Bozeman Health Deaconess 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: 41652 Based on record review and policy review, the facility failed to comply with the conditions of participation outlined in §489.24 (refer to Appendix V). The facility failed to send pertinent medical records to the receiving facility for 2 (#s 4 and 15) of 20 sampled patients who presented to the facility for examination and treatment of a medical condition. Findings include: Review of the facility’s policy titled, “Emergency Medical Treatment and Labor Act (EMTALA), dated 12/2024, showed a transfer is considered appropriate only when, “The transferring hospital sends to the receiving facility all medical records (or copies thereof)... 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... treatment provided ...” Review of patient #4’s ED record, dated 12/6/25, failed to show required medical records were sent to the receiving facility. (see C-2409) Review of patient #15’s EMTALA Request for Transfer/Consent to Transfer, dated 11/21/25, failed to show a completed transfer certification, identifying the medical records sent with the patient to the receiving facility. The form also did not contain a signature from the patient or the representative consenting to the transfer.(see C-2409)”

“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: 41652 Based on interview, record review, and policy review, the facility failed to obtain written consent from the patient or representative for transfer to a facility to receive a higher level of care for 1 (#15); and failed to document the provision of pertinent medical records for continuity of care for 2 (#s 4 and 15) of 20 sampled patients who presented at the facility for examination and treatment of a medical condition. Patient #s 4 and 15 were transferred in order to receive a higher level of care. Findings include: 1. Review of patient #4’s emergency department encounter, dated 12/6/25, showed an 85-year-old female was brought to the ED by ambulance after an unwitnessed ground-level fall. The patient was found to have a broken bone in her right thigh area. Due to the patient’s history and the complexity of the planned repair, the patient was transferred to Hospital B to receive a higher level of care. The entire medical record was reviewed and documentation of the pertinent medical records to be sent to the receiving facility was not found. During an interview on 12/18/25 at 10:20 a.m., staff member O stated the ED tech was usually responsible for copying the documents which needed to be sent to the receiving facility when a patient is transferred. Staff member O was unable to explain why the transfer form, which showed what was sent with the patient, was not completed for patient #4. Staff member O stated there was a list of chart contents on the the envelope used to hold paperwork during a transfer. She stated that was where she marked what was contained in the envelope. Staff member O stated she did not keep a copy of the list and was unable to confirm the pertinent medical records were sent with the patient to the receiving facility. 46400 2. Review of patient #15’s Emergency Department record, dated 11/21/25, showed he arrived at Hospital A by helicopter at 2:40 p.m., with complaints of isolated left leg and knee pain after being hit by a wrench while digging a well. Imaging revealed a “small popliteal artery dissection and a developing AV fistula with associated tibial plateau fracture and proximal fibula fracture.” The general surgeon consult showed, “Review of the CT images and patient examination with [vascular surgeon] we both feel this is a high-risk vascular injury for progression to complete occlusion with concomitant risk of limb loss and he should be transferred immediately to a facility with full time vascular surgery support.” An electronic EMTALA transfer form was completed and signed by the physician. There was no consent form signed by the patient or his representative or documentation of the pertinent medical records sent to the receiving facility. During an interview on 12/18/25 at 10:10 a.m., staff member L stated the provider was responsible for completing the medical record, the physician certification, including the accepting provider and receiving facility, the risks of transfer, as well as the method of transport. During an interview on 1/7/25 at 2:15 p.m., staff member P stated the process during a transfer was for the physician to fill the form out and obtain the patient signature. The form then has a label attached and is put into a secure pile to be scanned by medical records. The signed consent by patient #15 may have been lost or not scanned in correctly. Staff member P stated they were looking closer at the process to determine where the error occurred. Review of the facility policy titled Emergency Medical Treatment and Labor Act (EMTALA), dated 12/2024, showed: “ ...Definitions ...Transfer: ... the transfer of an individual to a medical facility is an ‘appropriate transfer’ only when: ...3. 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 transfer ...RELATED PROCEDURES: Transfer: ...A transfer of the patient to another appropriate medical facility may be made in the following circumstances: ... a physician has signed a certification that the medical benefits of the transfer are expected to outweigh the risks of transfer. The certification will state the reason for transfer, patient condition, benefit/risks of transfer, receiving hospital, mode of transportation, and patient consent ...””