Promedica Defiance Regional 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: 21893 Based on record review, document review, and staff interview; the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer (A2409) and failed to show evidence they did not refuse to accept an appropriate transfer of an individual from another hospital who requires specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual (A2411). The cumulative effect of this systemic practice resulted in the hospital’s inability to ensure that all patients arriving at the emergency department would receive an appropriate transfer and all transfers of individuals that the facility has the capacity to treat would be accepted. The facility sees an average of 1043 patients per month and an average of 61 patients per month are transferred to other facilities.”

“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: 21893 Based on medical record review and staff interview, the facility failed to ensure individuals transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer. This affected three (Patients #9, #11, and #12)of four patients out of 20 emergency department medical records reviewed. The facility sees an average of 1043 patients per month and an average of 61 patients per month are transferred to other facilities. Findings include: Review of the medical record for Patient #9 revealed an arrival date of 06/15/24 at 1:55 PM to the emergency department. The medical record contained documentation the patient had a major burn and inhalation injury and was sent by life flight to a Burn Center. The “Patient Transfer Certification Form,” signed by the physician, lacked documentation of patient specific risks and benefits of the transfer. Review of the medical record for Patient #11 revealed an arrival date of 05/13/24 at 12:39 PM to the emergency department. The medical record contained documentation the patient had a subdural hematoma and was transferred to an acute care hospital for a trauma and neurosurgical evaluation. The “Patient Transfer Certification Form,” signed by the physician, lacked documentation of patient specific risks and benefits of the transfer. Review of the medical record for Patient #12 revealed an arrival date of 03/26/24 at 1:06 AM to the emergency department. The medical record contained documentation the patient had hydronephrosis with renal and ureteral calculous obstruction. The medical record contained documentation the patient was transferred to an acute care hospital for lithotripsy. The “Patient Transfer Certification Form,” signed by the physician, lacked documentation of patient specific risks and benefits of the transfer. The “Patient Transfer Certification Form” had the following pre-printed statement in the Risks of Transfer box for all patients: “All transfers have inherent risks of delays in treatment or accidents, pain or discomfort upon movement, failure of equipment, and limited medical capacity of transport units that may limit available care in the event of a crisis.” During interview on 08/29/24 at 4:00 PM, Staff H and Staff I verified the above findings.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 21893 Based on document review and staff interview, the facility failed to show evidence they did not refuse to accept an appropriate transfer of an individual from another hospital who requires specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. The facility sees an average of 1043 patients per month and an average of 61 patients per month are transferred to other facilities. Findings include: Review of the medical record from the outside hospital for Patient #1 revealed an emergency department (ED) visit on 05/17/24 at 9:14 PM. The medical record stated Patient #1 was 29 weeks pregnant and had not felt the baby move on the day of the ED arrival. The ED physician note documented the patient’s obstetric (OB) physician was in a neighboring town (Bryan). Patient #1 walked to the ED. Patient #1 denied chest pain or shortness of breath but stated she had been having intermittent palpitations. Patient #1 denied nausea or vomiting and had some discomfort around her belly button. She denied contractions, vaginal bleeding, leakage of fluid, or urinary symptoms. A bedside ultrasound was completed with fetal movement and fetal cardiac activity. Fetal heart tones per nursing staff were 150s to 160. The physician noted the work up was reassuring, however, given Patient #1 was in her third trimester with decreased fetal movement the physician felt the patient should have a nonstress test completed. Since they could not complete the nonstress test at their hospital, the physician felt Patient #1 had to be transferred to a facility that could complete this for her. The note documented Patient #1 preferred to go to Promedica as it was closer, even though her OB physician was out of Bryan. The patient would have difficulty with transportation as she had walked to our hospital. The case was discussed with the house supervisor at Promedica. We then received a call back that the OB service there did decline to take her to labor and delivery (L&D) for nonstress testing. Subsequently, the case was discussed with Patient #1’s OB who felt reassured we were able to obtain fetal cardiac activity. Patient #1’s OB felt the nonstress test may be of limited utility as she would likely not be induced at 29 weeks if there was a poor tracing. The risks and benefits of nonstress testing were discussed with Patient #1. Patient #1 stated she intended to go to Bryan for the nonstress test, but she was to go by private vehicle. At 11:45 PM on 05/17/24 Patient #1 was discharged to another facility. Review of the ED log and the OB log lacked documentation Patient #1 presented to this facility on 05/17/24 or 05/18/24. On 08/27/24 at 2:15 PM Staff C was interviewed. Staff C stated if a patient presents to the Labor, Delivery, Recovery, and Postpartum (LDRP) Unit directly they would be on the obstetrical log. They did not accept or deny a referrals for a pregnant patient in the LDRP. The EDs would just call and let them know they were sending a patient over, generally by ambulance. These patients bypass the ED and come straight to the LDRP unit. They did approximately 30 deliveries a month and generally had two to four patients in the LDRP unit at a time. They have not been at capacity for maybe eight years. The next closest hospital with an OB unit was in Bryan about 15-20 minutes away. Review of the staffing sheets for LDRP dated 05/17/24 and 05/18/24 revealed five patients each day, two of which had delivered on 05/16/24 and two who had delivered on 05/17/24. There were three registered nurses on each shift on these dates. On 08/27/24 at 5:35 PM Staff D was interviewed. Staff D stated the house supervisor oversaw staffing and made the bed assignments, in addition to other duties. Staff D stated transfers to this facility were rare and most patients were transferred out to other facilities. Transfer requests from other facilities came to the House Supervisor who took the information and passed it on to the physician on-call. The physician then called the referring facility, discussed the patient with the physician there, and determined if the referral was accepted or declined. The physician would then let the House Supervisor know if a bed needed assigned. The House Supervisor would also assess staffing and determine if anyone needed to be called in for staffing reasons. Transfers that are not accepted are not documented anywhere. Most transfers into the hospital were for OB. Requests to transfer an OB patient would go to the OB physician on-call. Staff D did not remember any OB transfers that were declined. On 08/28/24 at 9:40 AM Staff E was interviewed. Staff E stated other facility’s EDs do not usually have external fetal monitoring and some ED doctors are not comfortable checking the cervix. For these reasons the EDs would send patients to this facility for evaluation, usually by ambulance unless it is a basic issue. They have not turned anyone away here. Staff E could not recall saying they would not take a patient or turning down a transfer. ED doctors usually wanted the patient evaluated here to see if they were in labor or to help with fetal monitoring. On 08/29/24 at 8:00 AM Staff G, the House Supervisor working at the time of the alleged refusal of transfer, was interviewed by phone. Staff G stated EDs call to request transfers and he would take their information and a call back number. Staff G then would contact the provider on-call and the provider would return the call and coordinate the transfer. Providers accepted or turned down patient transfer referrals. Usually a refusal was because they were not able to manage the patient here as they were a critical access hospital. The only time a House Supervisor would turn down a referral is if their beds were full. Staff G stated he has never turned down an OB patient. The operator could page the physician on-call directly as well. The physician would then let the House Supervisor know to assign a bed for the transfer. There were not a ton of calls for OB tests. If an OB patient was 20 weeks or greater she would go to LDRP. Staff G did not recall getting a call for OB testing on a night shift. Staff G stated he has not called a facility to turn down a referral as this would be done by the physician. On 08/29/24 at 3:45 PM, Staff H stated there was not a policy on who could accept a referral and that it was the physician’s decision. Staff H verified there was no process in place to log requests for transfer to this facility.”