Spartanburg Medical Center

“SURGICAL SERVICES CFR(s): 482.51 If the hospital provides surgical services, the services must be well organized and provided in accordance with acceptable standards of practice. If outpatient surgical services are offered the services must be consistent in quality with inpatient care in accordance with the complexity of services offered. This Condition is not met as evidenced by: 52713 Based on record review, interviews, and review of the hospital’s policies, Medical Doctor (MD)1 failed to identify the correct procedure to be completed after the consent was read during the surgical timeout for Patient (P) 1, one of one patients reviewed for surgical services. The findings included: Cross-Reference: A-0951 Surgical Services: Delivery of Service”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 52713 Based on record review, interviews, and review of the hospital’s policies and procedures the hospital failed to ensure Patient (P)1, one of one patients reviewed for surgical services, understood the nature of the surgical procedure to include that the surgery was for either the excision of a lipoma (non-cancerous fatty tumor) or the repair of an abdominal hernia (weakness of the muscle or surrounding tissue). Medical Doctor (MD) 1 failed to go over the surgical consent with P1 prior to the procedure and failed to obtain P1’s consent for excision of a lipoma. The findings included: Review of P1’s record on 7/14/25 at 11:59 AM revealed P1 was admitted to the facility on 3/7/25 for a planned surgical procedure. A History and Physical (H&P) assessment dated 2/22/25 indicated a surgical procedure was planned and was going to be either a lipoma excision or hernia repair. An interval H&P note dated 3/7/25 (the date of surgery), revealed “H&P reviewed. The patient was examined and there are no changes to the H&P.” Review of the surgical consent signed by MD1 and P1 on 2/25/25, revealed the consent was for an open umbilical hernia repair with mesh (material used to strengthen the weakened area), and did not include information about a lipoma excision. Review of the operative note by MD1, dated 3/7/25 revealed upon incision, a 2 x 3 cm (centimeter) lobular lipoma was identified in the subcutaneous tissue. MD 1 specified there was no evidence of a hernia or fascial defect. The lipomas were excised intact and P1 tolerated the procedure well. During an interview on 7/15/25 at 9:30 AM, Registered Nurse (RN) 1 stated that during the preprocedural timeout immediately prior to surgery, he/she peformed the timeout in front of MD1. As RN1 read the consent, he/she stated that no one spoke up about the consent being inaccurate. RN1 identified that he/she became aware of a different surgical procedure being done instead of the hernia repair listed on the consent during the debriefing timeout (after the surgery). RN1 stated that if a surgeon needed to do a different procedure from the informed consent, verbal consent could be done on the phone with the patient’s authorized representative. When asked if MD1 attempted to call P1’s authorized representative, RN1 replied, “No”. During an interview on 7/15/25 at 2:15 PM with MD1, he/she stated that P1 had a mass in the right upper quadrant (of the abdomen) based on ultrasound findings. MD1 stated there were gaps in communication. MD1 stated an office nurse wrote the surgical consent as an umbilical hernia repair. MD1 stated he/she should have been more attentive to the consent before signing it with P1 on 2/25/25. Review of the facility’s root cause analysis (RCA) on 7/16/25 at 10:55 AM revealed the recovery nurse taking care of P1 after the surgical procedure called MD1 due to the patient immediately asking about the incision being high on the abdomen instead of the umbilical area. The RCA indicated P1 was unaware of any ultrasound results relative to a mass. Review of the hospital policy, “Consent for Surgical Procedures, Medical Services, and Blood Administration,” revised December 2024, revealed that a consent form will be obtained for procedures that involve an incision or entry into a natural body opening. The consentor is not required to give complete disclosure of the treatment and risks; however, enough information must be provided for the patient to make an informed decision and can ask questions. Review of the hospital’s policy, “Patient Rights & Responsibilities,” effective 5/2/25, identified that the facility assumes the responsibility of assuring these rights are preserved for our patients.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 28883 Based on record reviews, interviews, and review of hospital policies the nursing staff failed to ensure appropriate wound care was provided for 4 of 7 patients reviewed with wounds, Patients (P) #3, #4, #6, and #7. Nursing staff failed to obtain treatment orders timely upon identification of open wounds with no documentation of treatment provided until seen by the Wound Care Nurse (WCN) for Patients (P) #3,#4,#6, and #7. Wound care was not provided as ordered for Patients (P) #3, and #4. Nursing staff failed to document accurate assessments of alterations in skin integrity/wounds to show a wound was present and/or the progression (improvement or regression) so appropriate treatment could be determined for Patients (P) #3, #4, #6, and #7. The findings included: Review of P3’s medical record on 7/15/25 at 9:50 AM revealed P3 was admitted to the hospital (Hospital #1) on 3/28/25 at 8:21 PM upon transfer from another hospital (Hospital #2) with diagnoses including Acute Respiratory Failure. A Braden score (a scale measuring a patient’s risk for developing pressure wounds with a score of 18 or less indicating risk is present and 10-12 indicating high risk) at the time was 12. Review of documentation by Hospital #2 revealed the sacral (tailbone) wound was as a pessure injury on 3/28/25 at 4:48 PM. Nursing assessments dated 3/28/25 at 8:00 PM, 3/29/25 at midnight, 3/29/25 at 4:00 AM and again at 8:00 AM revealed a dressing to the sacrum, clean, dry, and intact. There was no description of the wound documented by the nurses to give a clear picture of what the wound looked like, nor orders obtained for treatment of the sacral wound. On 3/29/25 at 12:30 PM, a nurse documented removing the foam border dressing, and placing a new dressing. There was no documentation of wound care to the sacrum besides changing the foam border dressing. Continued review of nursing assessment/documentation on 3/29/25, 3/30/25, and 3/31/25 revealed either a clean, dry, intact dressing or no dressing present to the sacral wound. On 4/1/25, a nurse documented the foam border dressing was changed, but no treatment was applied to the wound. It wasn’t until 4/2/25 at 5:15 PM that the WCN provided treatment to the sacral wound by removing the foam border dressing, cleansing the wound with normal saline, applying Cadoxemer Iodine (wound care gel), and placing another foam border dressing. The WCN documented the sacral wound as a pressure injury stage three (full thickness loss of skin extending into the underlying tissue), measuring 0.3 centimeters (cm) by 0.3 cm x 0.3 cm. A physician’s order for treatment of the sacral wound was not placed until 4/2/25 at 5:20 PM, after the WCN saw P1. These orders included information that the sacral wound was to be cleaned with normal saline, with the application of Cadexomer iodine and a foam border dressing, to be changed every other day and as needed. During an interview on 7/15/25 at 10:30 AM, Nurse Educator (NE)1 verified the above findings of no treatment orders placed for the sacral wound from admission on 3/28/25 until the afternoon of 4/2/25, and of no wound care besides the foam border dressing change for the same timeframe. According to NE1, the floor nurses can call the wound care nurses (who are on call 24 hours with a pager on weekends), and they can get orders for treatment. Continued review of documentation revealed on 3/29/25 at 12:30 AM, the nurse didn’t describe the wound. On 3/30/25 at 8:00 PM, the wound was described as white granulation tissue, (open at that time per NE1), with no dressing present over the wound. On 3/31/25 at 5:02 AM, the sacral wound was described as white, fragile; with no dressing present. On 3/31/25 at 7:59 AM, no dressing present, fragile. On 4/1/25 at 6:04 AM, the sacral wound was described by nursing as white, fragile; with the foam border dressing removed and applied. There was missing documentation for nursing assessments as to a description of the wound to include measurements or staging. During an interview on 7/15/25 at 11:42 AM, the above finding and concern about the nursing documentation was verified by NE1. On 4/2/25 at 5:12 PM, a WCN notified the physician of a coccyx wound and obtained orders for treatment. When asked if the floor nurse was supposed to look under the dressing and assess the wound, NE1 verified they should and stated there was missing documentation of the nurses’ assessments of the wound on the sacrum and with the nurses not documenting progression of the sacral wound or how it was looking. Continued review of P3’s record revealed wounds on the bilateral lower extremities also present on admission. A wound on the left medial (inner) ankle had orders dated 3/28/25 at 8:10 PM to change every other day after cleaning with normal saline and to provide treatment with Cadexmer Iodine with application of a foam border dressing every other day. Review of nursing wound treatment documentation revealed this wound care to the left medial ankle was not documented as provided on 3/30/25 as ordered. The finding was verified by NE1 during a concurrent interview. Review of P4’s record on 7/15/25 at 12:54 PM, revealed P4 was admitted on 3/13/25 with a diagnosis of septic shock (life threatening infection). An admission nursing assessment dated 3/13/25 at 5:00 PM revealed P4 had a Braden score of 19 at the time. Throughout the hospitalization, P4’s Braden score ranged from 8 through 19. On admission, a nursing assessment dated 3/13/25 at 5:00 PM did not identify any concerns with the skin on the sacrum. On 3/21/25 at 3:05 PM, a nurse noted an open sacral wound. There was no description, measurements or staging to determine what the wound looked like. Review of physician orders revealed no orders for treatment of a sacral wound from 3/21/25 (identification of the wound) through 3/24/25. Nursing documentation on 3/21/25 at 7:05 PM revealed a small open area to the sacrum. Nursing documentation revealed inconsistent and/or incomplete documentation related to the presence of or a description of the sacral wound, to give an accurate picture of how the wound looked or progressed. There was no mention of a sacral wound in the nursing documentation from 3/22/25. Review of nursing documentation revealed the following related to the sacral area skin: 3/22/25 at 7:05 PM Blanchable (skin becomes pale when pressure is applied) redness (erythema) to sacrum; 3/23/25 at 7:10 AM - sacral wound; 3/23/25 at 7:05 PM - sacral wound; 3/23/35 at 11:20 PM - sacrum blanchable (no mention of a wound); 3/24/25 at 07:05 PM sacrum blanchable; 3/24/25 at 11:05 AM, sacral wound. On 3/24/25 at 11:24 AM, an order was placed for a Wound Ostomy Nurse (Wound Care Nurse) to evaluate for a new open area to the sacrum. Nursing documentation revealed the following descripton: 3/24/25 at 7:05 PM, sacral redness; On 3/24/25 at 11:25 PM - sacrum blanchable; On 3/25/25 at 7:30 AM a sacral wound was documented on the LDA (Lines, Drains and Airway - an avatar in the electronic medical record) flowsheet. The nurse noted no dressing was present, and the site assessment of the wound was yellow, brown and the periwound (area around the wound) with blanchable erythema. A foam border dressing was applied, but no treatment documented to the wound bed. Review of nursing documentation revealed no treatment was documented for the sacral wound from 3/21/25 through 3/24/25. On 3/25/25 at 5:55 PM, a WCN documented the wound bed as being unstageable, yellow, brown, necrotic, with serosanguinous (thin light reddish drainage) scant drainage, and the periwound with blanchable erythema. The wound measured 4 cm x 2.6 cm. The nurse documented cleansing the wound with normal saline, and placing a transparent occlusive hydrocolloid (type of wound care dressing) dressing. According to the initial evaluation by the WCN, the patient’s prealbumin (measurement of a protein in blood which indicates nutritional status) dated 3/24/25 was low at 3.3 milligrams/deciliter (mg/dl); with the normal range being 15-30 mg/dl. P4’s Braden score at that time was 15. A low air loss (pressure relieving) mattress was documented on 3/25/25. On 3/25/25 at 5:56 PM, orders were put in for wound care to the sacrum to cleanse the sacrum with normal saline and apply a hydrocolloid to the wound bed and Tegaderm (occlusive dressing) dressing, change every third day. Review of treatment provided for the sacral wound documented by the nurses revealed the wound treatment provided was not what had been ordered for P4. On 3/28/25 at 5:05 AM and again at 11:05 AM, a nurse documented the application of petroleum gauze and tape, which was not ordered. Nursing documentation of a treatment for the sacral wound on 3/28/25 at midnight and on 3/29/25 at 9:35 PM revealed the wound was cleansed with soap and water when normal saline cleansing had been ordered. The nurse documented the placement of an abdominal pad for coverage when this was not ordered. On 3/30/25 at 8:45 AM, a floor nurse documented covering the sacral wound with a foam border dressing because a hydrocolloid was not available. On 4/1/25 at 4:55 PM, a floor nurse documented cleansing the wound with soap and water, and using a petroleum gauze impregnated with bismuth (type of wound dressing) and a foam border dressing for the sacral wound because a hydrocolloid dressing was not available. During an interview on 7/15/25 at 1:53 PM, NE1 verified the above findings after review of the record. During the interview, NE1 looked for a communication to the Providers to see if the floor nurses had attempted to get orders for treatment of the sacral wound but there was none besides the order dated 3/24/25 for the WCN to see the patient. During an interview on 7/17/25 at 9:36 AM, the Chief Nursing Officer (CNO) was informed of the concerns related to nursing assessments not identifying wounds or describing wound or skin alterations, and that when a wound was identified, there were no orders documented for treatment or treatment was minimal and/or did not include treatment to the wound bed. When a consult was placed for the WCN to see the patient, no orders were obtained for treatment of the wound until patients were seen by the WCN. The CNO stated their physicians rely on the wound team and nurses need to let physicians know about wounds and get orders for treatment. The CNO stated that’s what they should do every time, notify the physician and get orders. 52713 Review of P6’s medical record on 7/15/25 at 11:25 AM revealed s/he was admitted to the hospital on 3/22/25 following complaints of possible syncopal (temporary loss of consciousness due to a decrease in blood pressure) episodes, accompanied with an altered mental status. P6 was admitted to the inpatient care unit on 3/23/25 at 12:20AM, where a nursing assessment was conducted on 3/23/25 at 1:12 AM, and did not reveal the patient had any pressure wounds on arrival to the unit. On 3/25/25 at 1:13 PM, a consult was placed for the patient to be seen by the WCN for a wound. There was no nursing note to describe the wound, to stage it, or a measurement of the wound. There were no physician’s orders placed for treatment to this wound on identification. On 3/25/25 at 6:48PM, a bedside nurse documented the presence of “an open wound to the midline sacral area,” with no documentation of physician orders for treatment. A wound care consult was initiated, and P6 was evaluated by a WCN on 3/26/25 at 10:00AM. The WCN documented the wound as a stage three pressure injury. The WCN initiated wound care orders at that time, which included, cleansing the wound with normal saline and applying a hydrocolloid dressing, covered by a transparent occlusive dressing, that should be changed every three days or as needed. Review of P7’s medical record on 7/15/25 at 11:17 AM revealed the H&P identified that he/she had been admitted to the facility on 3/15/25 for a right ischial (lower bone of the pelvis) wound that needed debridement. P7 went to the operating room to get his right ischial wound debrided, and subsequently had a wound vac (a device with controlled suction to draw fluid out of a wound) placed to the area. On 3/27/25, a WCN took a photograph of a wound to the left buttocks (separate from the right ischial wound), but there was no assessment of the wound documented by the WCN or other nurse, nor wound care orders for treatment of the left buttocks implemented or placed. Review of the picture taken of the left buttock wound on 3/27/25 shows a small but open wound. Nursing put in a consult order for the WCN for treatment to the left buttocks on 3/30/25 at 7:15 PM. There were no physician’s orders documented for wound care to the left buttock or treatment documented by nursing staff of the left buttock wound from 3/27/25 through 3/30/25. A WCN came to see P7 on 3/31/25 and took another photograph of the wound to the left buttocks. In a review of the picture of the left buttock wound taken on 3/31/25, it appeared to be a larger open wound. Comparing P7’s photographs of the wound to the left buttocks, it appeared to progressively worsen from 3/27/25 to 3/31/25. A WCN implemented wound care orders, dated 3/31/25 at 3:37 PM, to include cleansing the wound with normal saline and apply Medihoney alginate (type of wound dressing) with a bordered foam dressing every other day or as needed. During an interview on 7/16/25 at 10:30 AM with WCN1, WCN2, and the WCN Manager (WCNM), it was stated that once a wound consult is initiated, the wound care team has 72 hours to assess the patient. WCN2 stated a bedside nurse and/or a physician can create a wound care consult. When asked how rapidly a wound can increase to a stage three pressure injury, WCN2 replied that it depends on the patient’s skin integrity, along with any comorbidities (other diagnoses) the patient may have. WCN1 stated a pressure injury/wound starts with erythema that is blanchable. WCN1 stated that policies are in place for bedside nurses to treat pressure wounds that are not considered a stage three or greater. Reviewing P7’s medical record with WCN2, it was confirmed that a wound care nurse took a photograph of the pressure wound to the left buttocks on 3/27/25, but there was no nursing note or wound care orders placed until 3/31/25. According to WCN1, the wound on the left buttocks would have been classified as a stage three pressure ulcer on 3/27/25. WCN1 confirmed there should have been a nursing note and orders for treatment of the left buttock wound implemented on 3/27/25. During an interview on 7/17/25 at 10:35 AM with NE1 and NE3, NE3 stated bedside nurses are not required to stage wounds because they are not trained. NE3 stated bedside nurses can rely on the wound policies regarding how to treat wounds and critical thinking should be utilized among bedside nurses for when he/she thinks a wound needs to be evaluated. During an interview with the Director of Risk Management (DRM) on 7/17/25 at 12:45PM, he/she confirmed there was room for opportunity for bedside nursing staff to identify a pressure injury when assessing patients upon admission. The DRM stated that nurse educators are routinely working with bedside staff regarding pressure injury/wound education and interventions. The DRM stated they implemented the use of incident reports for stage three or worse pressure injuries/wounds and once the facility reviews the incident reports, the unit manager can identify improvement processes and coordinate with nursing educators. Review of the hospital policy titled, “Assessment/Reassessment of the Patient,” effective November 2024, identified that for inpatient care areas, a registered nurse (RN) must complete an admission nursing assessment within eight hours of admission. The RN must conduct a full reassessment once a shift and focused reassessment with any change in condition or procedure. The wound consult team is responsible for assessing patients within 72 hours of referral and should reassess based on acuity. Review of the hospital’s policy titled, “Pressure Injury Prevention and Treatment Policy,” revised November 2024, identified a pressure injury/wound as localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. A stage three pressure ulcer is defined as full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue are often present ...fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. An unstageable pressure injury is defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. The policy indicated the primary nurse on admisison, dicharge and transfer, performs a thorough skin assessment within 24 hours of admission, with special attention to documentation of any pre-existing wounds or skin breakdown, and each shift. The policy also indicated with use of the Braden Scale, a patient receiving a score of 15-18 is considered to be at low risk for skin breakdown, a score of 13-14 is considered moderate risk, a score of 10-12 is considered high risk for skin breakdown, and a score of 9 or below is considered very high risk for skin breakdown. Review of the hospital policy titled “Wound Management/Treatment Policy,” effective 11/1/24, revealed Registered Nurses...Assess wound(s). Initiate a Wound Team evaluation as indicated. Notify the provider if: there is any necrotic material on the wound bed. If the wound has signs or symptoms of infectin. Wound(s) appear to be worsening. Cleanse the wound(s) with normal saline. If the wound is dry and flat any one of the following options is appropriate: Apply Xeroform and secure with Kerlex, Kling, or cloth tape. Cover with moist saline gauze and secure (wet to dry). Cover with a hydrocolloid. Use skin prep to periwound to ensure skin protection and increase hydrocolloid adherence. If the wound is wet and the surrounding tissue macerated, one of the following options is appropriate: Protect periwound with skin prep, cover wound with a calcium alginate sheet and cover with gauze, securing with a cloth tape or Kerlix. Loosely pack the wound with saline moist gauze and cover with gauze. Secure with cloth tape. It is important to correctly classify a wound by type in order to utilize appropriate treatment methods. Classify and document wounds as one of the folowing, Pressure injury, Lower extremity injury (venous stasis, arterial, diabetic). Traumatic wounds: Burns, Road rash, Lacerations. Complicated surgical Wounds.”

“OPERATING ROOM POLICIES CFR(s): 482.51(b) Surgical services must be consistent with needs and resources. Policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care. This Standard is not met as evidenced by: 52713 Based on record review, interviews, and review of the hospital’s policies, Medical Doctor (MD)1 failed to identify the accurate surgical procedure during the surgical timeout for Patient (P) 1, one of one patients reviewed for surgical services. The findings included: Review of P1’s record on 7/14/25 at 11:59 AM revealed a History and Physical (H&P), dated 2/22/25. The H&P, indicated the surgical procedure was going to be either a lipoma (non-cancerous fatty tumor) excision or an abdominal hernia (weakened muscle wall) repair. A surgical consent, dated and signed on 2/25/25, was for an open umbilical hernia repair with mesh (material used to strengthen the herniated area) and did not include information of a lipoma excision. Review of the operative note by MD1, dated 3/7/25 revealed an incision was made to repair P1’s hernia. Upon incision, findings were identified as a 2 x 3 cm (centimeter) lobular lipoma in subcutaneous tissue. MD 1 specified there was no evidence of a hernia or fascial defect. The lipomas were excised intact, and P1 tolerated the procedure well. During an interview with RN1 on 7/15/25 at 9:30 AM, RN1 confirmed he/she was the operating room nurse, also known as circulator, for P1 on 3/7/25. In the preoperative area, RN1 stated that he/she ensured that the surgical consent was signed by both MD1 and P1. In the preoperative area, P1 identified to RN1 that the surgical procedure was for hernia repair. In the timeout before the incision was made, RN1 read the informed consent aloud for MD1 to hear. As RN1 read the consent, MD1 did not object to indicate the procedure listed for a hernia repair was incorrect. Review of the facility’s root-cause analysis (RCA), related to the complaint, identified that communication with P1 should have occurred with MD1 prior to him/her entering the operating room. Communication during the time out should have been more robust when the conversation did not match what was on the consent. Review of the hospital’s policy, “Universal Protocol Surgical-Invasive procedure, Patient Identification Verification, Site Marking, and Time Out Verification,” effective 5/2/25, indicated the timeout is conducted in the location where the procedure occurs. It involves active communication among all members of the procedure team and is initiated by a designated team member. Section 4.1 of the policy, indicated the goal of the timeout is to confirm the correct patient, procedure, and site/side/level ...resolution of any discrepancy must occur before the commencement of the procedure.”

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion. This Standard is not met as evidenced by: 28883 Based on review of complaints/grievances, interviews, and review of the policy “Patient and Visitor Complaint and Grievance Policy”, the hospital failed to ensure written responses had been provided to two of twenty patients (Patients #3 and #31), for grievances reported to the hospital staff by phone. The findings included: During an interview on 01/07/2025 at 2:23 PM, the Guest Services Manager and EC (Emergency Center) Customer Services Manager were present. The Guest Services Manager stated if the complaint is submitted in writing, contains a serious issue, or if there is a nuance as to what response they are requesting; it would be put in as a grievance. Review of a complaint documented by a guest services representative for Patient #3 revealed it had been received by the hospital on 11/27/24. It documented the complaint event occurred on 11/27/24. “Guest Services received phone call from (Patient #3). Patient stated (Patient #3) had tests run to determine if (Patient #3) had a STD (Sexually Transmitted Disease) in the emergency room. (Patient #3) was also prescribed medication for a UTI. The test results came in after (Patient #3) was discharged and showed that (Patient #3) did have a STD, but now (Patient #3) is being told (Patient #3) had to schedule an appointment with (Patient #3) PCP [Primary Care Provider] or come back to the emergency room to be prescribed medication to treat the STD. (Patient #3) feels it is ridiculous to make an extra trip when the hospital already has (Patient #3) test results. (Patient #3) is asking for a phone call from management ...”. Under “Manager Review”. The EC Nurse Manager documented “ER MD’s (physicians) do not call patients with results. Patient cannot be prescribed medication when they are not a current patient.” Under “Guest Services Reviewer” the review was documented as completed by the EC Customer Service Manager. There was no documentation of a written response having been provided to the patient. After reviewing the complaint documentation for Patient #3, the Guest Services Manager stated the staff would not have treated it as a grievance if the manager called the patient, and the patient responded with the results saying “great”. The EC Customer Services Manager verified there had not been a written response documented as provided to Patient #3 for resolution of the grievance. The EC Customer Services Manager stated s/he was on vacation at the time, and felt the nurse manager would have taken care of whatever needed to be done. The EC Customer Services Manager stated s/he thought the complaint had been resolved with the patient. During an interview on 01/07/2025 at 2:40 PM, the EC Customer Services Manager stated that Guest Services will send the complaints for the EC to her/him. If they get a letter, it will be put in as a grievance. The EC Customer Services Manager stated s/he and the EC Nurse Manager, and at times the EC Chief Medical Officer, will review the complaint. The nurse manager will look at the clinical information; and address the complaint by putting in the clinical information relative to the complaint. The EC Customer Services Manager stated that for Patient #3, “I didn’t ask, hey did you call the patient.” The EC Customer Services Manger stated sh/he assumed the EC Nurse Manager called the patient back and if it was a complaint related to the EC, the Nurse Manager will assist with resolving the complaint. The EC Customer Services Manager further stated if it is related to an ED Provider, the ED Practice Manager of Physicians will assist with resolution of the complaint. The EC Customer Services Manager stated there have been no trending complaints from EC patients about not receiving their results or treatment. During an interview on 1/7/25 at 2:59 PM, the EC Nurse Manager reviewed the complaint documented for Patient #3. S/he stated that s/he had assumed that the nurse reviewer(s) had already called the patient with the lab results; and Patient #3 was still having problems even after receiving treatment. S/he was not sure why the treatment had not been called in. It could have been that the nurse reviewer could not get in touch with the patient. When asked about treating the complaint as a grievance, the EC Nurse Manager stated s/he doesn’t get involved in changing a complaint to a grievance. Phone calls and surveys are usually complaints, letters are treated as formal grievances. According to the EC Nurse Manager, it looked like Patient #3 was still sick after treatment and needed to come back in. When asked if s/he had called the patient in response to the request for a call back from management, the Nurse Manager stated s/he hadn’t. During an interview on 01/08/2025 between 12:32 PM and 1:25 PM, the Emergency Center Customer Service Manager and the Guest Services Manager were present. During the interview, 19 additional patient grievances/complaints were reviewed related to the quality of care for patients seen in the Emergency Department (ED). Of the 19 cases reviewed, one complaint documented for Patient #31 did not have a written response from the hospital provided to the patient relative to their complaint/grievance. Review of the complaint for Patient #31 revealed it came through the hospital’s Comment Line (nurse on call phone number) which was listed on the patient’s Emergency Department discharge paperwork. It was received by hospital staff on 10/7/24. The complaint form documented “Patient states (Patient #31) went to [hospital’s] ED on 8/24/24. (Patient #31) states (Patient #31) was sick and alone and didn’t know what else to do. S/he states that Dr. - came in the room and ‘slammed the door, acted hateful, called me a liar and drug addict’. (Patient #31) states that (Physician) also said ‘you don’t need a cane or walker’ and told (Patient #31) that (Patient #31) walks fine at home. (Patient #31) states (Patient #31) wasn’t asking for anything and (Physician) was mean to (Patient #31). (Patient #31) states (Patient #31) hasn’t been able to get over this and won’t ever be able to. (Patient #31) states ’(physician) called me a liar and drug addict. (Physician) is going to say (Physician) never said it but (Physician) did.’ (Patint #31) states that (Physician) made sure the door was shut since (Physician) knew (Patient #31) was going to say that ...”. Under “Manager Review” was a note that said “...nothing needed from nursing care reviewed. Will follow up with Provider”, and the initials of the ED Practice Manager. According to the EC Customer Services Manager, the ED Practice Manager followed up with the physician in question. The EC Customer Services Manager had documented a final review of the complaint. The EC Customer Services Manager stated s/he had not put in the complaint as a grievance since it came through the phone line. The EC Customer Services Manager stated no written response had been sent to the patient in response to the complaint, since it had not been treated as a grievance. The Guest Services Manager stated that it may not have been treated as a grievance since the patient had not requested a response. Review of the policy, #IM100.102, titled “Patient and Visitor Complaint and Grievance Policy”, effective date 10/04/2024, revealed under Policy Statement: “It is the policy of Spartanburg Regional Healthcare System (SRHS) to provide patients and families with appropriate channels for communication of dissatisfaction with organization services... Reported complaints regarding potential situations that endanger a patient, such as abuse and neglect, are addressed immediately. 3. Service Recovery ...4.1.1 Notify your manager and Guest Services of the complaint. 4.2. (An) Associate documents the complaint in the database and sends information to appropriate leaders for review. 4.3. A written response is required for the initial acknowledgement of the grievance (which may or may not include the resolution) within the timeframe of 7 to 10 calendar days. If the grievance is not resolved, the investigation is not complete, or if the corrective action is still being evaluated, the organization’s response should address that the organization is still working to resolve the complaint and that the organization will follow up with another written response within 30 days. If the complaint is still not resolved within 30 calendar days, the organization will follow up with another written response. The organization will attempt to resolve all grievances as soon as possible. 4.4. The written response; 4.4.1. Is in a language the patient understands; 4. 4.2 Includes the name of the organization contact person; 4.4.3. Notes the steps taken on behalf of the patient to investigate grievance; 4.4.4. Provides the results of the grievance process; and 4.4.5. Notes the date of completion (usually the date of the letter). 4.5. Document the grievance resolution in the database including actions taken, communication with the patient or patient representative, and a copy of the acknowledgement and/or resolution letter. 4.5.1. The organization is not required to include statements that could be used in a legal action against the organization but provides adequate information to include the items listed above ...5. A complaint may be, but not limited to, the following: 5.1. Relatively minor requests (e.g. linen change, housekeeping, food service). 5.2.2 Patient care concerns resolved at the time of the complaint by staff present 5.2.1. Staff present includes organization associates present at the time or who can arrive at the patient’s location to quickly resolve the complaint. 5.3. Billing issues are not usually considered grievances. 5.3.1. However, a Medicare beneficiary billing complaint related to rights & limitations provided by 42 CFR 489 is considered a grievance. 5.4. Patient satisfaction surveys 5.5.5.4.1. Unless the complaint would otherwise meet the definition of a grievance (e.g. attaching a letter to the survey). Comment line calls and phone calls. 5.5.1. Post-discharge/visit verbal communications about patient care that would have routinely been handled by staff present, if staff had been given the opportunity, will not be treated as a grievance. 5.6. Social media posts or reviews. 6. A grievance may be, but not limited to, the following: 6.1. Verbal or written complaint to the organization by the patient regarding 6.1.1. Patient care, 6.1.2. Allegation of abuse, neglect, or patient harm, 6.1.3. Failure of the organization to comply with CMS requirements; 6.2. Complaints postponed for later resolution; 6.3. Emails and faxed complaints; 6.4. Medicare beneficiary billing complaint related to Rights and Limitations (42CFR 489); 6.5. Patient or patient representative request for complaint to be handled as a formal complaint or grievance, or when a patient or patient representative requests a response from the organization, the complaint is considered a grievance. 7. SRHS Grievance Committee: 7.1. The SRHS Grievance Committee convenes as needed to discuss the progress of open cases. The committee members include Guest Services associates, SMC Emergency Center Customer Service associates and ad hoc members as appropriate. 7.2. On occasion, the patient may disagree with the grievance resolution. When this occurs, the documentation is reviewed to identify the steps taken to investigate the grievance. The SRHS Grievance Committee reviews the steps taken to investigate the grievance and the resolution response provided. The SRHS Grievance Committee determines if any further action is needed. After a decision is rendered, the Grievance Committee notifies the patient of the final decision of the Grievance Committee. This communication is documented in the database. 7.3. Data collected regarding patient grievances are reported and incorporated into the organization’s Quality Process Improvement Council (QPIC).”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 28883 Based on record review, interview, and review of the policy “Documentation of Post Discharge Intervention (Callback)”, 2 of 2 Registered Nurses (RNs #1 and #2) failed to ensure abnormal lab results had been brought to an ED Provider/Physician’s attention so that treatment could be initiated for Patient #3, one of fourteen patients reviewed with labs resulted after having been discharged from the Emergency Center. The findings included: Record review on 01/07/24 at 9:12 AM revealed Patient #3 arrived in the Emergency Center (EC) on 11/21/24 at 11:14 PM with a complaint of Urinary Tract Infection (UTI). The patient was discharged from the EC on 11/22/24 at 01:56 AM with the diagnosis of Cystitis with Hematuria along with a prescription for an antibiotic to treat the UTI. Review of the AVS (After Visit Summary) documented in the medical record stated for Patient #3 to start taking cefdinir (antibiotic); and to read the provided information about bladder infections. It stated Patient #3 had been seen for a bladder infection, dysuria, and inflammation of the bladder. It included information that lab tests completed were a urine pregnancy and urinalysis with microscopic. Lab tests in progress included GC(Gonorrhea)/CT(Chlamydia Trachomatis)/TV(Trichomonas Vaginalis), Multiplex Vaginal Panel (MVP), and Urine Culture. Under follow-up care was documented, “Call your healthcare provider if all symptoms are not gone after 3 days of treatment ... If a culture was done, you will be told if your treatment needs to be changed. If directed, you can call to find out the results ...”.A review of labs revealed a “final result” dated 11/22/24 at 05:25 AM, for a urine GC/CT/TV urine test had been positive for Trichomonas Vaginalis. This “final result” (which was abnormal) had been documented as reviewed by Registered Nurse (RN) #2 on 11/22/24 at 11:48 AM, and by RN #1 on 11/23/24 at 4:23 PM. A review of a Multiplex Vaginal Panel swab “final result”, posted on 11/22/24 at 03:01 AM was positive for Bacterial Vaginosis (BV) and Trichomonas Vaginalis. The results had been acknowledged by RNs #1 and #2 at the same time as the abnormal result for the urine; on 11/22/24 at 11:48 AM by RN #2, and on 11/23/24 at 4:23 PM by RN #2. A Urine culture final result was dated 11/23/24 at 07:59 AM and revealed a colony count greater than or equal to 10,000-99,000 (colony forming units) cfu/ml (milliliter) Escherichia Coli. These labs had all resulted after Patient #3 had been discharged from the Emergency Center. There was no documentation in the medical record that Patient #3 had been informed of the abnormal results or had received treatment other than the antibiotic provided on discharge from the EC. During an interview on 01/07/2025 at 12:36 PM, Registered Nurse (RN) #1 stated s/he works as a nurse reviewer for culture results that were pending at the time of patients’ discharge from the EC. If a lab comes back positive or abnormal, the patient’s chart is reviewed to see if the patient has already been treated. If found not treated, then the nurses will consult the EC physician by printing out the lab results for the physician, who would order a medication for treatment. The nurse would then call the patient, ask them which pharmacy they want the medication called to, and call the prescription in to the pharmacy. The nurses will then document this intervention; sometimes on the lab results portion of the medical record or they will put in a telephone encounter. A note would be in the record if they spoke to the Provider and patient. RN #1 verified s/he and RN #2 had documented they had reviewed Patient #3’s urine culture, Multiplex Vaginal Culture, and GC/CT/TV urine that had resulted after Patient #3 had left the EC. RN #1 stated Patient #3 had already received Cefednir treatment that was effective against the E-Coli urine culture results and that did not require notification of an ED Provider to change the treatment plan. RN #1 stated the other tests did require a consult with an EC Provider for treatment. S/he stated s/he had spoken to RN #2 about the review of Patient #3’s chart after this concern had been brought to her/his attention (during the survey). RN #1 was not sure why they both had failed to identify the abnormal vaginal swab result and the abnormal urine result (positive for Trichomonas and/or Bacterial Vaginosis) and communicate this information to an ED physician so that treatment could be provided. Review of the policy entitled “Documentation of Post Discharge Intervention (Callback)”. Policy # EC0013. Effective dates (include) 02/2024, revealed the policy was “To provide guidelines for Post Discharge follow up calls. Patients’ treatment plans are occasionally altered after discharge by appearance of new clinical data, new interpretation of old data, or an unanticipated change or perceived change in the patient’s clinical status. Appropriate management of data and patient, family, or caregiver concerns is equally important post discharge. It is vital to communicate and document an intervention or a decision that intervention is not necessary.” Under Procedure was documented, “ ...1. If needed, the EC (Emergency Center), ED (Emergency Department) nurse and physician will receive concerns and provide follow up after a patent is discharged. 2. Once data is provided to the EC, ED nurse and physician, they decide: 2.1. If previous treatment was adequate and appropriate- OR- 2.2. If additional steps are required to assure appropriate management. 3. Communication occurs via many mechanisms, including contact with the patient, family, another physician, extended care facility or authorities (within the confines of HIPAA). Intervention may include education, altering treatment plans (Physician only), discontinuing or prescribing medications (Physician only), arranging new follow-up or having the patient return to the EC/ED. 3.1. Document any additions in Electronic Medical Records. 4. Care plan-altering data that does not originate from the patient/family/caregiver (i.e. from within SMC). 4.1. Receive the information 4.1.1. Pathology 4.1.1.1. Positive blood cultures and other lab values may be called to the EC NAS (SMC) ... That information is passed on to the treating physician, if still present. If not, then any EC physician may be notified to take responsibility. 4.1.1.2. Other abnormal though non-critical laboratory results may be retrieved from the automatic reporting system and brought to an EC physician for follow-up ....4.1.2.2. Other calls regarding other patient test results are forwarded to the EC NAS ...to gather information. 4.2. Decide on intervention, if needed: The nurse and physician responsible for the report will investigate, using the medical record and other resources as necessary, to decide on a course of action. 4.3. Complete intervention 4.3.1. No further intervention may be required. 4.4. If intervention is required, the physician or nurse contacts the appropriate person(s) to complete the intervention, documenting the follow-up call in the medical record. 5. Family, caretaker or patient concerns may be communicated to the EC/ED. 5.1 Receive the information: a patient representative, nurse or physician may take the call, but the information is forwarded to the physician for his analysis. 5.2. Decide on intervention, if needed: the nurse and physician responsible for the report will investigate, using the medical record and other resources as necessary, deciding on a course of action. 6. Complete intervention 6.1 No further intervention may be required. If concern was not resolved during the original call, the physician or nurse should contact appropriate person(s) (within the confines of HIPAA) with explanation, education, and reassurance. 6.2. If intervention is required, the physician or nurse contacts the appropriate persons(s) to complete the intervention, documenting the follow-up call in the medical record.””

“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: 41743 Based on interview, record review, hospital Medical Staff Bylaws, on-call physician schedule, and review of facility Emergency Medical Treatment and Labor Act (EMTALA) policy, the hospital failed to ensure the on-call physician provided stabilizing treatment for one (1) of 30 patients reviewed with an Emergency Medical Condition (EMC). (Patient #1). The findings include: Cross reference A2404: To ensure the on-call physician provided an evaluation and/or stabilizing treatment for one (1) of 30 patients reviewed with an Emergency Medical Condition (EMC), Patient #1.”

“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: 41743 Based on interview, record review, hospital Medical Staff Bylaws, on-call physician schedule, and review of facility Emergency Medical Treatment and Labor Act (EMTALA) policy, the hospital failed to ensure the on-call physician provided stabilizing treatment for one (1) of 30 patients reviewed with an Emergency Medical Condition (EMC), (Patient #1). Findings include: Review of Patient #1’s medical record on 07/09/24 at 9:47 AM showed Patient #1 presented at Hospital A Emergency Department (ED) on 05/17/24 at 10:54 PM by car with spouse with a complaint of “vascular surgery last week on his/her carotid artery. Patient sts (states) that he/she noticed the swelling on the left side of his/her neck worsened tonight. Patient denies trouble swallowing or breathing at this time”. Patient #1 presented with signs and symptoms of a large, pulsating and increasing in size hematoma of the left neck. Review of the chart revealed at 11:05 PM, triage vital signs of blood pressure 187/109, pulse 58, respirations 16, oxygen level of 100%, and pain intensity of 8 out of 10. On 05/17/24 at 11:06 PM, Patient #1 was triaged for Emergency Severity Index (ESI) of 2. (ESI is an acuity scale with five levels to base patient medical conditions in acute care settings. Level 2 is defined as High risk of deterioration, or signs of a time-critical problem.) A Computer Tomography (CT) scan was ordered on 05/17/24 at 11:28 PM. Review of the CT scan report on 05/18/2024 at 1:27 AM revealed “Large perivascular hematoma along the left carotid artery, with foci of active bleeding, possibly arising from branches of the inferior thyroidal artery, additional edema/inflammatory changes within the left neck extending along the left pharyngeal wall/retropharynx, with mild narrowing of the oropharyngeal airway”. Review of ED Physician #1’s “First Contact History of Present Illness” dated 05/18/24 at 12:34 AM showed “Neck: Left sided swelling which is significant, rock-hard and with a palpable pulse. Associated ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) that tracks into the anterior chest wall. No voice change. Bleeding around the suture of the superior aspect of the incision”. On 05/18/24 at 1:07 AM, ED Physician #1 intubated the patient due to airway protection and the ESI acuity level was changed to a level 1 (Level 1 is defined as Immediate, life-saving intervention required without delay.) On 5/18/24 at 1:50 AM, Review of ACS (Acute Coronary Syndrome)/Trauma Consult Note by on-call Vascular Surgeon #1 stated, “Due to hemodynamic stability and secured airway, will plan for transfer back to Hospital B for left neck hematoma. Per Surgical Resident #1’s note within the on-call Vascular Surgeon #1’ s consult notes states “I was called by emergency attending around 1:00 AM for patient status post left Carotid Endarectomy by surgeon at Hospital B recently, presented to the hospital with neck swelling continued to worsen with some shortness of breath, at that time the patient was hypertensive when I got the phone call went from {spending} left neck swelling, patient underwent CAT scan...”. On 05/18/24 at 1:52 AM, ED Physician #1 documents “Discussed with on-call Vascular Surgeon #1. Evaluated by Surgical Resident #1 of surgery. On-call Vascular Surgeon #1 after evaluation by Surgical Resident #1 and reviewing imaging request patient be transferred to Hospital B”. Medical Decision Making by ED Physician #1 states “Differential Diagnosis: Pseudoaneurysm formation, hematoma, respiratory failure, impending arterial rupture. Provider notes further state “Our Vascular Surgeon, on-call [Vascular Surgeon #1 name] declined operative management per general surgery intern [this person is Surgical Resident #1] after multiple phone discussions with him. Will transfer to [Hospital B]”. On 05/18/24 at 2:18 AM, ED Physician #1 documents “Discussed with [Hospital B’s physician] agrees to accept”. On 05/18/24 at 3:32 AM, patient was transferred to the stretcher with EMS (Emergency Medical Services) and “noted as stable for transfer to [Hospital B] with transport”. On 05/18/24 at 3:34 AM, Patient #1 was discharged from the ED at Hospital A. Review of Hospital Transfer form dated 05/18/24 at 2:49 AM states, “Patient condition: Patient stabilized, Reason for transfer: Qualified clinical personnel or service unavailable...”. Review of EMS run sheet dated 05/18/24 at 3:31 AM, EMS transported Patient #1 to Hospital B via stretcher while intubated with cardiac monitoring, a propofol drip, nicardipine drip and Fentanyl Intravenous infusions (IV). Run sheet denotes arrival at Hospital B at 4:04 AM. Interviews During an interview by telephone on 07/10/2024 between 8:34 AM to 8:44 AM, ED Physician #1 stated that Patient #1 came to Hospital A’s ED on 05/17/2024 with his/her spouse and had massive, increasing swelling on the left side of his/her neck. Patient #1 had an endarterectomy performed at Hospital B on 05/09/2024. ED Physician #1 stated that the ED was “super busy “ and when he/she went in to see Patient #1 and telephoned the on call Vascular Surgeon #1 to express his/her concerns. ED Physician #1 states “I had never seen (swelling) that massive, pulsating ...I ‘ve worked ED in several hospitals”. ED Physician #1 stated that on call Vascular Surgeon #1 called him/her back to tell him/her that he/she was sending down the in-house surgeon on call to assess Patient #1. I had spoken with him/her already 3 times and after we intubated, 1 more time and he/she (on call Vascular Surgeon #1) said the intern (this person is Surgical Resident #1) told him/her the patient was stable and I said “NO”. ED Physician #1 states “10 minutes later, the intern (this person is Surgical Resident #1) said he/she (on call Vascular Surgeon #1) wanted the patient to be transferred to Hospital B. Lead Surveyor then asked ED Physician #1 why on call Vascular Surgeon #1 was asking for transfer and ED Physician #1 stated that on call Vascular Surgeon #1 felt his/her (Patient #1) surgery was done at Hospital B and he/she (Patient #1) was stable enough to go there. Lead Surveyor asked ED Physician #1 how he/she felt about the patient transfer and ED Physician #1 stated “I was uncomfortable with the transfer. I felt he/she was best served to go to OR (operating room) here ...was frustrating ...first time a physician on call did not come in”. During an in-person interview in the conference room on 07/10/2024 from 8:50 AM to 9:10 AM, Registered Nurse (RN) #1 stated that he/she was assigned to Patient #1 on 05/17/24 to 05/18/24. RN #1 reports that the swelling was continuing to grow and ED Physician #1 explained to the spouse and patient that they needed to put an airway in, patient nodded agreement and spouse verbalized agreement. Surgical Resident #1 was present and agreed with ED Physician #1 that the patient was “going to surgery”. RN #1 states “then ED Physician #1 told me to get him/her ready, he/she is going to Hospital B”. The Lead Surveyor asked who spoke with the spouse about the transfer consent and reports “me” ... and when asked why states “I’ m not sure ...doctors made the decision ...then I got his/her meds (medications) ready to go with him/her”. RN #1 states that he/she got Patient #1 ready for transport, spoke with the receiving hospital nurse for report and Patient #1’s spouse signed all consents but seemed to be concerned why it was “taking so long”. RN #1 states that ED Physician #1 had inferred earlier that the patient would be going to surgery, so RN #1 had been getting him/her ready to go to the Operating Room (OR) before the change to transfer. RN #1 states “it was crazy that day”. During an in-person interview in the conference room on 07/10/2024 from 9:47 AM to 10:07 AM, Chief Visionary Officer (CVO) states that he/she was aware of the event within one week and an internal investigation was done. He/she spoke with on call Vascular Surgeon #1 practice partners who felt that on call Vascular Surgeon #1 was not comfortable with “open cases... would not be able to meet the level expected”. CVO reports on call Vascular Surgeon #1 had been with the practice and with the hospital less than 1 year. CVO states that he/she spoke with on call Vascular Surgeon #1 and told him/her “not fitting what we need ...mutual agreement for us to part”. CVO states that specialty on-call physicians are to be immediately available to see, evaluate and treat patients and are under obligation to come in (to the hospital) and “take care of it (the situation)”. Lead surveyor asked if CVO felt there was any reason why on call Vascular Surgeon #1 wanted the patient transferred and states “I spoke with the Medical Director and partners ...something he/she was uncomfortable doing ...open procedures ... on call Vascular Surgeon #1 had transferred or not accepted another 3 patients within the past month”. This surveyor asked if an internal audit/investigation was done and CVO stated that no meetings were done, just an internal investigation, all done within 1 week of the incident. Surgical Resident #1 was interviewed in person on 07/10/24 from 3:03 PM to 3:16 PM. Surgical Resident #1 states on the night Patient #1 was in the ED there was “a lot of trauma going on” and the “Operating Rooms (OR) were already up and running.” Surgical Resident #1 states on call Vascular Surgeon #1 was at home and called him/her and asked him/her to see Patient #1. Surgical Resident #1 saw Patient #1 and ED Physician #1 had “already administered medication to intubate.” Surgical Resident #1 states Patient #1 had a “pulsatile expanding hematoma” and he/she agreed with the intubation” to secure an open airway and he/she “agreed with ED Physician #1’s concerns.” Surgical Resident #1 states he/she thought Patient #1 should go to the OR and he/she alerted the OR of the patient. Surgical Resident #1 states he/she called on call Vascular Surgeon #1 and on call Vascular Surgeon #1 “wanted to see the CTA (Computed Tomography)” which he/she states they could normally view remotely but on call Vascular Surgeon #1 “couldn’t open it or the Hospital B record”. On call Vascular Surgeon #1 asked Surgical Resident #1 about Patient #1’s vital signs which were stable. Surgical Resident #1 states, “So, technically hemodynamically stable.” Surgical Resident #1 states on call Vascular Surgeon #1 called back again and said Patient #1 “...needs to go back to Hospital B.” Surgical Resident #1 states he/she talked with the patient’s family member and explained the reason for the transfer stating, “...because we don’t know exactly what Hospital B had done...they did his/her surgery and are the most familiar with what they did.” Surgical Resident #1 states the family member said, ‘Ok.” When asked by the Lead Surveyor if there are other considerations in a case that is progressing in determining if a patient is stable for transport besides being hemodynamically stable, Surgical Resident #1 states, “l do agree it was a progressive process and needed to be dealt with immediately.” Medical Staff Bylaws Review of Acute Care Medical Staff Bylaws on 07/08/24 shows that “2.B. ACTIVE STAFF ...2.B.3. Responsibilities: (b) providing on-call coverage for the Emergency Department for unassigned patients and accepting referrals from the Emergency Department for follow-up care of patients without regard to financial status for the initial visit, arranging for ambulatory office follow-up, as appropriate, for any emergency center patient they consult on either via phone or in person”. EMTALA Policy Review of EMTALA Policy on 07/08/24 shows that “PROCEDURE, 5, 5.5, “Where, in the opinion of a Qualified Medical person or physician, the patient ’ s condition requires Stabilizing Treatment or further evaluation by another physician available through the on-call list, the patient will be seen by an on-call physician who will assume responsibility for the further care and treatment of the patient”. On-call schedule A review of the Vascular Surgery on-call schedule for May 17 - 18, 2024, revealed the hospital had a Vascular Surgeon available to provide evaluations and stabilizing treatment. The hospital on-call schedule revealed Vascular Surgeon #1 was listed as the available physician.”