Chi Health St. Francis

“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: 48575 Based on policy and procedure review, medical record review, staff and medical staff interviews the acute care facility (ACF) failed to follow their policy regarding a completed EMTALA transfer consent form for 1 (P19) of 4 sampled transfer medical records. This failed practice has the potential to affect all patients who require transfer from the ACF. According to facility provided information the Emergency Department (ED) transfers an average of 285 patients per month. See citation A2409, that also resulted in A2400 to not be met. Findings include: A. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department -(EMTALA)- (St. Francis),” approved 2/2023 revealed, “stable for transfer means: the physician determines within reasonable medical probability that the individual will sustain no material deterioration in the patient’s medical condition as a result of transfer. When the hospital transfers an individual with an EMC to another facility, the transfer will be carried out in accordance with the following procedures: the hospital will send to the receiving facility a copy of the completed applicable sections of the Transfer Consent Form.” B. Review of P19’s medical record revealed, P19 presented to the ACF-A on 10/19/2022 at 5:46PM via ground ambulance which was diverted to ACF-A 23 miles enroute from CAH-A to ACF-B during an interfacility transfer of the patient, pregnant at 29 weeks gestation with an EMC of profuse vaginal bleeding (pregnant woman bleeding a lot putting mom and baby at high risk). The original plan was for P19 to transfer from CAH-A via ground ambulance 120 miles to ACF-B for acute respiratory distress (not able to breathe or maintain oxygen levels to live). Review of the “ED Provider Notes” from ACF-A revealed, in part, “Patient is requiring 100% nonrebreather [oxygen therapy] in order to keep her oxygen level satisfactory” and that “as she was being transferred...she began having significant profuse vaginal bleeding and subsequently got diverted to our facility.” After consultation with its on-call OB/GYN specialist, ACF-A determined P19 was “no longer actively bleeding” and a “helicopter was summoned to properly take the patient to [ACF-B].” The “clinical impression” included “respiratory distress,” and Physician-A performed 45 minutes of “critical care” for “respiratory failure” prior to transfer. Review of ACF-A’s EMTALA Transfer Consent form signed by Physician-A 10/19/2022 at 7:57PM revealed P19 condition listed as “stable patient,” when intubation (a tube placed in the airway), ventilation (machine to breathe for the patient) and sedation (medication induced coma) was required at 8:41PM by the flight crew prior to air transfer at 9:40PM, and only one risk of transfer, “decompensation,” despite the ACF-A form states, “must be patient-specific diagnosis.” C. During an interview on 4/3/2024 at 9:39AM, RN-A revealed that the EMTALA transfer consent form in P19’s medical record was the most recent version. During an interview on 4/3/2024 at 3:09PM, Physician-A revealed, the decision to intubate P19 was requested by transport crew to secure the airway prior to transfer. “I called the Maternal Fetal Medicine (MFM) (specialized physician to care for a high risk pregnant patient and baby) to update on patient status with change of condition since accepting the patient.” [The ACF-A EMTALA transfer consent form lacked evidence of the updated patient condition, and risks of transfer for P19.]”

“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: 48575 Based on policy and procedure review, medical record review, staff and medical staff interviews the acute care facility (ACF) failed to properly list the unstable patient condition and risk of transfer on the EMTALA transfer form for 1 (P19) of 4 sampled transfer medical records. This failed practice has the potential to affect all patients who require transfer from the ACF. According to facility provided information the ED transfers an average of 285 patients per month. See citation A2400, that also resulted in A2409 to not be met. Findings include: A. Review of facility policy “Examination, Treatment, and Transfer of Individuals Who Come to the Emergency Department -(EMTALA)- (St. Francis),” approved 2/2023 revealed, “stable for transfer means: the physician determines within reasonable medical probability that the individual will sustain no material deterioration in the patient’s medical condition as a result of transfer. When the hospital transfers an individual with an EMC to another facility, the transfer will be carried out in accordance with the following procedures: the hospital will send to the receiving facility a copy of the completed applicable sections of the Transfer Consent Form.” B. Review of P19’s medical record revealed, P19 presented to the ACF-A on 10/19/2022 at 5:46PM via ground ambulance which was diverted to ACF-A 23 miles enroute from CAH-A to ACF-B during an interfacility transfer of the patient, pregnant at 29 weeks gestation with an EMC of profuse vaginal bleeding (pregnant woman bleeding a lot putting mom and baby at high risk). The original plan was for P19 to transfer from CAH-A via ground ambulance 120 miles to ACF-B for acute respiratory distress (not able to breathe or maintain oxygen levels to live). Review of the “ED Provider Notes” from ACF-A revealed, in part, “Patient is requiring 100% nonrebreather [oxygen therapy] in order to keep her oxygen level satisfactory” and that “as she was being transferred...she began having significant profuse vaginal bleeding and subsequently got diverted to our facility.” After consultation with its on-call OB/GYN specialist, ACF-A determined P19 was “no longer actively bleeding” and a “helicopter was summoned to properly take the patient to [ACF-B].” The “clinical impression” included “respiratory distress,” and Physician-A performed 45 minutes of “critical care” for “respiratory failure” prior to transfer. Review of ACF-A’s EMTALA Transfer Consent form signed by Physician-A 10/19/2022 at 7:57PM revealed P19 condition listed as “stable patient,” when intubation (a tube placed in the airway), ventilation (machine to breathe for the patient) and sedation (medication induced coma) was required at 8:41PM by the flight crew prior to air transfer at 9:40PM, and only one risk of transfer, “decompensation,” despite the ACF-A form states, “must be patient-specific diagnosis.” C. During an interview on 4/3/2024 at 9:39AM, RN-A revealed that the EMTALA transfer consent form in P19’s medical record was the most recent version. During an interview on 4/3/2024 at 3:09PM, Physician-A revealed, the decision to intubate P19 was requested by transport crew to secure the airway prior to transfer. “I called the Maternal Fetal Medicine (MFM) (specialized physician to care for a high risk pregnant patient and baby) to update on patient status with change of condition since accepting the patient.” [The ACF-A EMTALA transfer consent form lacked evidence of the updated patient condition, and risks of transfer for P19.]”