Wilkes-Barre General Hospital

“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: 36696 Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the receiving hospital and receiving physician consented to the transfer of an individual for one of 20 medical records reviewed (MR1). Findings include: Review on August 4, 2025, of facility policy, “EMTALA” reviewed February 2025, revealed “Purpose: The purpose of this policy is to ensure that the emergency medical treatment and patient transfer policy is based on federal law relating to the emergency medical treatment and medically appropriate transfer of individuals between hospitals. ...Definitions: Appropriate Transfer occurs when ...2) the receiving facility has the appropriate space and the qualified personnel for the treatment of the individual and has agreed to accept Transfer of the individual and to provide appropriate medical treatment; ...Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy. ...2. With respect to a pregnant woman who is having contractions; a. There is inadequate time to effect a safe Transfer to another Hospital before delivery; or b. The Transfer may pose a threat to the health or safety of the woman or the unborn child. ...Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. ...D. Transfer Procedures After determining that an individual with an unstabilized emergency medical condition will be transferred from the emergency department (or in the case of the patient in labor this may be the OB Department), the individual will be transferred in accordance with the following procedures: 1. Acceptance by Receiving Hospital and Receiving Physician. Prior to transfer, the receiving hospital and receiving physician must consent to the transfer of the individual and agree to provide appropriate medical treatment and hospital care. ...” Review on August 4, 2025, of MR1, revealed the patient presented to the Emergency Department (ED) on July 21, 2025, at 2131, via private vehicle. The patient reported being 34 weeks pregnant and was experiencing contractions six to eight minutes apart which started approximately 10 hours prior to coming to the ED. The patient was gravida four, para three; all pregnancies were delivered via cesarean section and were complicated by pre-eclampsia. Continued review of MR1 revealed physician documentation that at approximately 2138, [Name of local ambulance company] was notified via telephone of the emergent/911 transfer. The Transfer center was called at 2140 to notify of the emergent transfer in place. The call was placed on hold. While awaiting connection with the Obstetric attending via phone, [Name of local ambulance company] arrived to the ED at 2146 to transport the patient to [Name of local hospital] which is the nearest obstetric facility. The patient left the ED at 2148. At 2151, the Transfer center returned to the line with OTH1. When sharing the story with OTH1 regarding the urgency for sending the patient, OTH1 stated that their neonatal intensive care unit (NICU) was full and they could not accept the patient. OTH1 recommended [Name of another facility in this health system] be contacted. At 2157, CF2 spoke with OTH2, who stated the patient should be transferred to [Name of local hospital] for urgent evaluation as this was the closest facility with full capabilities for evaluating the patient. The Transfer center proceeded to contact OTH1, where OTH1 and OTH2 discussed the proper disposition for the patient. OTH2 continued to support the need for the patient to present to [Name of local hospital] for evaluation. After continued discussion, the conversation ended with OTH1 being made aware that an emergent transfer was already underway, and CF2 wanted to give notification of the patient’s pending arrival. Continued review on August 4, 2025, of MR1 revealed the facility, “Patient Transfer Form - EMTALA” revealed no documentation of an accepting physician. Interview on August 4, 2025, with EMP1 and EMP3 confirmed the above findings. Review on August 4, 2025, of the facility provided audio recording from the Transfer center dated July 21, 2025, revealed the conversation between CF2 and OTH1. OTH1 stated the facility could not accept the patient, as the NICU was level red. CF2 informed OTH1 the patient was already enroute to the facility. OTH1 repeated they could not accept the patient. The Transfer center then connected CF2 to OTH2, which was another network provider affiliated with the local network provider that refused the transfer. OTH2 stated the patient should go to the nearest labor and delivery unit given the status of the patient. OTH1 was then brought back on the call, and once again stated the NICU is level red. The call ended with OTH1 being notified the patient was underway and coming to the nearby facility. Interview on August 4, 2025, with EMP1 confirmed the above findings.”

“ON CALL PHYSICIANS CFR(s): 489.20(r)(2) and 489.24(j)(1-2) §489.20(r)(2) [The hospital (including both the transferring and receiving hospitals), must maintain] a list of physicians who are on call for duty after the initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. §489.24(j)(1) Each hospital must maintain an on-call list of physicians on its medical staff in a manner that best meets the needs of the hospital’s patients who are receiving services required under this section in accordance with the resources available to the hospital, including the availability of on-call physicians. §489.24(j)(2)(i) The hospital must have written policies and procedures in place to respond to situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician’s control. §489.24(j)(2)(ii) The hospital must have written policies and procedures in place to provide that emergency services are available to meet the needs of patients with emergency medical conditions if it elects to permit on-call physicians to schedule elective surgery during the time that they are on call or to permit on-call physicians to have simultaneous on-call duties. This Standard is not met as evidenced by: 36696 Based on review of facility documents, staff interview (EMP), and review of medical records (MR), it was determined the facility failed to ensure the physician identified as “on-call” for gynecology was available to provide treatment necessary to stabilize a patient with an Emergency Medical Condition for one of one medical record reviewed (MR1). Findings include: Review on March 18, 2024, of the facility policy, “EMTALA” reviewed January 2020, revealed “Purpose: The purpose of this policy is to ensure that the emergency medical treatment and patient transfer policy is based on federal law relating to the emergency medical treatment and medically appropriate transfer of individuals between hospitals. ...Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; b. Serious impairment to bodily functions; or c. Serious dysfunction of any bodily organ or part; or ...On-Call List refers to the list that the Hospital maintains that identifies those physicians who are “on-call” for duty after the initial Medical Screening Examination to provide further evaluation and/or treatment necessary to stabilize an individual with an Emergency Medical Condition. The purpose of the On-Call List is to ensure that the Dedicated Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide treatment necessary to stabilize individuals with Emergency Medical Conditions. ...III. On-Call 1. The Hospital maintains a list of physicians who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition or a woman in labor. 2. The list is available in the Emergency Department. The list is retained for a period of five years. 3. All physicians or specialties are not required to be present on the Hospital’s on-call list at all times. 4. On-call physicians, after being contacted by the Emergency Department, must respond within a reasonable timeframe. 5. If the attending Emergency Department physician determines that the patient’s medical condition requires the services of a specialist and the on-call specialist is not available or there is no physician on call for the particular specialty, the Emergency Department physician will arrange for appropriate transfer of the patient in accordance with this Policy and the requirements of EMTALA. ...” Review on March 20, 2024, of the facility, “Wilkes Barre General Hospital Medical Staff Rules And Regulations,” dated March 2023, revealed “...6.2 Consultations, Referrals & Emergency Department Call 6.2(a) When the Emergency Department Physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Physician is needed, the patient shall be permitted to request the services of a specific private physician. This request will be documented in the patient’s medical record. The Emergency Department Physician will utilize the rotation call list as set forth in this Section 6.2 if the patient does not have a private Physician who is available and qualified to provide the necessary services. ...6.2(d) The rotation call list, containing the names and phone numbers of the on-call physicians shall be posted in the Emergency Department. In the event the patient does not have a private physician, the private physician refuses the patient’s request to come to the Emergency Department, or the physician cannot be contacted within twenty (20) minutes of the initial request, the rotation call list shall be used to select a private physician to provide the necessary consultation or treatment for the patient. A physician who has been called from the rotation list may not refuse to respond. ...Physicians called are required to respond to Emergency Department call by telephone within ten (10) minutes. ...” Review on March 18, 2024, of MR1, revealed the patient presented to the ED on March 6, 2024, at 18:12 PM, with the complaint of abdominal pain. A CT of the abdomen and pelvis was completed at 19:13 PM which revealed both ovaries were enlarged with a thin-walled cyst anterior to the uterus and ovaries that measured approximately 10.6 x 8.3 centimeters (cm). Magnetic Resonance Imaging (MRI) was recommended. A call was placed to the on-call physician (OTH2) at 23:00 PM with no response. A second call was placed to OTH2 at 00:33 AM. An MRI was completed with physician documentation that revealed a large mass with ovarian etiology. There was a concern about the possibility of an ovarian torsion (when the ovary and sometimes fallopian tube twist on the tissues that support them and can cut off blood supply to the ovary and if not treated promptly can cause tissue in the organ to die). At 04:05 AM a third call was placed to the OTH2 with no response. At 05:22 AM OTH1 discussed the case with a physician at another local hospital and that physician accepted MR1. MR1was transferred to that local hospital at 07:00 AM . Interview on March 18, 2024, with EMP1 at approximately 10:15 AM, confirmed the above findings. EMP1 confirmed OTH2 did not respond to 3 calls placed by the ED physician and MR1 had to be transferred to another local hospital for gynecological care. Review on March 18, 2024, of the ED on-call gynecologist schedule dated March 6, 2024, revealed OTH2 was on-call from 07:00 AM on March 6, 2024, to 07:00 AM on March 7, 2024. Interview on March 18, 2024, with EMP1, at approximately 10:20 AM, confirmed the above findings. Interview on March 18, 2024, with OTH2 at approximately 1:20 PM, revealed they were aware they were on-call on March 6, 2024. OTH2 revealed the ringer on their phone was turned off so they never heard the phone ring.”