Alleghany Memorial 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: 40299 Based on policy reviews, medical record reviews, and staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 489.24. The findings included: The hospital’s Dedicated Emergency Department (DED) failed to provide an appropriate transfer for a patient that presented to the DED requesting assistance for one (1) of 20 sampled DED patients who presented to the hospital, (Patient #3). ~ Cross Refer to §489.24(d)(3) Stabilizing Treatment - Tag 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: 40299 Based on policy review, medical record review, and staff interviews, the hospital’s DED (Dedicated Emergency Department) failed to provide an appropriate transfer for a patient that presented to the DED requesting assistance for one (1) of 20 sampled DED patients who presented to the hospital, (Patient #3). The findings include: Review of the hospital policy titled “Emergency Medical Treatment and Active Labor Act (EMTALA)” with an effective date of 07/2023 revealed “ ... Permissible Transfers: 1. Transfer to another medical facility of a patient presenting with an emergency medical condition is appropriate under any of the following conditions: a. The emergency medical condition has been stabilized. b. The individual’s emergency medical condition has not been stabilized, but the individual, or a legally responsible person acting on the individual’s behalf, after being informed in writing of the hospital’s obligation to provide further examination and treatment and/or the risk of transfer, and after being advised that the transfer is not medically recommended, requests transfer to another medical facility against medical advice (AMA). c. The individual’s emergency medical condition has not been stabilized, but a qualified medical provider has signed the certificate on the Patient Transfer Form stating that, based upon information available to him or her at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment in another facility outweigh the increased risk to the individual ...from effecting a transfer, and the patient requests or consents to transfer. ...Effecting Transfer 1. Transfer of a patient in an emergency medical condition to another facility requires: a. That medical treatment has been provided to minimize the risks to the individual’s health ... b. The receiving facility has been contacted to verify that there is available space and qualified personnel for treatment of the individual, and to obtain the receiving physician and facility’s agreement to accept transfer. c. All medical records relating to the individual’s emergency medical condition should be sent (or faxed as soon as possible) with the transferred individual, including records relating to the emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests and the individual’s written informed consent to transfer, or the physician’s certification of the benefits of transfer, and the name and address of any on-call physician who has refused or failed to appear within reasonable time to provide necessary stabilizing treatment. ...” Review of the DED medical record on 05/14/25 revealed Patient # 3 was a 44-year-old female that presented to the DED on 07/22/2025 at 1309 with an arrival complaint of “wants to see (Mental Health Agency [MHA] #5). Review of the medical record revealed the patient did not arrive via EMS. Review of the Provider note at 1316 revealed “ ... arrives by walking and advises he wants to speak to MHA #5 and is homeless but is not homicidal and not suicidal. ... called local police ... for them to pat him down and secured any belongings and we will IVC (involuntary commitment) paper this man. The last few visits he was here he left AMA (against medical advice) and then returned in 1 to 2 days. ... HPI (history present illness): Patient presents to the emergency room with a history of having substance abuse. He states that he is basically using amphetamines (stimulant drugs that increase the activity of the central nervous system). He is desiring to see MHA #5 for help. ... Review of Systems ... Psychiatric/Behavioral: Positive for behavioral problems. The patient is nervous/anxious. ... Physical Exam: Psychiatric: Comments: Patient denies any SI (suicidal ideation -thoughts of hurting self) or HI (homicidal ideation -thoughts of hurting others) or any psychosis (condition where a person loses touch of reality) at this time. He reports ‘he is homeless and needs help.’ (RN #2 reports ‘this man is not homeless and actually knows this man’s family.’) ... Assessment & (and) Plan ED Disposition: Data Unavailable Final diagnoses: None ...” Patient #3 was given an acuity (emergency severity index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute) of “5”. Review of the ED Triage Notes Addendum at 1337 revealed “Pt (patient) arrived to ER (emergency room) with behavioral health issues. He recently was here voluntary around 1 month ago for the same complaint however, he left AMA before finding placement in rehab (rehabilitation). Patient endorses drug history. States today he ‘wants to talk to MHA #5’. He denies suicidal or homicidal ideations at this time. LEO (law enforcement officer) present as well for safety. Patient states he was ‘kicked out from his wife’s house’ because they are ‘psych’ and has no place to reside. Again he denied SI (suicidal ideation - thoughts of hurting oneself)/HI (homicidal ideation - thoughts of hurting others). States he ‘only wants to talk to MHA #5.’ Call into MHA #5 placed, spoke with (Name) who states she will call back soon.” Review of the Nurse note at 1637 revealed “MHA #5 here. Patient tells them he wants to ‘kill his wife and beat up other people’. He is now making homicidal threats so according MHA #5, he can be IVC. Papers now being drawn up however according to (Name), magistrate states ‘all hospitals should have a way to access NC File and Serve.’ CNO #3 spoke with both (Name) and (Name assistant) who reports the magistrate of (County Name) cannot accept paper copies of IVC. (CNO #3) spoke with CAO #6 who states since staff is not available or trained for NC File and Serve, patient will need to be transferred to a capable facility.” Nurse note at 1808 revealed “Sheriff’s dept (department) transferring patient to Hospital B due to being unable to appropriately IVC him here. Patient left building at 1745.” Review of the ED Care Timeline revealed Patient #3 was discharged at 1809. Review of the Provider note at 1832 revealed “Please note there was a bit of a confusion today because instead of paper IVCs we were made aware today that it was now only acceptable for electronic IVC. Therefore CNO #3 and administration was called and it was a bit of confusion and that means the patient had to be sent to Hospital B.” Review of the (County Name) County Communications revealed on 07/22/2025 there were multiple calls to speak with an officer and the last call was for transport of a patient from Hospital A’s ED to Hospital B’s ED. Interview on 10/08/2025 at 1443 with Registered Nurse (RN) #2 revealed she knew Patient #3. Patient #3 came in, said he wanted to hurt others and himself. Patient #3 has a history of coming in, leaving, and then coming back multiple times. The process had to be restarted each time. Law enforcement told the facility staff to call them the next time Patient #3 comes in. Law enforcement was called on 07/22/2025 and they came. The IVC paperwork was filled out and sent to the magistrate, however this time the magistrate said they could no longer take the paperwork that it had to be completed online. Interview revealed CNO #3 and CAO #6 were not aware of this change. Hospital B was the closest place to get the IVC completed online. Interview revealed the “patient was voluntary and was medically cleared”. Interview RN #2 got training on the new online system for IVC the next shift she worked and there have not been any other patients that this has happened to. Interview on 10/08/2025 at 1532 with Chief Nursing Officer (CNO) #3 revealed she remembered Patient #3. CNO #3 was working in the inpatient area on 07/22/2025 when Patient #3 was in the emergency department. RN #2 notified CNO #3 the magistrate no longer accepts IVC paperwork. CNO #3 revealed Technician (Tech) #1 called Hospital B to see if they had and could process the IVC online and serve the papers. Hospital B confirmed they could. MD #4 wanted Patient #3 to go to Hospital B to be IVC’d due to MHA #5 request and Patient #3’s history of leaving without treatment. MD #4 discharged Patient #3 back to the officer to be taken to Hospital B to be IVC’d. CNO #3 spoke with State Representative #7 with the go live for electronic program from the Raleigh office. State Representative #7 gave CNO #3 the information needed to get registered/signed up for the new online process for IVC. CNO #3 got everyone signed up, educated and ensured everyone completed the training on the new method. CNO #3 had everyone trained the following week, she also put a binder in the ED as a reference for staff if they had any questions when first using the online process. The first time staff used the online process there was a contact number to get in touch with someone who could “hand hold” them on how to complete the online method. Interview revealed multiple agencies including the police department and MHA #5 were aware of the new process for IVC however they were not aware when it would go into effect. Telephone interview on 10/09/2025 at 1211with Medical Doctor (MD) #4 revealed he did not recall Patient #3 and had not reviewed the paperwork. MD #4 was there when CNO #3 got the call notification from the magistrate notifying they no longer were taking paper IVC. MD #4 did not see Patient #3. Interview revealed the “officer made the decision to take pt to Hospital B”. MD #4 called Hospital B as a courtesy to see if they had capability to perform the IVC process online and the Provider as Hospital B said they could not accept the patient. MD #4 explained he was not sending the patient to Hospital B, he was just trying to get information. MD #4 released Patient #3 to the police and the police made the decision to take Patient #3 to Hospital B. MD #4 saw Patient #3 walk out with law enforcement, he appeared stable. MD #4 stated they had to be very careful with psychiatric patients. If patients are on the property and were SI or HI by court of law they had to see and IVC them. Interview revealed MD #4 was unsure who made the calls to see which hospital had IVC capabilities. Hospital B was the closest and the officer took the patient there. Interview revealed the law enforcement officer made the decision to take the patient there. Interview revealed one of the changes is that Hospital A now have staff that can perform the electronic IVC. CNO #3 put paperwork out for everyone to get qualified to perform the electronic IVC. Telephone interview on 10/10/2025 at 1000 with Tech #1 revealed she remembered Patient #3. Tech #1 was trying to get the IVC paperwork filled out, called the police department for them to take the paperwork to the magistrate. The law enforcement officer who arrived at Hospital A notified Tech #1 they could no longer take paperwork for IVC that needed to be done online. The magistrate was asked to contact the facility about this. Tech #1 tried to find a facility that was capable of filing the online IVC. Tech #1 spoke with a male at Hospital B and told them they were trying to find a facility that could file the online IVC. Tech #1 told the male the decision had not been made if the patient was going to Hospital B but that he may. During this time the law enforcement officer was still talking with his office to see if there was anything they could do to help since Hospital A were not aware of the change in the process. Tech #1 was unsure who made the decision to take the patient to Hospital B. Interview revealed training on the online IVC process was set up immediately. Staff took the training on their next scheduled work shift. Tech #1 was not aware of any other patient affected.”