Parkwest Medical Center

“DISCHARGE PLANNING TIMELY EVALUATION CFR(s): Any discharge planning evaluation must be made in a timely basis to ensure the appropriate arrangements for post-hospital care will be made before discharge and to avoid unnecessary delays in discharge. This Standard is not met as evidenced by: 41291 Based on hospital policy review, medical record and interview, the hospital failed to ensure post-hospital care needs were secured with the home health agency (HHA) and infusion agency prior to discharge, regarding new tube feeding orders and education for 1 patient (Patient #11) of 2 patients reviewed for discharge planning. The findings include: Review of the facility’s policy titled, “Care Management/Interdisciplinary Discharge Planning,” revised 1/2029, revealed “...The Care Management Department, in conjunction with the medical...multidisciplinary patient care staff, will coordinate and provide...services for the patient...family...Post-acute care needs...identified...to meet the identified needs, preferences...goals to ensure...appropriate, safe...smooth transition of care...” Review of Patient #11’s medical record revealed the patient presented to the facility’s Emergency Department on 5/8/2023, with complaints of cough and shortness of breath. The patient was admitted from 5/9/2023-5/14/2023 with Aspiration Pneumonia, Dysphagia, Myasthenia Gravis (a neuromuscular disorder that leads to weakness of skeletal muscles) and Myotonic Dystrophy (a complex, inherited condition that causes progressive muscle atrophy and weakness). Review of Patient #11’s Gastroenterology Daily Progress Note dated 5/10/2023, revealed the patient was tolerating liquids. After a discussion with the patient’s wife and Neurology, it was agreed to proceed with gastrostomy tube placement. The procedure was discussed in detail. The patient and wife were aware “...as...daughter has a gastrostomy tube with the same neurological condition...” Review of Patient #11’s Hospitalist Daily Progress Note dated 5/11/2023 at 2:43 PM, revealed a plan for PEG (Percutaneous Endoscopic Gastrostomy-a tube inserted into the stomach for nutritional feedings and mediation administration) insertion; “...Discussed with Case Management to arrange for home tube feedings...orders will depend on nutritionist recommendation...Likely discharge either on Friday or Saturday depending on how patient tolerates...tube feeds...” Review of Patient #11’s Case Management Narrative Note dated 5/12/2023 at 9:00 AM, revealed the discharge summary was faxed to the home health agency to notify of pending discharge to home on 5/14/2023. Review revealed the discharge summary did not include the planned home bolus tube feedings (bolus is the amount of tube feeding given at one feeding interval, approximately equal to a meal) or family educational needs. Review of Patient #11’s Nutrition Note dated 5/12/2023 at 1:14 PM, revealed “...For home bolus TF [tube feeding] regimen after d/c [discharge], recommend 7 total cartons Jevity 1.2...daily over 4 bolus feedings/day (mealtimes & before bed) w [with]/80 mL[milliliters] H2O [water] flush before & after each bolus feeding. First 3 bolus feedings - 2 cartons each & last feeding - 1 carton...” Review revealed this order did not get faxed to the infusion agency when Patient #11 was discharged. Review of Patient #11’s Case Management Narrative Note dated 5/17/2023 at 10:22 AM, revealed the infusion agency notified the Case Manager the wife of Patient #11 had called about the patient’s tube feedings and supplies, “...as this was not arranged prior to the patient’s DC [discharge] 5/14 [5/14/2023]...” The Case Manager faxed the documentation to the infusion agency with confirmation of receipt to, “...assist with securing TF [tube feeding] arrangement post DC...” During an interview on 12/3/2024 at 9:18 AM, Hospitalist A stated he relied on the nursing team to ensure the patient and family are educated on discharge care and instructions. During an interview on 12/3/2024 at 9:48 AM, Discharge Care Coordinator B stated on Friday 5/12/2023, home health had been arranged for Patient #11 and they were waiting on the home dietary orders for tube feedings from the RD (registered dietician). Discharge Care Coordinator B stated she did not get the dietary orders on 5/12/2024, before she left for the day. She stated she was unaware the orders had been written, and the orders did not get faxed to the infusion agency to set up in-home tube feedings or family education. During an interview on 12/3/2024 at 9:53 AM, Case Manager (CM) C stated when she saw Patient #11 on 5/12/2023 (Friday) the RD had not seen the patient or made dietary recommendations. CM C stated the RD, after seeing Patient #11 and writing recommendations for in-home tube feedings, should have notified nursing or case management, but that did not happen. No order was placed in the electronic medical record (EMR) for the recommended tube feedings. Patient #11 was discharged on a Sunday and there was no Case Manager available to ensure the aftercare, for home discharge had been arranged and the patient had everything needed to go home. The CM stated typically, before a patient is discharged home with skilled nursing services, and tube feeding is considered a skilled service, the infusion agency will send a nurse to the hospital to start education with the patient and family. After bedside education is completed, the infusion nurse will notify the Case Manager involved with the patient to let them know the education is completed. CM C stated this did not happen because the infusion agency was not made aware of the pending discharge with tube feeding recommendations. During an interview on 12/3/2024 at 1:28 PM, the RD stated she was consulted on Patient #11 for new tube feeding recommendations and the patient would be going home on bolus tube feeding at discharge on 5/12/2023. The RD stated she spoke with the family on 5/12/2023, went over tube feedings and provided them with a pamphlet titled, “Your Guide to Home Tube Feeding.” She was unable to recall the patient’s or wife’s knowledge of tube feeding. The RD stated she places her recommendations in the patient’s EMR, she does not notify anyone after she places her recommendations. The RD stated she is unaware of how case management or nursing are aware of her recommendation, but there had never been a problem that she was aware of, “...I put the note in and then case management takes care of it...” She was unaware of any process changes. During an interview on 12/3/2024 at 10:15 AM, Unit Manager E stated if Patient #11 and the wife had not received discharge education about the tube feeding and the staff were not sure if everything had been arranged for discharge, then she expected there to be a discussion among the discharge nurse, unit shift leader, house supervisor, case management, and/or the provider of home services to ensure the patient and the family were ready for discharge and had what they needed to go home.”

“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: 30553 Based on review of facility policy, review of on-call schedules, medical record review, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) and failed to provide an appropriate transfer for 1 patient (#15) who presented to the Emergency Department (ED) with complaints of abdominal pain of 22 ED records reviewed. The findings include: Patient #15 was presented to Facility A on 8/31/2024 with a diagnosis of Abdominal Pain. Medical record review showed a medical screening examination (MSE) was initiated by the Emergency Department (ED) Physician. Diagnostic testing was completed. The Computed Tomography (CT) scan of the abdomen showed a Small Bowel Obstruction. The ED Physician spoke with the on-call general surgeon and bariatric surgeon at Facility A and the on-call bariatric surgeon at Facility B. There were discussions related to the transfer from or retaining the patient at Facility A. Facility A’s bariatric surgeon felt the patient should be transferred to Facility B for continued care with the bariatric surgeon who performed an initial gastric bypass procedure (weight loss surgery). Facility B’s bariatric surgeon accepted the patient but felt the procedure could be performed at Facility A. There were no additional diagnostics performed, including a repeat CT scan or Lactic Acid blood level, to conclude if the patient had a closed loop bowel obstruction or if the patient was septic. Patient #15 was transferred to Facility B on 9/1/2024, where an exploratory laparoscopy (surgical procedure) with segmental small bowel resection and anastomosis (repair) was performed. Refer to A-2406 and A-2409”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30553 Based on review of facility policy, review of on-call schedules, medical record review, and interviews, the facility failed to provide a thorough and ongoing Medical Screening Examination (MSE) for 1 patient (#15) who presented to the Emergency Department (ED) with complaints of abdominal pain of 22 ED records reviewed. The findings include: Review of facility policy, “Emergency Medical Treatment and Active Labor (EMTALA) Guidelines,” revised 5/2024, showed “...Medical Screening Examination [MSE] is defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an Emergency Medical Condition [EMC] or not, an MSE is an ongoing process that begins with triage...the MSE may include...other examinations, test, or procedures as deemed necessary by the treating practitioner...” Review of the on-call schedules for Facility A showed on 8/31/2024, the facility had on-call surgeons for Bariatrics and General Surgery. Review of the ED Central Logs showed Patient #15 presented to Facility A’s ED on 8/31/2024 at 6:16 PM, with Abdominal Pain. Medical record review of an ED Nursing Triage record, dated 8/31/2024 at 6:27 PM, showed the patient presented with abdominal cramping, stabbing pain into his back and left side. The pain started two hours prior to arrival. The patient was triaged with an Emergency Severity Index (ESI) of a 2, indicating emergent needs. Medical record review of an ED Physician’s Record, dated 8/31/2024 at 9:24 PM, showed the patient had intermittent cramping and pain over the past week. The patient presented with an acute onset of abdominal pain with radiation to his left flank, approximately two hours prior to arrival with nausea and vomiting. The patient’s abdomen was mildly distended with diffuse tenderness, which was worse to the left side. Diagnostic testing was ordered and completed to include the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipase, and a Computed Tomography (CT) of the abdomen and pelvis. Medical record review of the CT of the abdomen and pelvis findings, dated 8/31/2024 at 7:50 PM, showed short segment focally dilated small bowel loop in the mid abdomen measuring up to 4 centimeters (cm) with adjacent fluid and edema, “...this is potentially a closed loop obstruction with dilated short segment closely positioned transition sites. Overall, findings are suspicious for small bowel obstruction/developing obstruction.” Medical record review of the ED Physician’s notes dated 8/31/2024, showed the following: 8:35 PM - The case was discussed with Facility A’s on-call general surgery, there was some uncertainty if this was a true bowel obstruction, due to the patient’s normal white blood cell count and a heart rate of 56. The on-call bariatric surgeon at Facility B was called. 9:04 PM - The on-call bariatric surgeon at Facility B was consulted and determined he would be able to accept patient, but there were currently no beds available at Facility B. It was determined the patient’s presentation would be discussed with the on-call bariatric surgeon at Facility A. 9:12 PM - The patient’s case was discussed with Facility A’s on-call for bariatric surgery and he recommended the patient be transferred to Facility B, where the patient’s initial bariatric surgery was performed. Facility B’s transfer center informed Facility B they were able to accept the patient on transfer and arranged the transfer. 10:30 PM - The patient’s transfer in progress to Facility B. The diagnoses included Obstructed Internal Hernia and Small Bowel Obstruction. Medical record review showed no documentation the on-call bariatric surgeon at Facility A evaluated the patient during the admission on 8/31/2024. There were no additional diagnostics performed to ascertain an ischemic injury (lack of blood supply) or to rule out Sepsis. Medical record review of an Admission History and Physical from Facility B, dated 9/1/2024 at 3:00 AM, showed the patient had a previous Laparoscopic Gastric Bypass in June 2023. About 14 hours prior to arrival, the patient had a sudden onset of left-sided abdominal pain. He presented to Facility A on 8/31/2024, where he was diagnosed with a Closed Loop Bowel Obstruction in the jejunojejunostomy (surgical procedure) region. A request for transfer was made. On arrival, the patient continued to have pain which was stated as 8-9 out of 10 to the left side. His physical examination showed bloating, positive for abdominal pain, nausea, and dry heaves. His abdomen was nondistended, he had guarding and tenderness with positive rebound tenderness. His CT of the abdomen showed evidence of a Closed Loop Bowel Obstruction, likely related to an Internal Hernia around the jejunojejunostomy region. A discussion with the patient showed “...my recommendation to proceed immediately to the operating room, as was planned prior to his transfer. We discussed the plan for an exploratory laparoscopy. However, I did tell him that given the degree of incarceration that this is likely to be present and the potential for ischemic bowel there is a likelihood that we would need to convert to an open laparotomy. We discussed some of the other etiologies for bowl obstruction such as adhesions. We discussed the potential need for bowel resection. We discussed how nonoperative management was essentially not an option at this point. Patient expressed his understanding and agreement to proceed to the operating room...” Medical record review of an operative report, dated 9/1/2024 at 3:36 PM, showed an exploratory laparoscopy with segmental small bowel resection and anastomosis was performed. The patient was admitted to Facility B. During an interview on 10/15/2024 at 2:45 PM, the ED Nurse Manager stated the patient presented to the ED on 8/31/2024 with back and abdominal pain. The ED Physician had spoken with General Surgery regarding the patient, and it was felt related to the patient’s normal WBC and low pulse, there was questions if the patient had a true bowel obstruction. The ED physician spoke with the on-call Bariatric Surgeon at Facility B who stated he would accept the patient but there were no inpatient beds. The on-call surgeon suggested speaking with Facility A’s on-call bariatric surgeon and the patient not be transferred. The ED Physician spoke with Facility A’s on-call Bariatric Surgeon who felt since the patient had the gastric bypass at Facility B, it would be best for the patient to transfer to Facility B. During an interview on 10/15/2024 at 3:30 PM, ED Physician #1 and ED Medical Director, stated the patient presented with abdominal pain, nausea and vomiting on 8/31/2024. The patient had a previous gastric bypass June 2023. A CT of the abdomen and pelvis was completed which showed a closed loop bowel obstruction. She had spoken with Facility A’s on-call General Surgeon and there were some questions related the patient’s WBC was not elevated and the patient’s heart rate was in the 50’s. She had called the Facility B’s on-call bariatric surgeon who stated he would accept the patient but there were no beds. The on-call surgeon at Facility B asked for the on-call Bariatric Surgeon at Facility A to be called for possible surgical intervention and the patient not be transferred. She called Facility A’s Bariatric Surgeon, who stated if at all possible, the patient should be transferred to Facility B related to previous gastric bypass surgery in the past. During a telephone interview on 10/16/2024 at 8:00 AM, Facility A’s General Surgeon stated the ED physician had called him regarding the patient. The patient’s CT showed a possible small bowel obstruction. He had a previous gastric bypass at EMC. The patient’s WBC was normal and the patient did not present with sepsis. During a telephone interview on 10/16/2024 at 1:01 PM, Facility’s A’s Bariatric Surgeon #1, stated he was on-call for 8/31/2024. The ED Physician called and the patient’s presentation and diagnostic findings were discussed. He had spoken with the on-call Bariatric Surgeon at Facility B on the phone regarding the patient’s diagnostic findings who felt the patient could be kept at Facility A. The discussions included most surgeons would like to evaluate and treat their own patients, patients could be admitted to the pre-operative unit for evaluation and then taken to surgery. He stated “...he did not like my suggestions and was not happy. He did not think the patient needed transfer related to there were no beds. I told him the patient could be a transfer from ED to ED and he could see the patient in the ED if the beds were the issue. There was an agreement for the transfer to [Facility B] as the patient would probably need surgical intervention...” He confirmed he did not evaluate the patient in the ED on 8/31/2024. During a telephone interview on 10/16/2024 at 4:40 PM, the complainant stated the patient was transferred from Facility A to Facility B on 9/1/2024. The Risk Manager from Facility A had confirmed Facility A had capacity and availability to perform the surgery. The Bariatric Surgeons from both facilities had spoken on the phone on 8/31/2024. After discussion, there was an agreement for the transfer to Erlanger. The Bariatric Surgeon at Facility B felt the patient did not need transfer and the patient could have been managed at Facility A. During a telephone interview on 10/21/2024 at 10:00 AM, Bariatric Surgeon #2 the patient was in a facility who had the capacity to treat and admit the patient. He had questioned why the procedure could not be performed at Facility A. He had spoken with the ED Physician who stated the patient had a small bowel obstruction. The ED Physician had talked with the surgeon who thought the patient needed transfer related to previous surgery at Facility B. He had spoken with the on-call bariatric provider at Facility A and informed the surgeon the facility did not open beds and the patient could be treated at [Facility A] and not transferred. Bariatric Surgeon #2 stated “...[named Bariatric Surgeon #1] told me he had often had patients transferred and he would see the patient in the ED or in the preoperative area. I told him I was not refusing the patient, but I felt the patient could be treated there and not transferred...” The patient arrived at Facility B on 9/1/2024 and was taken to surgery for an exploratory laparotomy. The patient was admitted and discharged home on 9/3/2024.”

“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: 30553 Based on review of facility policy, review of on-call schedules, medical record review, and interviews, the facility inappropriately transferred 1 patient (#15) who presented to the Emergency Department (ED) with complaints of abdominal pain of 22 ED records reviewed. The facility had the capability and capacity to treat Patient #15, but transferred instead. The findings include: Review of facility policy, “Emergency Medical Treatment and Active Labor (EMTALA Guidelines,” revised 5/2024, showed “...the hospital will not transfer patients who are potentially unstable as long as the hospital has capacity and capabilities to provide stabilizing treatment to the patient...” Review of the on-call schedules for Facility A showed on 8/31/2024, the facility had on-call surgeons for Bariatrics and General Surgery. Review of the hospital census for 8/31/2024, showed the facility had the capacity to admit. The facility had 284 staffed beds with 249 of those beds designated for acute care. The facility-wide census was as follows on 8/31/2024: 7:00 AM: 226 patients 7:00 PM: 213 patients Medical record review of an ED Nursing Triage record, dated 8/31/2024 at 6:27 PM, showed Patient #15 presented with abdominal cramping, stabbing pain into his back and left side. The pain started two hours prior to arrival. The patient was triaged with an Emergency Severity Index (ESI) of a 2, indicating emergent needs. Medical record review of an ED Physician’s Record, dated 8/31/2024 at 9:24 PM, showed the patient had intermittent cramping and pain over the past week. The patient presented with an acute onset of abdominal pain with radiation to his left flank approximately two hours prior to arrival with nausea and vomiting. The patient’s abdomen was mildly distended with diffuse tenderness, which was worse to the left side. Diagnostic testing was ordered and completed to include the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipase, and a Computed Tomography (CT) of the abdomen and pelvis. The patient’s CT scan of the abdomen and pelvis showed a Small Bowel Obstruction. Medical record review of the ED Physician’s notes, dated 8/31/2024, showed the following: 8:35 PM - The case was discussed with Facility A’s on-call general surgery. The on-call bariatric surgeon at Facility B was called. 9:04 PM - The on-call bariatric surgeon at Facility B was consulted and determined he would be able to accept the patient, but there were currently no beds available at Facility B. It was determined the patient’s presentation would be discussed with the on-call bariatric surgeon at facility A. 9:12 PM - The patient’s case was discussed with Facility A’s on-call for bariatric surgery who recommended the patient be transferred to Facility B, where the patient had his bariatric surgery. 10:30 PM - It was determined the patient would be transferred to Facility B. The diagnoses included Obstructed Internal Hernia and Small Bowel Obstruction. Medical record review showed no documentation the bariatric on-call surgeon at Facility A evaluated the patient. Medical record review of an Admission History and Physical from Facility B, dated 9/1/2024 at 3:00 AM, showed the patient had a previous Laparoscopic Gastric Bypass in June 2023. About 14 hours prior to arrival, the patient had a sudden onset of left-sided abdominal pain. He presented to (Facility A) on 8/31/2024, and was diagnosed with a Closed Loop Bowel Obstruction in the jejunojejunostomy (surgical procedure) region. A request for transfer was made for the patient. On arrival, the patient continued to have pain which was stated as 8-9 out of 10 to the left side. His CT of the abdomen showed evidence of a Closed Loop Bowel Obstruction, likely related to an Internal Hernia around the jejunojejunostomy region. The patient was taken to the operating room where an Exploratory Laparoscopy with Segmental Small Bowel Resection and Anastomosis was performed. The patient was admitted to Facility B. During an interview on 10/15/2024 at 2:45 PM, the ED Nurse Manager stated the patient presented to the ED on 8/31/2024 with back and abdominal pain. The ED Physician had spoken with General Surgery regarding the patient, and it was felt related to the patient’s normal WBC and low pulse, there was questions if the patient had a true bowel obstruction. The ED physician spoke with the on-call Bariatric Surgeon at Facility B who stated he would accept the patient but there were no inpatient beds. The on-call surgeon suggested speaking with Facility A’s on-call bariatric surgeon and the patient not be transferred. The ED Physician spoke with Facility A’s on-call Bariatric Surgeon who felt since the patient had the gastric bypass at Facility B, it would be best for the patient to transfer to Facility B. During an interview on 10/15/2024 at 3:30 PM, ED Physician #1 and ED Medical Director, stated the patient presented with abdominal pain, nausea and vomiting on 8/31/2024. The patient had a previous gastric bypass June 2023. A CT of the abdomen and pelvis was completed which showed a closed loop bowel obstruction. She had spoken with Facility A’s on-call General Surgeon and there were some questions related the patient’s WBC was not elevated and the patient’s heart rate was in the 50’s. She had called the Facility B’s on-call bariatric surgeon who stated he would accept the patient but there were no beds. The on-call surgeon at Facility B asked for the on-call Bariatric Surgeon at Facility A to be called for possible surgical intervention and the patient not be transferred. She called Facility A’s Bariatric Surgeon, who stated if at all possible the patient should be transferred to Facility B related to previous gastric bypass surgery in the past. During a telephone interview on 10/16/2024 at 8:00 AM, Facility A’s General Surgeon stated the ED physician had called him regarding the patient. The patient’s CT showed a possible small bowel obstruction. He had a previous gastric bypass at EMC. He did not evaluate the patient during his admission on 8/31/2024. During a telephone interview on 10/16/2024 at 1:01 PM, Facility’s A’s Bariatric Surgeon #1, stated he was on-call for 8/31/2024. The ED Physician called and the patient’s presentation and diagnostic findings were discussed. He had spoken with the on-call Bariatric Surgeon at Facility B on the phone regarding the patient’s diagnostic findings who felt the patient could be kept at Facility A. The discussions included most surgeons would like to evaluate and treat their own patients, patients could be admitted to the pre-operative unit for evaluation and then taken to surgery. He stated “...he did not like my suggestions and was not happy. He did not think the patient needed transfer related to there were no beds. I told him the patient could be a transfer from ED to ED and he could see the patient in the ED if the beds were the issue. There was an agreement for the transfer to [Facility B] as the patient would probably need surgical intervention...” He confirmed he did not evaluate the patient in the ED on 8/31/2024. During a telephone interview on 10/16/2024 at 4:40 PM, the complainant stated the patient was transferred from Facility A to Facility B on 9/1/2024. The Risk Manager from Facility A had confirmed Facility A had capacity and availability to perform the surgery. The Bariatric Surgeons from both facilities had spoken on the phone on 8/31/2024. The Bariatric Surgeon at Facility B felt the patient did not need transfer and the patient could have been managed at Facility A. During a telephone interview on 10/21/2024 at 10:00 AM, Bariatric Surgeon #2 the patient was in a facility who had the capacity to treat and admit the patient. He had questioned why the procedure could not be performed at Facility A. He had spoken with the ED Physician who stated the patient had a small bowel obstruction. The ED Physician had talked with the surgeon who thought the patient needed transfer related to previous surgery at Facility B. He had spoken with the on-call bariatric provider at Facility A and informed the surgeon the facility did not open beds and the patient could be treated at [Facility A] and not transferred. The patient arrived at Facility B on 9/1/2024 and was taken to surgery for an exploratory laparotomy.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 30553 Based on review of facility policy, medical record review, review of Emergency Department (ED) video footage and interviews, the facility failed to provide a triage assessment or medical screening examination for 1 patient (#24) who presented to the ED with hypertension, nausea and vomiting of 26 ED records reviewed. The findings include: Review of the facility policy “Emergency Medical Treatment & Active Labor ACT (EMTALA),” revised 5/2024, showed “...comes to the emergency department...has presented at a hospital’s emergency department, and request examination or treatment for a medical condition...triage-refers to the clinical assessment if the individual’s presenting signs and symptoms at the time of arrival at the hospital in order to prioritize when the individual will be seen by a physician or other qualified medical personnel [QMP] for completion of the medical screening examination. Medical Screening Examination [MSE] will be performed for any individual that...had requested for examination or treatment...MSE may include [1] assessment of the chief complaint as recorded in the patient’s triage record [2] vital signs upon admission and upon discharge...” Review of the facility policy “Documentation and nursing care of the patient in the Emergency Department,” revised 1/2020, showed “...Triage Assessment: Registered Nurse or Provider will complete a triage assessment and triage classification on all patients who present to the Emergency Department. The nature of illnesses and injuries of these patients will govern the classification to assign priorities for a patient’s treatment. The triage process should never delay care of a patient presenting with life threatening needs. The Emergency Severity Index (ESI) triage system (tool used for Emergency Department triage) will be used to prioritize patients presenting to the Emergency Department seeking care...” Review of the ED Central Log showed Patient #24 presented to the ED on 9/2/2024 at 10:08 PM, with complaints of headache, nausea and vomiting and at 11:51 PM, the patient was coded as left the ED prior to triage. Medical record review of an ED Nurses Note, dated 9/2/2024 at 11:50 PM, showed at 11:12 PM, the patient was called for triage and the patient was not in the ED lobby. Continued review showed at 11:30 PM, the patient was called for triage, the patient was not in the ED lobby, and the patient was removed from the tracking board “...assumed to have left prior to triage...” There was no documentation of vital signs for the patient or documentation of the risk and benefits of leaving prior to a nursing triage assessment. Medical record review showed the patient arrived at Facility B on 9/2/2024 at 11:33 PM. Medical record from Facility B revealed an ED Nursing Triage record, dated 9/2/2024 at 11:38 PM, showed the patient had complaints of a headache which started around noon on 9/2/2024 and she had a previous history of elevated blood pressure. She complained of a headache with a pain score of a 10 (0-10 scale with 10 being the worst). The triage record showed an Emergency Severity Index score of a 2, indicating urgent needs. Review of Facility A’s ED video footage for 9/2/2024 showed the following: 10:08 PM: The patient ambulated into the main ED entrance with another female. The patient went to the ED lobby desk where she was met by the ED Greeter. The patient walked toward the ED restroom. 10:09 PM (45 seconds): the greeter took the patient’s registration paperwork to the triage room. 10:11 PM (36 seconds): the patient ambulated from the ED restroom with another female to a seat in the waiting room. The female went to desk and got an emesis bag for the patient. 10:24 PM: there were patients going into and coming out of the triage room. 10:35 PM (24 seconds): the female with the patient got a blanket from the greeter for the patient. 11:10 PM (24 seconds) (62 minutes after arrival): the patient went to the desk and gave the blanket back to the greeter and walked out the ED main entrance door. During a telephone interview on 9/16/2024 at 6:25 PM, the complainant stated she had a previous history of hypertension. She stated they went to [Facility A] ED on 9/2/2024 around 9:00 PM-10:00 PM with an elevated blood pressure, nausea and vomiting. The patient’s vital signs were never taken and she was not taken into a room for evaluation. They waited in the ED Lobby for 45 minutes and left the ED. The patient went to [Facility B] where she was evaluated, an EKG and a CT of the head was performed. During an interview on 9/19/2024 at 10:45 AM, the ED Director stated the patient was listed on the ED Central Log as a “left prior to triage.” The ED Director confirmed a quick registration was completed for Patient #24 and the triage nurse was notified. Interview confirmed the patient was not triaged and no vital signs were obtained. During a telephone interview on 9/19/2024 at 1:40 PM, the ED Medical Director stated any patient who presented to the ED for evaluation would be registered, triaged and a medical screening examination would be performed. During a telephone interview on 9/23/2024 at 6:50 PM, Patient Care Technician #1 stated Patient #24 presented with hypertension, nausea and vomiting. She confirmed she registered the patient, but did not obtain vital signs for the patient. The patient came to the desk stating she was leaving the ED prior to the triage and she did not notify the triage nurse Patient #24 was leaving.”