Box Butte General 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: 48575 Based on policy review, medical record review, medical staff interview, the facility failed to stabilize and provide an appropriate transfer to 1 (Patient 20) out of 20 ED sampled patients in active labor. This failed practice has the potential to place the life of the pregnant mother and unborn baby at risk. According to facility provided data the ED sees an average of 428 patients per month for the past 6 months. See citations A2407 and A2409 that also resulted in A2400 to be not met.”

“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: 48575 Based on policy review, medical record review, medical staff interview, the facility failed to provide stabilizing treatment for an emergency medical condition (EMC) of active labor for 1 (Patient 20) of 20 emergency department (ED) sampled patients. This failed practice has the potential to place the life of the pregnant mother and unborn baby at risk. According to facility provided data the ED sees an average of 428 patients per month for the past 6 months. See citations A2400 and A2409 that also resulted in A2407 to be not met. Findings include: A. Review of facility policy titled, “Obstetrics Department EMTALA guidelines,” (no date) revealed a woman who experiences contractions is presumed to be in true labor unless a physician certifies that the woman is in false labor. A physician certification of false labor is required prior to discharge. A qualified medical personnel (QMP) is defined as an individual (Physician, Advanced Practice Provider (APP) or Registered Nurse (RN) with triage authority) qualified to perform a medical screening exam (MSE) on obstetrical patients. An EMC is defined as acute symptoms that place the health of the pregnant individual or unborn child in serious jeopardy....with respect to a pregnant individual having contractions there is inadequate time to safely transfer before delivery. B. Review of the Electronic Medical Record (EMR) showed P20 presented to Facility A, the CAH OB triage area on 1/7/2026 at 8:58PM with a complaint of, “active labor at term, patient feels she can’t make it to Facility B,” gravida 4 (fourth pregnancy) with an estimated due date of 1/9/2026 and history of precipitous (labor and delivery are quick). Review of Physician-A cervical exam showed Patient 20 had a cervical dilation at 5 centimeters (the cervix is opening to the uterus), effacement 30 percent (thinning of the cervix, 100% equals the birth canal is fully open for a vaginal delivery), and negative 3 fetal station (the position the baby is in the mothers pelvis) with patient 20 reporting strong contractions (tightening and relaxing of the uterine muscle that the body natural pushes the baby down for delivery) every 2 to 3 minutes. Review of the EMR .showed no documentation that P20 was offered to be admitted and provided stabilizing treatment for the emergency medical condition of active labor within the hospital’s capabilities. P20 was discharged at 10:30pm and traveled via private vehicle approximately 56 miles to facility B for treatment and stabilization of active labor. Review of P20’s EMR from Facility B showed the following: -11:20pm crowning (baby’s head is visible through the mothers vaginal canal). -11:24: 9 pound (lb) 15.4 ounces (oz) infant delivered in private vehicle by Facility B physician. -11:32pm: medications administered to P20 related to post delivery bleeding. Review of the EMR from facility B showed P20 and baby were discharged home on 1/9/2026. C. During an interview with Physician-A on 1/14/2026 at 12:36 PM revealed they thought that Facility A couldn’t do VBACs (vaginal birth after cesarean-section) because anesthesia was not in house. Physician-A confirmed that they did not call Physician-B who was the scheduled back up with cesarean-section (a surgical procedure where a doctor delivers a baby through cuts made in the mother’s abdomen and uterus, instead of through the birth canal) capability on 1/7/2026. Physician-A revealed they didn’t identify active labor as an EMC with Patient 20, made a mistake did not listen to gut and now understands not to discharge a patient in active labor. Physician-A confirmed did not call Facility B for prior acceptance and discharged patient 20 in a personal vehicle versus ambulance transport.”

“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 review, medical record review, medical staff interview, the facility failed to provide the appropriate transfer and obtain prior acceptance from Facility B for a patient with an emergency medical condition (EMC) of active labor for 1 (Patient 20) of 20 emergency department (ED) sampled patients. This failed practice has the potential to place the life of the pregnant mother and unborn baby at risk. According to facility provided data the ED saw an average of 428 patients and transferred 32 patients per month for the past 6 months. See citations A2400 and A2407 that also resulted in A2409 to be not met. Findings include: A. Review of facility policy titled, “Obstetrics Department EMTALA guidelines,” (no date) revealed a woman who experiences contractions is presumed to be in true labor unless a physician certifies that the woman is in false labor. A physician certification of false labor is required prior to discharge. A qualified medical personnel (QMP) is defined as an individual (Physician, Advanced Practice Provider (APP) or Registered Nurse (RN) with triage authority) qualified to perform a medical screening exam (MSE) on obstetrical patients. An EMC is defined as acute symptoms that place the health of the pregnant individual or unborn child in serious jeopardy. “With respect to a pregnant individual having contractions there is inadequate time to safely transfer before delivery.” An appropriate transfer is defined as to stabilize the patient to minimize the risks during transfer. The receiving facility (Facility B) will accept the transfer and confirm availability of space and personnel (capability and capacity). The physician certificate and patient consent for transfer form to be completed prior to the patient leaving the hospital. B. Review of Patient 20’s electronic medical record revealed P20 presented to Facility A, the CAH OB triage area on 1/7/2026 at 8:58 PM with a complaint of, “active labor at term, patient feels she can’t make it to Facility B,” gravida 4 (fourth pregnancy) with an estimated due date of 1/9/2026 and history of precipitous (labor and delivery are quick). Review of Physician-A cervical exam showed Patient 20 had a cervical dilation at 5 centimeters (the cervix is opening to the uterus), effacement 30 percent (thinning of the cervix, 100% equals the birth canal is fully open for a vaginal delivery), and negative 3 fetal station (the position the baby is in the mothers pelvis) with patient 20 reporting strong contractions (tightening and relaxing of the uterine muscle that the body natural pushes the baby down for delivery) every 2 to 3 minutes. Review of the EMR showed no documentation that P20 was offered to be admitted and provided stabilizing treatment for the emergency medical condition of active labor within the hospital’s capabilities. P20 was discharged at 10:30pm and traveled via private vehicle approximately 56 miles to facility B for treatment and stabilization of active labor. Review of the EMR showed no documentation of prior acceptance from facility B (a physician and the facility need to have capacity-bed availability for the patient and the capability-staff and resources to care for the patient that is determined by the facility in the moment.) and did not complete the physician certificate and patient consent for transfer form prior to the patient leaving the hospital. Review of P20’s EMR from Facility B showed the following: -11:20pm crowning (baby’s head is visible through the mothers vaginal canal). -11:24pm: 9 pound (lb.) 15.4 ounces (oz) infant delivered in private vehicle by Facility B physician. -11:32pm: medications administered to P20 related to post delivery bleeding. Review of the EMR from facility B showed P20 and baby were discharged home on 1/9/2026. C. During an interview with Physician-A on 1/14/2026 at 12:36 PM revealed they thought that Facility A couldn’t do VBACs (vaginal birth after cesarean-section) because anesthesia was not in house. Physician-A confirmed that they did not call Physician-B who was the scheduled back up with cesarean-section (a surgical procedure where a doctor delivers a baby through cuts made in the mother’s abdomen and uterus, instead of through the birth canal) capability on 1/7/2026. Physician-A revealed they didn’t identify active labor as an EMC with Patient 20, made a mistake did not listen to gut and now understands not to discharge a patient in active labor. Physician-A confirmed did not call Facility B for prior acceptance and discharged patient 20 in a personal vehicle versus ambulance transport.”