauma Surgeon, stated that he spoke to Staff K, Physician, after Patient #1’s embolization and was told he had a bleeding artery, the bleeding stopped, and the patient was hemodynamically stable. He was informed the patient had an embolization but was not told which vessels were involved, only that the bleeding was stopped. He stated that it may not have been possible for Staff K to know which vessels were involved at the time and an educated guess would have to be made until there was a thorough review of imaging. He believed the providers had 24 hours to complete a brief operative note and 48 hours to complete a full report when a patient was transferred. During a telephone interview on 11/06/25 at 11:00 AM, Staff V, ED Physician, stated that he did not receive report from Staff K, Physician or Staff L, Trauma Surgeon, after the patient’s embolization procedure. He typically “washed his hands” of patient’s when they left the ED. The responsibility to inform the receiving hospital of the embolization procedure details fell to the performing physician or trauma surgeon. During a telephone interview on 11/05/25 at 10:00 AM, Staff J, PA, stated that she did not know how Patient #1’s IR procedure report was provided to Hospital B. She received a call from a “male physician” at Hospital B asking what IR procedure was performed on Patient #1. She was only able to state an embolization, but she did not know which vessels were involved, there was no surgical report available. The expectation was for a brief operative report to be completed immediately. There was not enough information available for the receiving facility. She stated that it was “a problem” that the operative report was not completed until two hours and 40 minutes after the patient was transferred. During a telephone interview on 11/13/25 at 8:30 AM, Staff N, Facility C Registered Nurse (RN), stated that he was not provided details of which vessels were involved in the embolization. He transported Patient #1 from the IR suite and the embolization report was not available. He was not present during the procedure; he waited in the ED for 1.5 to two hours before he was taken to the IR suite after the embolization was completed. He received report from Staff J, PA, and Staff M, RN. He did not receive information from Staff K, Physician.”