Avita Ontario

“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: 45751 Based on Emergency Medical Service (EMS) run report, interviews, and policy review, the facility failed to ensure patients were not refused transport to the facility. This affected one patient (#21) of 20 patients reviewed for EMTALA. Findings include: Review of EMS run report dated 12/31/25 revealed Patient #21 was involved in a low impact motor vehicle accident (MVA) in which they were a restrained passenger of the car. Patient #21 was assessed at the scene and found to be alert and oriented to event, person, place, and time, no neurological deficits, noncompliant of head injury and no trauma to the head was observed, face normal, neck normal, abdomen small abrasion on left lower right side in the area of the seatbelt, ambulatory, denied chest pain or difficulty breathing, and was able to move all extremities with ease and denied numbness or tingling. Glasgow Coma Scale (GCS) was normal with no deficits. Vital signs were were unremarkable. Narrative from EMS report revealed they were dispatched to a two-vehicle motor vehicle collision (MVC) with unknown injuries. Upon arrival, the crew identified four occupants involved. Patient #21 was found standing outside the vehicle. Patient #21 was initially undecided about EMS evaluation but subsequently consented to assessment. Patient #21 ambulated independently and without difficulty to the ambulance. Patient #21 reported minor right lower sided pain in the area of the seatbelt, which they stated occurred immediately following the MVC. Patient #21 advised the pain had subsided during the course of the assessment and monitoring. Patient #21 was restrained in the front seat passenger in the vehicle that was struck on the driver’s side by the front bumper of another vehicle during a low-speed impact. Patient #21’s vehicle sustained scraping damage from the driver’s side front to rear. Driver side airbag did deploy. The vehicle exited the roadway and came to rest upright in a grassy area on all four wheels. Patient #21 was pregnant and denied any pregnancy related complications, including gestational diabetes. Patient #21 denied any loss of consciousness, head strike, neck pain, abdominal pain, or other injuries. Transport narrative revealed Patient #21 requested non-emergent transport to Avita Ontario stating that primary care and obstetric providers are affiliated with the facility. While arriving at Avita Ontario, radio report was provided to the Emergency Department (ED). The receiving nurse relayed instructions to the ED attending physician. ED physician stated the patient was considered a trauma patient and would not be accepted at Avita Ontario and that transport should instead be diverted to another hospital. Interview on 02/18/26 at 2:09 P.M. with Vice President/Chief Nursing Officer (VP/CNO) A and via phone EMS coordinator B revealed that EMS coordinator received a call from the EMS that transported Patient #21 that they were attempting to bring the patient to the ED and when report was called to the ED, they were informed the patient was a trauma patient and needed to be diverted to another hospital. EMS asked to talk to the ED physician personally to relay the information and was told the physician refused to talk to him. EMS stated to EMS coordinator that the patient wanted to come to Avita due to OB doctor being there. EMS stated that they wanted to explain to the ED physician that it was a minor crash and the patient only had an abrasion to the abdomen from the seatbelt. VP/CNO stated they contacted the EMS on behalf of Avita and apologized for the experience they had and did not want to tarnish the relationship between the hospital and EMS. VP/CNO stated that they were informed the patient was never brought onto Avita property and they were denied and rerouted on the scene. Interview on 02/19/26 at 2:37 P.M. with ED Physician D revealed they have trauma criteria they follow that determines which patients they will defer to a trauma center if stable enroute to the hospital. Physician D revealed he recalled the incident with Patient #21 and the patient was in the third trimester of pregnancy, a MVA with a seatbelt mark and airbag deployment and they belonged in a trauma center in case there were internal injuries. Physician D stated they did not have a trauma surgeon at the hospital. Physician D stated the patient had not been at the hospital and was never on the hospital grounds. Interview on 02/19/26 at 4:11 P.M. via phone with EMS AA revealed that the ambulance was at the entrance into the driveway of Avita when he was informed the patient was to be transported to another hospital. EMS AA stated the patient only had a reddened area on her lower abdomen consistent with the seatbelt. EMS AA stated the patient was pregnant and originally did not want to go to the hospital from the scene. EMS AA stated he was unsure how far along the pregnancy was. EMS AA stated they talked her into going to the hospital to be checked out and they wanted to go to Avita due to her doctor and OB were affiliated with the hospital. EMS AA stated that when they called report to the ED the nurse was asking all kinds of questions and when the ED physician came into the room the nurse informed the physician that they had a pregnant female in a MVA with redness to the abdomen and the physician stated to take the patient to another hospital as it was a trauma patient. EMS AA stated he asked to talk to the ED physician directly to explain the patient was not critical and it was a low speed MVA where the patient was a restrained passenger and the airbag only deployed on the drivers side. EMS AA stated that the nurse was told the ED physician refused to speak with EMS AA. Review of policy titled, “A-ED-EMTALA,” reviewed 03/21/2025 revealed EMTALA applies to hospitals with emergency departments participating in the Medicare program and includes all individuals regardless of their Medicare/Medicaid eligibility, or their ability to otherwise pay for services rendered. Any individual presenting to the ED shall be provided with a medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC), stabilizing treatment or appropriate transfer if an EMC is found. In the event an individual leaves prior to receiving a MSE, ED personnel should, to the extent possible, document such occurrence. When EMTALA applies: when an individual comes to the ED requesting an examination or treatment or when a request is made on an individual’s behalf, when an individual presents elsewhere on hospital property and requests an exam or treatment or it is requested on his/her behalf, or a prudent layperson believes an exam or treatment is necessary, based on an individual’s appearance or behavior, when an individual arrives by ambulance at the time the ambulance enters hospital property, and when an individual requests pharmacy services (may involve medical conditions), Where EMTALA applies: the ED hospital campus- within 250 yards of hospital property including parking lots, sidewalks, and driveways, and excludes other structures or areas of the hospital’s main buildings that are not part of the hospital, such as physician offices, and health centers that participate separately under Medicare.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 45751 Review of emergency room log for December 2025, emergency medical service (EMS) run report, interviews, and policy review, the facility failed to log all patients who presented to emergency department. This affected one patient (#21) of 20 patients reviewed to emergency room log. Findings include: Review of EMS run report dated 12/31/25 revealed Patient #21 was involved in a low impact motor vehicle accident (MVA) in which they were a restrained passenger of the car. Patient #21 was assessed at the scene and found to be alert and oriented to event, person, place, and time, no neurological deficits, noncompliant of head injury and no trauma to the head was observed, face normal, neck normal, abdomen small abrasion on left lower right side in the area of the seatbelt, ambulatory, denied chest pain or difficulty breathing, and was able to move all extremities with ease and denied numbness or tingling. Glasgow Coma Scale (GCS) was normal with no deficits. Vital signs were were unremarkable. Narrative from EMS report revealed they were dispatched to a two-vehicle motor vehicle collision (MVC) with unknown injuries. Upon arrival, the crew identified four occupants involved. Patient #21 was found standing outside the vehicle. Patient #21 was initially undecided about EMS evaluation but subsequently consented to assessment. Patient #21 ambulated independently and without difficulty to the ambulance. Patient #21 reported minor right lower sided pain in the area of the seatbelt, which they stated occurred immediately following the MVC. Patient #21 advised the pain had subsided during the course of the assessment and monitoring. Patient #21 was restrained in the front seat passenger in the vehicle that was struck on the driver’s side by the front bumper of another vehicle during a low-speed impact. Patient #21s vehicle sustained scraping damage from the driver’s side front to rear. Driver side airbag did deploy. The vehicle exited the roadway and came to rest upright in a grassy area on all four wheels. Patient #21 was pregnant and denied any pregnancy related complications, including gestational diabetes. Patient #21 denied any loss of consciousness, head strike, neck pain, abdominal pain, or other injuries. Transport narrative revealed Patient #21 requested non-emergent transport to Avita Ontario stating that primary care and obstetric providers are affiliated with the facility. While arriving at Avita Ontario, radio report was provided to the Emergency Department (ED). The receiving nurse relayed instructions to the ED attending physician. ED physician stated the patient was considered a trauma patient and would not be accepted at Avita Ontario and that transport should instead be diverted to another hospital. Review of ED log for December 2025 revealed Patient #21 was not on the log. Interview on 02/19/26 at 4:11 A.M. via phone with EMS AA revealed that the ambulance was at the entrance into the driveway of Avita when he was informed the patient was to be transported to another hospital. EMS AA stated the patient only had a reddened area on her lower abdomen consistent with the seatbelt. EMS AA stated the patient was pregnant and originally did not want to go to the hospital from the scene. EMS AA stated they talked her into going to the hospital to be checked out and they wanted to go to Avita due to her doctor and OB were affiliated with the hospital. EMS AA stated that when they called report to the ED the nurse was asking all kinds of questions and when the ED physician came into the room the nurse informed the physician that they had a pregnant female in a MVA with redness to the abdomen and the physician stated to take the patient to another hospital as it was a trauma patient. EMS AA stated he asked to talk to the ED physician directly to explain the patient was not critical and it was a low speed MVA where the patient was a restrained passenger and the airbag only deployed on the drivers side. EMS AA stated that the nurse was told the ED physician refused to speak with EMS AA. Review of policy titled, “A-ED-EMTALA,” reviewed 03/21/2025 revealed EMTALA applies to hospitals with emergency departments participating in the Medicare program and includes all individuals regardless of their Medicare/Medicaid eligibility, or their ability to otherwise pay for services rendered. Any individual presenting to the ED shall be provided with a medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC), stabilizing treatment or appropriate transfer if an EMC is found. In the event an individual leaves prior to receiving a MSE, ED personnel should, to the extent possible, document such occurrence. Central log of ED patients must be maintained with name (identity of patient), and disposition of patient (transferred, discharged, refused treatment, etc.).”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 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: 45751 Based on emergency medical service (EMS) run report, interview, and policy review the facility failed to provide a medical screening for one patient (#21) of 20 patients reviewed for medical screenings. Findings include: Review of EMS run report dated 12/31/25 revealed Patient #21 was involved in a low impact motor vehicle accident (MVA) in which they were a restrained passenger of the car. Patient #21 was assessed at the scene and found to be alert and oriented to event, person, place, and time, no neurological deficits, noncompliant of head injury and no trauma to the head was observed, face normal, neck normal, abdomen small abrasion on left lower right side in the area of the seatbelt, ambulatory, denied chest pain or difficulty breathing, and was able to move all extremities with ease and denied numbness or tingling. Glasgow Coma Scale (GCS) was normal with no deficits. Vital signs were were unremarkable. Narrative from EMS report revealed they were dispatched to a two-vehicle motor vehicle collision (MVC) with unknown injuries. Upon arrival, the crew identified four occupants involved. Patient #21 was found standing outside the vehicle. Patient #21 was initially undecided about EMS evaluation but subsequently consented to assessment. Patient #21 ambulated independently and without difficulty to the ambulance. Patient #21 reported minor right lower sided pain in the area of the seatbelt, which they stated occurred immediately following the MVC. Patient #21 advised the pain had subsided during the course of the assessment and monitoring. Patient #21 was restrained in the front seat passenger in the vehicle that was struck on the driver’s side by the front bumper of another vehicle during a low-speed impact. Patient #21s vehicle sustained scraping damage from the driver’s side front to rear. Driver side airbag did deploy. The vehicle exited the roadway and came to rest upright in a grassy area on all four wheels. Patient #21 was pregnant and denied any pregnancy related complications, including gestational diabetes. Patient #21 denied any loss of consciousness, head strike, neck pain, abdominal pain, or other injuries. Transport narrative revealed Patient #21 requested non-emergent transport to Avita Ontario stating that primary care and obstetric providers are affiliated with the facility. While arriving at Avita Ontario, radio report was provided to the Emergency Department (ED). The receiving nurse relayed instructions to the ED attending physician. ED physician stated the patient was considered a trauma patient and would not be accepted at Avita Ontario and that transport should instead be diverted to another hospital. Interview on 02/18/26 at 2:09 P.M. with Vice President/Chief Nursing Officer (VP/CNO) A and via phone EMS coordinator B revealed that EMS coordinator received a call from the EMS that transported the above patient that they were attempting to bring the patient to the ED and when report was called to the ED they were informed the patient was a trauma patient and needed to be diverted to another hospital. EMS asked to talk to the ED physician personally to relay the information and was told the physician refused to talk to him. EMS stated to EMS coordinator that the patient wanted to come to Avita due to OB doctor being there. EMS stated that they wanted to explain to the ED physician that it was a minor crash and the patient only had an abrasion to the abdomen from the seatbelt. VP/CNO stated they contacted the EMS on behalf of Avita and apologized for the experience they had and did not want to tarnish the relationship between the hospital and EMS. VP/CNO stated that they were informed the patient was never brought onto Avita property and they were denied and rerouted on the scene. Interview on 02/19/26 at 2:37 P.M. with ED Physician D revealed they have trauma criteria that they follow that determines which patients they will defer to a trauma center if stable enroute to the hospital. Physician D revealed he recalled the incident with Patient #21 and the patient was in the third trimester of pregnancy, a MVA with a seatbelt mark and airbag deployment and they belonged in a trauma center in case there were internal injuries. Physician D stated they did not have a trauma surgeon at the hospital. Physician D stated the patient had not been at the hospital and was never on the hospital grounds. Interview on 02/19/26 at 4:11 A.M. via phone with EMS AA revealed that the ambulance was at the entrance into the driveway of Avita when he was informed the patient was to be transported to another hospital. EMS AA stated the patient only had a reddened area on her lower abdomen consistent with the seatbelt. EMS AA stated the patient was pregnant and originally did not want to go to the hospital from the scene. EMS AA stated they talked her into going to the hospital to be checked out and they wanted to go to Avita due to her doctor and OB were affiliated with the hospital. EMS AA stated that when they called report to the ED the nurse was asking all kinds of questions and when the ED physician came into the room the nurse informed the physician that they had a pregnant female in a MVA with redness to the abdomen and the physician stated to take the patient to another hospital as it was a trauma patient. EMS AA stated he asked to talk to the ED physician directly to explain the patient was not critical and it was a low speed MVA where the patient was a restrained passenger and the airbag only deployed on the drivers side. EMS AA stated that the nurse was told the ED physician refused to speak with EMS AA. Review of policy titled, “A-ED-EMTALA,” reviewed 03/21/2025 revealed EMTALA applies to hospitals with emergency departments participating in the Medicare program and includes all individuals regardless of their Medicare/Medicaid eligibility, or their ability to otherwise pay for services rendered. Any individual presenting to the ED shall be provided with a medical screening examination (MSE) to determine the presence of an emergency medical condition (EMC), stabilizing treatment or appropriate transfer if an EMC is found. In the event an individual leaves prior to receiving a MSE, ED personnel should, to the extent possible, document such occurrence. When EMTALA applies: when an individual comes to the ED requesting an examination or treatment or when a request is made on an individual’s behalf, when an individual presents elsewhere on hospital property and requests an exam or treatment or it is requested on his/her behalf, or a prudent layperson believes an exam or treatment is necessary, based on an individual’s appearance or behavior, when an individual arrives by ambulance at the time the ambulance enters hospital property, and when an individual requests pharmacy services (may involve medical conditions), Where EMTALA applies: the ED hospital campus- within 250 yards of hospital property including parking lots, sidewalks, and driveways, and excludes other structures or areas of the hospital’s main buildings that are not part of the hospital, such as physician offices, and health centers that participate separately under Medicare.”