Monadnock Community 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: 26364 Based on interview and record review the hospital’s dedicated emergency department (ED) failed to comply with the requirements for the Emergency Medical Treatment and Labor Act (EMTALA) at 42 CFR §489.20. (Patient identifiers are #1, #2, and #8.) Findings include: The hospital failed to provide a medical screening examination to 1 of 20 patients reviewed who arrived to the hospital campus ED. (Patient identifier is #2). Refer to TAG 2406. The hospital failed to complete appropriate transfers for 2 of 20 patients reviewed who were transferred from the ED to other hospitals. (Patient identifiers are #1 and #8.) Refer to TAG 2409. 43002”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 26364 Based on record review and interview, the hospital failed to provide an appropriate medical screening examination (MSE) to 1 of 3 individuals who presented to the emergency department (ED). (Patient identifiers is #2.) Findings include: Patient #2 Review on 4/9/24 at approximately 11:30 a.m. of Patient #2’s medical record revealed they arrived at the dedicated ED via police vehicle on 3/18/24 at approximately 4:42 p.m. with a petition to have a compulsary medical examination done evaluation at a different hospital. The patient left with the police without receiving a MSE to go to a different hopsital for evaluation. Review on 4/9/24 of the hospital policy titled “Patient Transfer Policy” dated “5/2023” revealed the following” “A. Transfers 1. All patients presenting to [Pronoun omitted] for treatment shall have an appropriate medical screening examination by qualified personnel.”...4. The transferring physician shall explain and document the need, benefits, risks, and alternatives regarding transfer to the patient or person acting on the patient’s behalf... “. No patient will be transferred to another acute care facility until the attending physician has made arrangements with the facility. Contact with and acceptance by a physician at the receiving facility will be confirmed prior to transfer...8. Patients who come or are brought to the hospital for psychiatric evaluation must be screened for an EMC. If no emergency medical condition is determined to exist, but Involuntary Emergency Admission (IEA) to a designated receiving facility is deemed necessary due to a psychiatric condition, then a physician’s certification of transfer must be completed...10. Review all sections of [Pronoun omitted] transfer form[“Cobra form”] to ensure that all proper areas are completed and all required signature(s) are present. “ Interview with Staff H (Quality Director) and Staff I (Chief Nursing Officer) on 4/9/24 at approximately 2:30 p.m. confirmed the above findings.”

“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: 43002 Based on interview and record review, it was determined that the hospital failed to appropriately transfer patients after determining if a patient had an emergency medical condition and the recieving hospital agreed to accept the patient for 2 of 20 patients reviewed presenting to the emergency department (ED). (Patient #1 and #8.) Findings include: Patient #1 Review on 4/9/24 of the facility’s ED Patient Log for Patient #1 revealed that the arrival time to the ED was on 2/29/24 at 3:29 p.m. and discharged at 4:45 p.m. Further review revealed the log was coded “Transferred”. Review on 4/9/24 of Patient #1’s medical record revealed that Patient #1 arrived to the emergency room on 2/29/24 with visual disturbance, right facial numbness/drooping, and the inability to focus. Further review revealed that Patient #1 was transported via 911 to another local hospital on 2/29/24 at 4:45 p.m. There was no documentation of communication with the receiving hospital, including the date and time of the transfer request and the name of the person accepting the transfer or summary of the risks and benefits of transfer. There was no documentation that the hospital sent medical records related to the emergency condition to the receiving hospital. Review on 4/9/24 of Patient #1’s Medical Screening Exam, completed by Staff A (Physician’s Assistant) and co-signed by Staff B (Medical Doctor), dated 2/29/24 revealed under Emergency Department Course/Medical Decision Making, “... Following transport, I contacted the [Receiving Hospital] emergency department and advised the charge nurse of the patient’s impending arrival.. Interview on 4/9/24 at approximately at approximately 1:00 p.m. with Staff J (ED Clinical Director) confirmed the above findings. Interview on 4/9/24 at 2:18 p.m. with Staff G (Quality Staff) confirmed that the transfer paperwork was not completed and that Staff A contacted the receiving hospital after the patient had left the facility. Patient #8 Review on 4/9/24 of the facility’s ED Patient Log for Patient #8 revealed that the arrival time to the ED was 4/3/24 at 2:57 a.m. Further review revealed the log was coded “Transfer”. Review on 4/9/24 of Patient #8’s ED notes revealed that the patient arrived on 4/3/24 to the ED via private car for suicidal complaints. Review on 4/9/24 of the Transfer Certification Notice of Hospital Responsibilities revealed the physician failed to sign the certification or summarize the risks and benefit of the transfer. Interview on 4/9/24 at approximately at approximately 1:00 p.m. with Staff J (ED Clinical Director) confirmed the above. Review on 4/9/24 of the hospital policy titled “Patient Transfer Policy” last revised 5/23 revealed the following, “... External Acute Transfers... 1. All patients presenting to... Community Hospital for treatment shall have an appropriate medical screening examination by qualified personnel.”... 3.... The physician will certify that this decision is based on information available at the time of transfer... If the physician is not readily available, the certificate may be completed by a qualified medical person in consultation with the physician. The physician, however, makes the transfer determination and countersigns the certificate within 24 hours... 4. The transferring physician shall explain and document the need, benefits, risks, and alternatives regarding transfer to the patient or person acting on the patient’s behalf... 5. No patient will be transferred to another acute care facility until the attending physician has made arrangements with the facility. Contact with and acceptance by a physician at the receiving facility will be confirmed prior to transfer... 8. Patients who come or are brought to the hospital for psychiatric evaluation must be screened for an EMC. If no emergency medical condition is determined to exist, but Involuntary Emergency Admission (IEA) to a designated receiving facility is deemed necessary due to a psychiatric condition, then a physician’s certification of transfer must be completed...10. Review all sections of... Hospital transfer form[“Cobra form”] to ensure that all proper areas are completed and all required signature(s) are present... “”