Great Falls Clinic Hospital

“MEDICAL STAFF PERIODIC APPRAISALS CFR(s): 482.22(a)(1) The medical staff must periodically conduct appraisals of its members. This Standard is not met as evidenced by: 35356 Based on interview and record review, the facility failed to ensure periodic appraisals were conducted at least every two years for medical staff members. This deficient practice increases the likelihood for negative patient outcomes related to determining the suitability of continuing medical staff privileges sooner than three years. Findings include: During an interview on 8/17/26 at 2:45 p.m., staff member H stated the medical staff were re-evaluated every three years to determine if individuals membership or privileges should be continued, discontinued, or revised. Staff member H stated the medical staff reviewed each practitioner every three years and reviewed such things as continued education, competencies, as well as any potential concerns which could potentially affect the outcome of care provided by the provider such as malpractice cases which had been brought up against a practitioner or any other concerns which may warrant a change in current provider privileges. During an interview on 8/17/26 at 4:47 p.m., staff member V stated the facility conducted staff member reappraisals every three years. Review of the following staff members credentialing files showed the following Medical Staff Privileging Approval Letters, with the scheduled reappointment (reappraisal) review dates: - Staff member L, showed an Initial Medical Staff Appointment for a Courtesy Provider was approved on 4/30/26, with a reappointment scheduled on 4/30/29. - Staff member M, showed an Initial Medical Staff Appointment for a Courtesy Provider was approved on 3/2/26, with a reappointment scheduled on 3/2/29. - Staff member N, showed an Initial Medical Staff Appointment for an Active Provider was approved on 7/19/24, with a reappointment scheduled on 7/19/27. - Staff member O, showed an Initial Medical Staff Appointment for an Active Provider was approved on 4/14/25, with a reappointment scheduled on 4/14/28. - Staff member P, showed an Initial Medical Staff Appointment for a Courtesy Provider was approved on 6/30/26, with a reappointment scheduled on 6/30/29. - Staff member Q, showed an Initial Medical Staff Appointment for an Active Provider was approved on 4/3/26, with a reappointment scheduled on 4/3/29. - Staff member R, showed an Initial Medical Staff Appointment for an Active Provider was approved on 8/14/25, with a reappointment scheduled on 8/14/28. - Staff member S, showed an Initial Medical Staff Appointment for a Courtesy Provider was approved on 4/3/26, with a reappointment scheduled on 4/3/29. - Staff member T, showed a Medical Staff Reappointment for a Courtesy Provider was approved on 5/19/26, with a scheduled reappointment date of 5/19/28. Review of the facility’s Medical Staff Bylaws, with an approval date of 10/14/26, showed, “ ...6.9-3 Standards and Procedure for Review of Application for Reappointment and/or Modifications: When a Medical Staff Member submits an application for reappointment, and every three (3) years thereafter, or when the Member submits application request for modification of Staff status or Clinical Privileges, the Member shall be subject to an in-depth review generally following the procedures set forth in Sections 6.8-1 through 6.8-8 ...” For the deficient practice associated with the development of Medical Staff Bylaws, see A0363.”

“CRITERIA FOR MEDICAL STAFF PRIVILEGING CFR(s): 482.22(c)(6) [The bylaws must:] Include criteria for determining the privileges to be granted to individual practitioners and a procedure for applying the criteria to individuals requesting privileges. For distant-site physicians and practitioners requesting privileges to furnish telemedicine services under an agreement with the hospital, the criteria for determining privileges and the procedure for applying the criteria are also subject to the requirements in §482.12(a)(8) and (a)(9), and §482.22(a)(3) and (a)(4). This Standard is not met as evidenced by: 35356 Based on interview and record review the facility failed to ensure they developed Medical Staff Bylaws which contained criteria for the reappraisal of the medical staff privileging to be reevaluated at least every two years. This deficient practice increases the likelihood of negative patient outcomes related to determining the suitability of continuing medical staff privileges sooner than three years. Findings include: Review of the facility’s Medical Staff Bylaws, with an approval date of 10/14/26, showed, “ ...6.9-3 Standards and Procedure for Review of Application for Reappointment and/or Modifications: When a Medical Staff Member submits an application for reappointment, and every three (3) years thereafter, or when the Member submits application request for modification of Staff status or Clinical Privileges, the Member shall be subject to an in-depth review generally following the procedures set forth in Sections 6.8-1 through 6.8-8 ...” During an interview on 8/17/26 at 2:45 p.m., staff member H stated the medical staff were re-evaluated every three years to determine if an individual’s membership or privileges should be continued, discontinued, or revised. Staff member H stated she would not be able to state with certainty if the Medical Staff Bylaws reflected the three-year reappraisal recommendation.”

“PATIENT RIGHTS: NOTICE OF RIGHTS CFR(s): 482.13(a) Patients’ Rights: Notice of Rights This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the hospital failed to inform or provide confirmation in the medical record ensuring a patient received patient rights information prior to undergoing an outpatient procedure, and admission to the hospital following an outpatient procedure for 1 (#3) of 8 sampled patients. Findings include: Review of patient #3’s electronic medical record dated 8/7/25-8/9/25, showed no documentation or confirmation patient #3 received the hospital’s patient rights document prior to the outpatient bronchoscopy procedure or at the time of admission following complications from the outpatient bronchoscopy procedure. During an interview on 9/23/25 at 12:11 p.m., patient #3 stated she had not received a copy of her patient rights prior to her outpatient bronchoscopy procedure or at the time of admission following the bronchoscopy procedure complications. Patient #3 stated she did not know what her patient rights were while being treated at the hospital. During an interview on 9/24/25 at 4:03 p.m., staff member A stated, “We do not have any documentation that shows patients have received their patient rights.” Review of a facility policy titled, “Hospital Admission Criteria and Process of the Medical, Surgical and progressive Care Unit, Coronary Care Unit admission,” approval pending 9/2025, showed: “ ... Hospital Admission Criteria: 2. All patients will be provided with an admission packet, including patient’s rights and responsibilities ...” [sic]”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the hospital failed to ensure a patient was provided with adequate information to make an informed decision prior to undergoing a medical procedure and failed to ensure informed consent forms were signed prior to the start of two invasive procedures for 1 (#3) of 8 sampled patients. This failure caused patient #3 to undergo a procedure without full understanding or agreement of the procedure. Findings include: 1. During an interview on 9/23/25 at 12:11 p.m., patient #3 stated she had a bronchoscopy procedure done on 8/7/25 with staff member H. Patient #3 stated, “[Staff member H] never went over any of the potential side effects of the procedure with me, not at my pre-op appointment or on the day of the bronchoscopy. I had asked the nurses in pre-op questions, but they said to ask [Staff member H] when he came in. I waited for him to come in and he never did. When I looked at my consent form it had a bunch of handwritten information on it that I could not read. It was not legible. I remember them taking me back to the operating room and the anesthesia nurse put a large mask on my face and it smelled and tasted funny; I began to feel sleepy. I remember someone saying she had not signed the consent, and they literally put a pen in my hand and told me to sign the form. I was trying to ask what it was and what it meant and was told to just sign it. That was the last thing I remember until after the bronchoscopy.” During an interview on 9/24/25 at 8:45 a.m., staff member E stated she had been one of the pre-op nurses on the day of patient #3’s bronchoscopy. Staff member E stated informed consents are completed by the physicians. Staff member E stated physicians reviewed the consent with the patient prior to them going to the procedure room, but staff member H consented his patients in the procedure rooms, and he is the only physician that does that. During an interview on 9/24/25 at 9:30 a.m., staff member F stated she had been working in pre-op on the day of patient #3’s bronchoscopy. Staff member F stated she was unsure how staff member H reviewed informed consent with his patients, but did not recall seeing staff member H prior to patient #3’s bronchoscopy. During an interview on 9/24/25 at 10:15 a.m., taff member G could not recall if patient #3 signed the informed consent form in pre-op or in the procedure room. Staff member G stated, “It does not matter where the patient signs as long as they are not sedated.” During an interview on 9/24/25 at 11:00 a.m., staff member H stated, “I go over the generic risks and benefits at the time of the procedure.” Staff member H stated it was not appropriate for a consent form to be signed if anesthesia had already been started. During an interview at 1:00 p.m., staff member N stated she was in the procedure room when patient #3 had her bronchoscopy. Staff member N stated anesthesia usually started when the patient gets to the procedure room. Staff member N stated she remembered the consent was not signed, so they had patient #3 sign it. During an interview on 9/24/25 at 1:35 p.m., staff member L stated she was in the procedure room during patient #3’s bronchoscopy. Staff member L stated, patient #3’s informed consent was not completed properly.” Staff member L stated, “It does not matter where a patient signs the consent as long as the mental status is not altered. We did stick a pen in her hand and asked her to sign the consent. I was the witness on the consent.” Review of patient #3’s anesthesia record, dated 8/7/25, showed: Anesthesia start time as 1501(3:01 p.m.) at that time the anesthesia record showed Sevo (Sevoflurane-an inhaled anesthetic agent used to induce and maintain general anesthesia during surgery) was started, 100 micrograms of fentanyl (a powerful, highly addictive narcotic opioid used as an adjunct in anesthesia) was administered, 150 milligrams of propofol (a medication used to induce and maintain general anesthesia) was administered and another 50 milligrams of propofol was administered close to 3:15 p.m., and 50 milligrams of Rocuronium (a fast acting, muscle relaxant given prior to general anesthesia) was administered. Review of patient #3’s informed consent form dated 8/7/25, showed patient #3 signed and dated the informed consent form, but there was no documentation of what time patient #3 signed the informed consent form. Patient #3’s informed consent form showed staff member H signed and dated the informed consent form on 8/7/25 at 3:20 p.m. 19 minutes after the anesthesia record showed anesthesia had been started. 2. During an interview on 9/23/25 at 12:11 p.m., patient #3 stated after her procedure it was hard to breath. An x-ray was completed and showed she had a pneumothorax. A pneumothorax occurs when air leaks into the space between the lung and the chest wall, preventing the lung from fully expanding during breathing. A pneumothorax is a risk that is associated with a bronchoscopy procedure. Patient #3 was admitted to the hospital for montioring and the following morning staff member H placed a chest tube. A chest tube is an invasive procedure, which is a flexible tube inserted into the chest to draib exess air, blood, or fluid from the pleural space (the area round the heart and lungs). This allows for the lung to re-expand and make breathing easier. Staff member H did not explain the procedure, or the risks and benefits associated with the procedure. Patient #3 comfirmed she did not give verbal or written consent prior to the procedure. During an interview on 9/24/25 at 11:00 a.m., Staff member H stated the next morning he was notified that patient #3’s lung had collapsed. Staff member H stated he had spoken to the patient and let her know that a chest tube would need to be placed. Staff member H stated he came back later that morning and placed the chest tube at bedside. Staff member H stated he had prepped the area, injected the numbing agent and placed the chest tube. Staff member H did not recall if patient #3 had signed a consent for the procedure. During an interview on 9/24/25 at 11: 52 a.m., staff member J stated she was unsure if an informed consent was completed or if the risks and benefits were discussed with patient #3. During an interview on 9/24/25 at 3:42 p.m., staff member P stated he was present in the room with staff member j when staff member H placed the chest tube. Staff member P stated he was unsure if an informed consent form was completed or if any risks or benefits were discussed with patient #3. Review of patient #3’s procedure/op note for the placement of the chest tube, dated 8/8/25 showed staff member H completed the note and electronically signed the note on 8/8/25 at 10:40 a.m. Review of patient #3’s electronic medical record, dated 8/7/25-8/9/25, showed a chest tube consent form dated 8/8/25, was signed only by staff member H on 8/8/25 at 12:15 p.m., after the procedure had been completed. The consent form contained no documentation of a discussion of the potential risks, benefits, or alternatives. Patient #3’s signature was not present on the form. Review of a facility policy titled, “Informed Consent,” dated 9/2025, showed: “Policy: 1. It is the policy of [Facility Name] that a patient or patient representative shall give voluntary and informed consent for all care, treatment, and services involving material risk. ... 3. In non-emergent situations, the patient shall receive a clear explanation of his or her condition and of proposed invasive procedures ... The patient shall be informed of the possible benefits of the care, treatment and services, possibilities of any material risk of side effects of the care ... and any alternative forms of care ... ... a. In order to give informed consent, the patient must be informed of: 1. The nature of the proposed care, treatment, services, medications, interventions, or procedures; 2. Potential benefits, risks, or side effects, including potential problems ...; 3. The likelihood of achieving care, treatment, and service goals; 4. Reasonable alternatives ...; 5. The relevant risks, benefits, and side effects related to alternatives ...; ... 7. Invasive procedures-Most procedures involving puncture or incision of the skin or insertion of an instrument or foreign material into the body ... Invasive procedures require patient informed consent... ...Types of consent: a. Operation/ invasive procedure 1. ... informed consent shall be obtained and documentation placed in the patient’s chart prior to the performance of operations or invasive procedures that have material risk ... ...3. Requirements For a Valid Consent form: a. If the patient chooses to proceed, for all operations and for invasive procedures that carry material risk, a consent form shall be signed by the patient or legal guardian or representative before that care, treatment and services is begun. b. A valid consent form must include: 1. The patients legal name ...; 2. Name of the hospital; 3. The complete name of the surgery, procedure, or diagnostic test to be performed, as written specifically by the physician ...; 4. Statement that the procedure or treatment, including anticipated benefits, material risk, and alternative therapies were explained to the patient ...; 5. The patient’s signature ...; 6. The date and time the consent signature is obtained; 7. The name and title of the person witnessing the signature ...; ... 5. Frequency of Obtaining Consent a. The patient’s informed consent shall be obtained before each procedure ... ...12. Persons Not Authorized to Provide consent a. Non-emergent medicated patients: 1. Consent for care, treatment and services are not valid if obtained when a patient is medicated and not alert. A patient may not sign a consent for after the administration of a narcotic, barbiturate or tranquilizer, whether scheduled or as needed, and whether pain medication or pre-operative medication until the patient appears alert. ...14. Witnessing of consent forms a. The signing of forms documenting informed consent for invasive, non-invasive and special procedures shall be witnessed. Review of a facility policy titled, “Code of Conduct,” dated 7/24, showed: “ ... Patients have the right of informed consent. No medical procedure can be performed without the patient’s consent. ...””

“PATIENT SAFETY CFR(s): 482.21(a), (c)(2), (e)(3) (a) Standard: Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will ... identify and reduce medical errors. (2) The hospital must measure, analyze, and track ...adverse patient events ... (c) Program Activities ..... (2) Performance improvement activities must track medical errors and adverse patient events, analyze their causes, and implement preventive actions and mechanisms that include feedback and learning throughout the hospital. (e) Executive Responsibilities, The hospital’s governing body (or organized group or individual who assumes full legal authority and responsibility for operations of the hospital), medical staff, and administrative officials are responsible and accountable for ensuring the following: ... (3) That clear expectations for safety are established. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the facility failed to ensure that its Quality Assessment and Performance Improvement (QAPI) program effectively identified and addressed adverse outcomes related to post-procedural complications for 1 (#3) of 8 sampled patients. Findings include: During an interview on 9/24/25 at 11:00 a.m., staff member H stated, “Complications such as a pneumothorax only happen in about one percent of bronchoscopy procedures.” Staff member H did not report the complication. During an interview on 9/25/25 at 11:01 a.m., staff member B stated she did not recall patient #3’s complication (pneumothorax) being reported or an incident report being filled out. Staff member B stated, “Most providers will not report any adverse events because they are covered in the risks and benefits of the consent forms. Very few providers will report something like that (complication from a procedure) because it is a common side effect and a risk for that procedure (Bronchoscopy).” Review of a facility policy titled, “Occurrence Reporting (RL Solutions), Corp 1013.2, dated 5/2024, showed: “... Events involving known surgical procedural risks and/or complications.” Review of a facility policy titled,” Quality Management System/Quality Assessment and Performance Improvement, Corp 1019.3,” dated 8/20/24, showed: “ ... The Medical Executive Committee (MEC), Governing Board, Medical Staff, and Administration are responsible for ensuring: ... 3. Quality improvement program prioritizes patient safety ... 4. Hospital-wide quality assessment and performance improvement efforts address priorities for improved quality of care ... 5. Clear expectations for safety are established. ...””

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 47752 Based on interview, record review, and policy review, the hospital failed to ensure patient medical records included properly completed informed consent forms to include patient signature, date, time, or physician performing the procedure for 4 (#s 1, 3, 4, and 7) of 8 sampled patients. Findings include: Review of patient #1’s informed consent form, dated 6/26/25, showed patient #1 signed the informed consent form but there was no documented date or time of when the consent form was signed by patient #1. Review of patient #3’s informed consent form, dated 8/7/25, showed patient #1 signed the informed consent form but there was no documented date or time of when the consent form was signed by patient #3. Review of patient #3’s informed consent form, dated 8/8/25, showed no documented patient signature, date, or time, on the consent form. Staff member H’s signature was the only signature on the consent form. Review of patient #4’s informed consent form, dated 6/5/25, showed patient #4 signed the informed consent form but there was no documented time of when the consent was signed by patient #4. Review of patient #7’s informed consent form, dated 9/16/25, showed there was a signature present on the consent, but it is unknown who signed the consent. On the informed consent form the “Relationship to Patient,” line was blank, and the signature did not match the signature on file for patient #7’s spouse. Patient #7 was intebated and sedated and unable to sign the informed consent form. During an interview on 9/24/25 at 9:50 a.m., staff member A stated the expectation of the hospital was to ensure consent to treat forms and all informed consent forms were completely filled out. During an interview on 9/25/25 at 1:06 p.m., staff member Q stated when she reviewed a chart she looked for completeness of the chart to include date and time on all consent forms. Staff member Q could not recall if patient #s 1, 3, 4 and 7’s medical records were complete. Review of a facility policy titled, “Informed Consent,” dated 9/2025, showed: “ ... b. A valid consent form must include: ... 5. The patient’s signature ... or representative. 6. The date and time the consent signature was obtained.””

“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: 45448 Based on interview, 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 provide stabilizing treatment within the capability and capacity of the hospital for 2 (#’s 8 and 12) patients who presented to the emergency department with emergency medical conditions, of 20 sampled patients reviewed. Patients #8 and 12 were subsequently transferred to another hospital and stabilized. Findings include: Review of a facility policy titled, “EMTALA - Medical Screening and Stabilization,” with an effective date of January 5, 2016, showed, “Policy: Any person who presents to the hospital or any off-campus provider-based department of the hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening exam (MSE) performed by a qualified medical person (QMP) to determine whether an EMC exists. ... If the QMP determines an EMC exists, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the hospital....” Record review of a facility policy, “EMTALA - On-Call Coverage,” dated 1/5/16, showed, “ ... Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. ... The hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC in accordance with resources available to the hospital. ... 8. Physician’s Responsibility. When a physician is identified as being the On-Call Physician for a given specialty, it shall be that physician’s duty and responsibility to assure the following: ... b. Arrival or response to the Emergency Department within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The Emergency Department Physician, in consultation with the On-Call Physician, shall determine whether the individual’s condition requires the On-Call to see the individual immediately. The determination of the Emergency Department Physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. ...” Patient #8, a 75-year-old female, presented to the ED on 3/14/24 at 6:58 p.m., seeking care for chest pain. Patient #8 had a history of a heart attack and significant heart risk factors. Two EKGs (tracing of the electrical conduction of the heart) were conducted and showed ST elevation (indication of a heart attack). The patient was subsequently diagnosed with a STEMI (indicates the blockage of an artery that provides blood to the heart muscle). The hospital had cardiac catheterization lab staff, as well as other specialty staff and surgical teams available, should complications occur. The hospital had a staffed intensive care unit (ICU), and an on-call cardiologist, Staff N, who was privileged in cardiac catheterization. Staff member CC consulted staff member N and was instructed to transfer patient #8 to [another hospital] for further care. Patient #8 was transferred to [another hospital] on 3/14/24 at 7:55 p.m. for emergent heart catheterization. Patient #12, a 79-year-old male, presented to the ED seeking care for chest pain on 4/26/24 at 4:05 p.m., less than two hours after he was discharged from the hospital for treatment related to a fast and irregular pulse. Patient #12 had a history of heart disease and significant heart risk factors. The patient’s vital signs included a consistently slower than normal pulse, elevated blood pressures, and an electrocardiogram (EKG) with changes (can indicate an evolving heart event). Staff member X consulted staff member N, the cardiologist on call, who reviewed the patient’s EKG and determined the patent needed a heart catheterization. The hospital had cardiac catheterization lab staff, other specialty staff and surgical teams available should complications arise, and a staffed ICU, however, staff member N instructed staff member X to transfer the patient. Patient #12 was transferred to [another hospital] on 4/26/24 at 8:39 p.m. (Refer to A-2407)”

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 45448 Based on observation, interview, and policy review, the facility failed to post signs specifying the rights of individuals to receive examination and treatment for emergency medical conditions, and the rights of women in labor, in a conspicuous area to be noticed by all individuals entering and receiving care in the emergency department. Findings include: During an observation and interview on 6/4/24 at 8:11 a.m., the ED reception area was observed to have no visible EMTALA signs posted, stating the rights of individuals with an emergency medical condition or women in labor seeking care. Staff member C said the ED had undergone a remodel and the signs did not get replaced. During an observation and interview on 6/4/24 at 8:22 a.m., the ED exam room and nurses station area was observed to have no visible EMTALA signs posted for individuals with an emergency medical condition or women in labor seeking care. Staff member F said he was not aware of any EMTALA signs posted within the ED. Review of a facility policy, “EMTALA- Medical Screening and Stabilization,” dated January 5, 2016, showed: “ ...6. Required Signage: Each department that provides MSEs shall post a sign that is clearly visible within 20 ft, in a place or places likely to be noticed by all individuals that enter the department that includes: a. A statement that the hospital participates in Medicaid. b. The rights of patients with EMCs and women in labor. Such rights include the right to receive, within the capacity and capabilities of the hospital’s staff and facilities: i. An appropriate MSE ... ii. Necessary stabilizing treatment (including treatment for an unborn child); and iii. An appropriate transfer to another facility if necessary, even if the individual cannot pay, does not have medical insurance or are not entitled to medicare or Medicaid. ...””

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 45448 Based on interview, record review, and policy review, a facility provider failed to appear at the facility when requested to provide stabilizing treatment for patients experiencing an emergency medical condition for 1 (#12) of 20 sampled patients. This failure resulted in the patient being transferred to another facility for care. Findings include: Patient #12, a 79-year-old male, was admitted to the facility for observation with a fast and irregular pulse on 4/25/24 and discharged to home on 4/26/24 at 4:05 p.m. Patient #12 returned to the ED by private vehicle on 4/26/24 at 6:00 p.m. with complaint of chest pain in the left upper chest which radiated to both arms and the left side of his jaw. Patient #12 described his symptoms of chest pain as a pressure with shortness of breath. Patient #12 stated his symptoms started 45 minutes prior to his arrival at the ED. Patient #12 had a history of heart disease with multiple stents placed in his heart, an irregular heartbeat, high blood pressure, elevated cholesterol, diabetes, sleep apnea, and an enlarged heart, all of which are significant heart risk factors. Review of patient #12’s medical record showed: -4/26/24 at 6:00 p.m., the patient presented to the ED via private vehicle complaining of pain in the middle of his chest which radiated to both of his arms and the left side of his jaw. The pain was reported to be a 6/10 by patient #12. -4/26/24 at 6:08 p.m., an EKG was performed and showed a slow pulse of 53 (normal range is 60 to 100 beats per minute), with delayed electrical conduction through his heart. -4/26/24 at 6:12 p.m., Vital Signs; BP 216/104 (normal range is less than 120/80), P 58, R 20, Pulse Oximetry 97% on room air, T 98.0. -4/26/24 at 7:17 p.m., a second EKG was performed and showed a slow pulse of 54 and delayed electrical conduction. -4/26/24 at 7:53 p.m., a third EKG was performed and showed a slow pulse of 51 and delayed electrical conduction. -4/26/24 at 8:00 p.m., Vital Signs taken; BP 171/83 (still elevated), P 56, R 12, Pulse Oximetry 97% on room air. -4/26/24 at 8:39 p.m., patient #12 was transported to [another hospital] via ambulance for further care. During an interview on 6/5/24 at 5:05 p.m., staff member X stated he was the ED physician that cared for patient #12 on 4/26/24. Staff member X said the patient’s chest pain was treated with several medications. A laboratory test (Troponin I) which helps determine if there has been heart muscle damage, was negative. The patient continued to have chest pain, and a second EKG showed mild changes which were a cause for concern. Staff member X stated he confirmed with multiple staff that the hospital had the capability and capacity to conduct emergency cardiac catheterizations and verified with the facility Chief of Staff [staff member E] the capability, capacity, and expectation of the on-call cardiologist to provide necessary care to the patient. Staff member X contacted staff member N and forwarded patient #12’s EKG for his review. Staff member N determined the patient needed a heart catheterization, however, despite multiple phone calls from staff member X requesting him to provide the necessary care for the patient, staff member N refused and stated he “was not coming in,” that he “was not contractually obligated to come in after hours,” and instructed staff member X to transfer the patient. Review of the facility’s on-call schedule for cardiology showed staff member N was on call on 4/26/24. During an interview on 6/12/24 at 2:30 p.m., staff member N stated he was a Board-certified Cardiologist in non-invasive [external] and invasive [internal] interventional cardiology. Staff member N stated the facility has full Cath lab capabilities and staff are available 24/7. Staff member N confirmed patient #12 was one of his regular patients and the patient would consider him to be his primary cardiologist. Staff member N stated patient #12 presented to the ED on 4/26/24 with a chief complaint of chest pain. Staff member N stated the patient’s pain was reported as being similar to a previous MI. He stated he reviewed the patient’s EKG and clearly noted ST elevation. Staff member N stated he did not report to the facility to treat the patient, and instructed staff member X to promptly transfer the patient to [another hospital] for immediate cath lab services. Review of the facility’s Medical Staff Rules and Regulations, dated 9/13/23, showed each specialty is responsible for developing an on-call schedule with the name of the physician who is to be available to provide treatment to an individual with an emergency medical condition (EMC). Review of a facility document titled, “Employment Agreement”, with a commencement date of March 1, 2023, showed staff member N entered into an employment contract with the facility for a term of three years. Review of the contract showed, “Practitioner shall practice medicine and provide medical services related to the specialty/subspecialty identified on Exhibit A (the “Services”) to patients as set forth herein on and after the date listed on Exhibit A (the “Commencement Date”), consistent with Practitioner’s licensure, training and privileges, including but not limited to examining patients; performing medical procedures; prescribing medication or treatment; consulting with other practitioners; and providing call coverage as set forth on Exhibit A. ... EXHIBIT A Certain Contract Terms ... Call Coverage: ... As a requirement under this Agreement, Practitioner shall be required to provide call coverage for the Clinic at the Hospital up to 14 days per month ...Practitioner has historically responded to emergent and STEMI patients during normal clinic hours, which shall be continued. Should Clinic/Hospital adopt a program for STEMI patients, such program shall include the following capabilities: 1. Cardiovascular Thoracic surgeon with availability and on call for additional support and a call schedule posted for confirmation. 2. Full heart surgical support team available to assist with procedures. 3. Confirmed bed capacity at the hospital.” Review of the facility’s Cardiothoracic/Vascular on-call schedule showed staff member Z was the Cardiothoracic/Vascular Surgeon on-call on 4/26/24. Review of the facility’s CT Surgery on-call schedule showed eight staff members were assigned for on-call duties on 4/26/24. Review of the facility’s Anesthesia on-call schedule showed staff member BB was the anesthesiologist on-call on 4/26/24. Review of the facility’s Cardiac Cath Lab on-call schedule showed four staff members were assigned on-call duties on 4/26/24. Review of facility documents showed the facility is licensed for 36 Med/Surg beds and 10 ICU beds. Review of the facility’s ICU daily census report showed there were 7 patients receiving care in the 10 bed ICU on 4/26/24. Review of patient #12’s medical record from the receiving facility showed: -4/26/24 at 8:59 p.m., the patient arrived at the receiving facility ED. Patient #12 was evaluated by NF2 and NF3. Patient #12’s vital signs were recorded as: BP 210/118 (still elevated), P 74, R 12, Pulse Oximetry 94%, T 97.9. -4/26/24 at 9:04 p.m., an EKG was performed; NF2 interpreted the results as persistent right bundle branch pattern (delayed conduction of electrical impulses through the heart which are responsible for triggering contraction of the heart muscle) and no changes which would indicate the patient was having a heart attack. NF2 compared the EKG from the previous facility and noted there were some subtle ST changes, but not enough to meet the criteria for an acute heart attack. Patient #12 was treated with an intravenous medication used to treat the patient’s chest pain and elevated blood pressure (the medication causes the patient’s blood vessels to dilate or get bigger around, and improves blood flow to the heart and other vital organs). During an interview on 6/17/24 at 4:00 p.m., NF3 stated patient #12 was transferred to his facility [another hospital] in an unstable condition. NF3 said it was determined patient #12’s cardiac findings did not require immediate heart catheterization, and he was admitted to the progressive care unit. The following morning (4/27/24) patient #12 underwent an ultrasound of his heart and a heart catheterization. NF3 stated patient #12 had a blockage in one of the large arteries which supplies blood to the heart muscle. Review of a facility policy titled, “EMTALA - Medical Screening and Stabilization”, with an effective date of January 5, 2016 showed, “Policy: Any person who presents to the hospital or any off-campus provider-based department of the hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening exam (MSE) performed by a qualified medical person (QMP) to determine whether an EMC exists. ... If the QMP determines an EMC exists, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the hospital. Record review of a facility policy, “EMTALA - On-Call Coverage,” dated 1/5/16, showed, “ ... Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. ... The hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC in accordance with resources available to the hospital. ... 8. Physician’s Responsibility. When a physician is identified as being the On-Call Physician for a given specialty, it shall be that physician’s duty and responsibility to assure the following: ... b. Arrival or response to the Emergency Department within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The Emergency Department Physician, in consultation with the On-Call Physician, shall determine whether the individual’s condition requires the On-Call to see the individual immediately. The determination of the Emergency Department Physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. ...””

“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: 41652 Based on interview, record review, and policy review, the facility failed to provide stabilizing treatment within the facility’s capability and capacity, for 2 (#s 8 and 12) patients who presented with emergency medical conditions, of 20 sampled patients who presented to the ED for emergency care. Findings include: 1. Patient #8, a 75-year-old female, presented to the ED on 3/14/24 at 6:58 p.m. seeking care for chest pain. The patient had a history of high blood pressure and diabetes (both cardiac risk factors), and a heart attack that required stent [small tubes placed to open the blocked arteries] placement approximately five years prior. The ED provider notes, completed by staff member CC, showed the patient’s chest pain started on 3/13/24, resolved, and then returned at 11:00 a.m. on 3/14/24, and had continuously increased throughout the day. Patient #8 had two EKGs which showed ST elevation (indication of a heart attack). The patient was subsequently diagnosed with a STEMI (indicates the blockage of an artery that provides blood to the heart muscle). Staff member CC consulted staff member N, the cardiologist on-call, and was instructed to transfer patient #8 to [another hospital] for further care. Patient #8 was transferred to [another hospital] on 3/14/24 at 7:55 p.m. for emergent heart catheterization. Review of patient #8’s EHR, dated 3/14/24, showed the following: -3/14/24 at 6:55 p.m., an EKG was performed and showed ST elevation. The EKG was interpreted as a STEMI and signed at 6:56 p.m. by staff member CC. -3/14/24 at 7:07 p.m., Labs were drawn. Pertinent abnormal results included an elevated Troponin I of 1.160 (reference range 0.00-0.012 ng/ml) indicating heart muscle damage. -3/14/24 at 7:28 p.m., a second EKG was performed, was abnormal, and indicated total blockage of a coronary artery. The EKG was interpreted as a STEMI and signed at 7:29 p.m. by staff member CC. Review of patient #8’s “Emergency Department Note,” dated 3/14/24 and signed by staff member CC, showed: “ ...Patient is EKG positive for a STEMI spoke with [staff member N] who recommends transfer to [another hospital]. Spoke with [NF5] ER doc at [another hospital] and he agrees to transfer and accepts the patient. Patient is in stable condition upon transfer ...” During an interview on 7/8/24 at 9:36 a.m., staff member CC stated she consulted staff member N [cardiologist on call] regarding patient #8’s care on 3/14/24, who told her to transfer the patient to another hospital. Staff member CC stated she assumed if Cath lab services were available, staff member N would have come in to do the heart catheterization procedure. Review of the facility’s Medical Staff Rules and Regulations, dated 9/13/23, showed each specialty is responsible for developing an on call schedule with the name of the physician who is to be available to provide treatment to an individual with an emergency medical condition (EMC). Review of the facility’s Cardiology on-call schedule showed staff member N was on-call on 3/14/24. During an interview on 6/12/24 at 2:30 p.m., staff member N stated he was a Board-certified Cardiologist in non-invasive (external) and invasive (internal) interventional cardiology. Staff member N stated the facility has full Cath lab capabilities and staff are available 24/7. Staff member N confirmed patient #8 presented to the ED on 3/14/24 with complaints of chest pain. He stated the patient’s EKG results showed she was having an active STEMI. Staff member N stated staff member CC consulted him on the patient and he told staff member CC to transfer the patient to [another hospital] for an emergent cardiac catheterization. Staff member N stated although the facility has full Cath lab capabilities, the facility does not always have a care team in the ICU (Intensive Care Unit), so the facility is only able to treat stable patients during regular business hours when there is full, competent staff available to safely care for STEMI patients. Staff member N stated he had the capacity and privileges to perform the procedure for patient #8, but he did not report to the facility to perform the cardiac catheterization for patient #8. Record review of a facility document titled, “Cardiac Service 24/7 Growth Plan” showed, “... Notes ...3/11/24 24/7 cath lab call starts today.” During an interview on 6/6/24 at 11:18 a.m., staff member U said he oversaw ancillary support functions. Staff member U stated the facility has a cath lab team on-call and the facility has 24/7 availability to patients for cath lab services. Staff member U stated the 24/7 capabilities have been available since March 2024. Review of an email provided by staff member C, dated 7/8/24, showed that if cardiac cath lab services were needed after hours prior to 3/18/24, cardiac cath lab staff members were generally on call and would attempt to accommodate the needed services. During an interview on 6/5/24 at 2:18 p.m., staff member H stated she had been a travel RN in the Cath lab since October of 2023 and was currently the Cath Lab Director. Staff member H stated the Cath lab had been a 24-hour a day, seven days a week service since February of 2024. During an interview on 6/11/24 at 9:00 a.m., staff member E stated she was the Chief of Medical Staff and that the hospital provided 24/7 Cath lab coverage which began in March of 2024. During an interview on 6/6/24 at 10:09 a.m., staff member G [former ED Director] stated the facility began the process of expanding the Cath lab services to 24/7 beginning in January of 2024, and was advised by facility leadership there was 24/7 coverage for Cath lab services at the time of patient #8’s ED encounter on 3/14/24. Review of facility document titled, “Employment Agreement”, with a commencement date of March 1, 2023, showed staff member N entered into an employment contract with the facility for a term of three years. Review of the contract showed, “Practitioner shall practice medicine and provide medical services related to the specialty/subspecialty identified on Exhibit A (the “Services”) to patients as set forth herein on and after the date listed on Exhibit A (the “Commencement Date”), consistent with Practitioner’s licensure, training and privileges, including but not limited to examining patients; performing medical procedures; prescribing medication or treatment; consulting with other practitioners; and providing call coverage as set forth on Exhibit A. ... EXHIBIT A Certain Contract Terms ... Call Coverage: ... As a requirement under this Agreement, Practitioner shall be required to provide call coverage for the Clinic at the Hospital up to 14 days per month ...Practitioner has historically responded to emergent and STEMI patients during normal clinic hours, which shall be continued. Should Clinic/Hospital adopt a program for STEMI patients, such program shall include the following capabilities: 1. Cardiovascular Thoracic surgeon with availability· and on call for additional support and a call schedule posted for confirmation. 2. Full heart surgical support team available to assist with procedures. 3. Confirmed bed capacity at the hospital.” Review of the facility’s Cardiothoracic/Vascular Surgery on-call schedule showed staff member Z was on-call 3/14/24. Record review of the facility’s CT Surgery on-call schedule showed 8 staff members were assigned for on-call duties on 3/14/24. Record review of the facility’s Anesthesia on-call schedule showed staff member BB was the anesthesiologist on-call on 3/14/24. Review of facility documents showed the facility is licensed for 10 ICU beds, with 5 patients receiving care in the 10 bed ICU on 03/14/24. Record review of facility’s Telemedicine Contract with Access Services, “Facility Addendum - Telemedicine Pulmonary and Critical Care Services,” dated 2/15/2021, showed, “... the Services performed pursuant to this Agreement will occur 24 hours a day, 365 days a year, and will include the following telemedicine pulmonary and critical care services: ... a. Pulmonary and Critical Care Services: ... will evaluate, stabilize, and appropriately treat or otherwise manage the care of patients requiring internal medicine, pulmonary and critical care, and related medical services in the ICU and Med-Surg wards. ...” Review of patient #8’s [another hospital] EHR, dated 3/14/24, showed the following: -3/14/24 at 8:04 p.m., arrived at receiving facility ED via ambulance with diagnosis of STEMI. -3/14/24 at 10:00 p.m., sent emergently to cath lab for left heart catheterization and placement of two stents. During an interview on 6/18/24 at 3:00 p.m., NF5 stated he was the ED physician at [another hospital] who cared for patient #8 on 3/14/24. NF5 stated he accepted patient #8 for transfer with a diagnosis of a STEMI who required an emergent heart catheterization. During an interview on 6/11/24 at 9:00 a.m., staff member E [Chief of Medical Staff] stated there had been some resistance from the cardiologists regarding the 24/7 cardiac cath lab coverage, that there had been two incidents of patients being transferred to [another hospital] for cath lab services since she had been informed of the 24/7 Cath lab availability, and that the ED Director posted a sign regarding Cath lab availability after the 3/14/24 incident occurred with patient #8. During an interview on 6/6/24 at 10:09 a.m., staff member G [former ED Director] confirmed that she posted a notice about coverage for the Cath lab on the wall behind the ED provider’s computers on 3/18/24 to ensure everyone was aware the services were available. 2. Patient #12, a 79-year-old male, was initially admitted to the facility for observation with a fast and irregular pulse on 4/25/24 and discharged to home on 4/26/24 at 4:05 p.m. Patient #12 returned to the ED by private vehicle on 4/26/24 at 6:00 p.m. with a complaint of chest pain in the left upper chest which radiated to both arms and the left side of his jaw. Patient #12 described his symptoms of chest pain as a pressure with shortness of breath. Patient #12 stated his symptoms started 45 minutes prior to his arrival at the ED. Patient #12 had a history of heart disease with multiple stents placed, an irregular heartbeat, high blood pressure, elevated cholesterol, diabetes, sleep apnea, and an enlarged heart. These diagnoses placed patient #12 at a higher risk for complications. Review of patient #12’s medical record showed: -4/26/24 at 6:00 p.m., the patient presented to the ED via private vehicle complaining of pain in the middle of his chest which radiated to both of his arms and the left side of his jaw. The pain was reported to be a 6/10 by patient #12. -4/26/24 at 6:08 p.m., an EKG was performed and showed a slow pulse of 53 (normal range is 60 to 100 beats per minute), with delayed electrical conduction through his heart. -4/26/24 at 6:12 p.m., Vital Signs; BP 216/104 (normal range is less than 120/80), P 58, R 20, Pulse Oximetry 97% on room air, T 98.0. -4/26/24 at 7:17 p.m., a second EKG was performed and showed a slow pulse of 54 and delayed electrical conduction. -4/26/24 at 7:53 p.m., a third EKG was performed and showed a slow pulse of 51 and delayed electrical conduction. -4/26/24 at 8:00 p.m., Vital Signs taken; BP 171/83 (still elevated), P 56, R 12, Pulse Oximetry 97% on room air. -4/26/24 at 8:39 p.m., patient #12 was transported to [another hospital] via ambulance for further care. During an interview on 6/5/24 at 5:05 p.m., staff member X stated he was the ED physician that cared for patient #12 on 4/26/24. Staff member X said the patient’s chest pain was treated with several medications. A laboratory test (Troponin I) which helps determine if there has been heart muscle damage, was negative. The patient continued to have chest pain, and a second EKG showed mild changes which were a cause for concern. Staff member X stated he confirmed with multiple staff that the hospital had the capability and capacity to conduct emergency cardiac catheterizations and verified with the facility Chief of Staff [staff member E] the capability, capacity, and expectation of the on-call cardiologist to provide necessary care to the patient. Staff member X contacted staff member N and forwarded patient #12’s EKG for his review. Staff member N determined the patient needed a heart catheterization, however, despite multiple phone calls from staff member X requesting him to provide the necessary care for the patient, staff member N refused and stated he “was not coming in,” that he “was not contractually obligated to come in after hours,” and instructed staff member X to transfer the patient. Review of the facility’s on call schedule for cardiology showed staff member N was on call on 4/26/24. During an interview on 6/12/24 at 2:30 p.m., staff member N confirmed patient #12 was one of his regular patients and the patient would consider him to be his primary cardiologist. Staff member N stated patient #12 presented to the ED on 4/26/24 with a chief complaint of chest pain. Staff member N stated the patient’s pain was reported as being similar to a previous MI. He stated he reviewed the patient’s EKG and clearly noted ST elevation. Staff member N stated did not report to the facility to treat the patient, and instructed staff member X to promptly transfer the patient to [another hospital] for immediate cath lab services. Record review of the facility’s Cardiac Cath Lab on-call schedule showed 4 staff members were assigned on-call duties on 4/26/24. During an interview on 6/6/24 at 10:09 a.m., staff member G stated she was contacted via phone by staff member X on 4/26/24. Staff member G stated staff member X called and confirmed the facility had an emergent cardiac catheterization laboratory (cath lab) team on call. During an interview on 6/6/24 at 2:15 p.m., staff member W said she was on-call for the cath lab on 4/26/24. Staff member W stated staff member X had called her to confirm the cath lab on-call team was available to treat a patient with an emergency. Staff member W stated she confirmed to staff member X that the cath lab team was available to perform emergent cardiac catheterizations. Record review of the facility’s Cardiothoracic/Vascular on-call schedule showed staff member staff member Z was the Cardiothoracic/Vascular Surgeon on-call on 4/26/24. Record review of the facility’s CT Surgery on-call schedule showed 8 staff members were assigned for on-call duties on 4/26/24. Record review of the facility’s Anesthesia on-call schedule showed staff member BB was the anesthesiologist on-call on 4/26/24. Review of the facility’s ICU daily census report dated 4/26/24, showed there were 7 patients receiving care in the 10 bed ICU. During an interview on 6/11/24 at 9:00 a.m., staff member E stated she was the facility Chief of Staff. Staff member E stated she received a call from staff member X on the evening of 4/26/24. Staff member E stated she confirmed to staff member X the facility had the capacity to perform emergent heart catheterization’s, and a cath lab team was on-call for emergent heart cath’s. Staff member E stated the cath lab staff have been on-call and available for emergent cath lab services for some time, and the facility has had at least one cardiologist on call for emergencies. Review of patient #12’s medical record from the receiving facility showed: -4/26/24 at 8:59 p.m., the patient arrived at the receiving facility ED. Patient #12 was evaluated by NF2 and NF3. Patient #12’s vital signs were recorded as: BP 210/118 (still elevated), P 74, R 12, Pulse Oximetry 94%, T 97.9. -4/26/24 at 9:04 p.m., an EKG was performed; NF2 interpreted results as persistent right bundle branch pattern (delayed conduction of electrical impulses through the heart which are responsible for triggering contraction of the heart muscle). NF2 compared the EKG from the previous facility and noted there were some subtle changes, but not enough to meet the criteria for an acute heart attack. Patient #12 was treated with an intravenous medication used to treat the patient’s chest pain and elevated blood pressure. The medication causes the patient’s blood vessels to dilate (get bigger around) and improves blood flow to the heart and other vital organs. During an interview on 6/17/24 at 4:00 p.m., NF3 stated patient #12 was transferred to his facility [another hospital] in unstable condition. NF3 said it was determined patient #12’s myocardial findings did not require immediate heart catheterization, and he was admitted to the progressive care unit. The following morning (4/27/24) patient #12 underwent an ultrasound of his heart and a heart catheterization. NF3 stated patient #12 had a blockage in one of the large arteries which supplies blood to the heart muscle. Review of a facility policy titled, “EMTALA - Medical Screening and Stabilization”, with an effective date of January 5, 2016, showed: “Policy: Any person who presents to the hospital or any off-campus provider-based department of the hospital requesting assistance for a potential emergency medical condition (EMC) will receive a medical screening exam (MSE) performed by a qualified medical person (QMP) to determine whether an EMC exists. ... If the QMP determines an EMC exists, the individual will be provided necessary stabilizing treatment, within the capacity and capability of the hospital, or an appropriate transfer, as defined by and required by EMTALA. ... Stabilizing treatment within hospital capability and transfer. Record review of a facility policy, “EMTALA - On-Call Coverage,” dated 1/5/16, showed: “ ... Physicians on the list must be available after the initial examination to provide treatment necessary to stabilize individuals with emergency medical conditions (EMC) who are receiving services in accordance with the resources available to the hospital. ... The hospital must maintain a list of physicians who are on-call for duty after the initial examination to provide treatment necessary to stabilize an individual with an EMC in accordance with resources available to the hospital. ... 8. Physician ’ s Responsibility. When a physician is identified as being the On-Call Physician for a given specialty, it shall be that physician ’ s duty and responsibility to assure the following: ... b. Arrival or response to the Emergency Department within a reasonable timeframe (generally, response by the physician is expected within 30 minutes). The Emergency Department Physician, in consultation with the On-Call Physician, shall determine whether the individual ’ s condition requires the On-Call to see the individual immediately. The determination of the Emergency Department Physician or other practitioner who has personally examined the individual and is currently treating the individual shall be controlling in this regard. ...” 45448”