Southern Tennessee Regional Health System Lawrence

“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: 33763 Based on hospital document review, policy review, medical record review, law enforcement document review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical attention were provided an appropriate and ongoing Medical Screening Examination (MSE) for 1 of 20 (Patient #4) sampled patients reviewed. The findings included: Medical record review revealed Patient #4 was taken to the ED via law enforcement on 9/4/2025 after the Patient was taken from a local residence where she was yelling, uncooperative and had reportedly bitten a family member. The Patient arrived at the ED at 6:12 PM and was escorted by law enforcement to a room deemed safe for psychiatric patients, where Registered Nurse (RN) #1 attempted to complete a triage assessment. Patient #4 was uncooperative with the RN, belligerent, and became combative and verbally aggressive when the RN attempted to obtain vital signs and remove the Patient’s clothing and belongings to put the Patient in a hospital gown. The RN was unsuccessful in completing the triage assessment for Patient #4, but was assigned an Emergency Severity Index (ESI - a tool for prioritizing patients in the emergency department) level 2, emergent (the patient is high-risk or has a potentially life-threatening condition). There was no documentation a MSE was completed by ED Provider #1 to determine if an Emergency Medical Condition existed for Patient #4. The RN documented Patient #4 struck her on her arm, and law enforcement personnel arrested the Patient and escorted the Patient back to jail at 6:53 PM. Patient #4 remained in jail until 9/6/2025 when she was transported by law enforcement to Hospital #2, an inpatient psychiatric hospital, where she was involuntarily admitted. Cross Refer to A-2406.”

“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: 33763 Based on hospital document review, policy review, medical record review, law enforcement document review, and interview, the hospital failed to ensure all patients presenting to the Emergency Department (ED) seeking medical attention were provided an appropriate and ongoing Medical Screening Examination (MSE) for 1 of 20 (Patient #4) sampled patients reviewed. The findings included: Review of the hospital’s “Medical Staff Bylaws” dated 1/2/2025 revealed, “...Each member of the Medical Staff shall...Provide his/her patients with continuous care at the generally recognized professional level of quality...Abide by the Medical Staff Bylaws and other lawful standards, policies and Rules and Regulations of the Medical Staff...Appendix “B” - Rules & Regulations... Emergency Medical Screening, Treatment, Transfer...Screening (1) Any individual who presents to the Emergency Department of this Hospital for care shall be provided with a medical screening examination to determine whether that individual is experience an emergency medical condition. Generally, an “emergency medical condition” is defined as active labor or as a condition manifesting such symptoms that the absence of immediate medical attention is likely to cause serious dysfunction or impairment to bodily organ or function, or serious jeopardy to the health of the individual or unborn child...All patients shall be examined by qualified medical personnel, which shall be defined as a physician...Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge...” Review of the hospital’s “Entry into ED Process, 780-1002” policy effective 4/2025 revealed, “Purpose To describe the two-tiered system of the triage and medical screening process which is an organized systematic method of assessment and prioritization of patient care needs ensuring immediate care of the acute patient...Triage is a sorting process to determine the order in which patients will be provided a medical screening examination by a physician or qualified medical person. Triage is not the equivalent of a medical screening examination and does not determine the presence or absence of an emergency medical condition. Using the Emergency Severity Index (ESI), which is a five level tool to rate patient acuity, the triage nurse will rate the patient’s acuity from level 1 (most urgent) to level 5 (least resource intensive)...Level 1: Requires immediate response (e.g. cardiac arrest) Level 2: Treatment to commence within ten minutes (e.g. airway risk) Level 3: Treatment to commence within 30 minutes (e.g. hypertension)...Triage directs patients to treatment areas within the department most appropriate for their needs...Medical Screening Exam is process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...Such screening must be done within the facility’s capability and available personnel, including on-call physicians. The medical screening exam is an ongoing process and the medical record must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred/discharged...All patients will be triaged upon arrival to the ED...Patients with emergency medical condition (category I or II) will be placed in an available treatment area for immediate initiation of the medical screening exam...[Named hospital] will perform the Medical Screening Exam (MSE) to determine if an emergency medical condition exists...The MSE must be the same MSE that the hospital would perform on any individual coming to the hospital’s emergency department with those signs and symptoms...A MSE is not an isolated event. It is an ongoing process. The record must reflect continued monitoring according to the patient’s needs and must continue until he/she is stabilized or appropriately transferred/discharged. There should be evidence of this evaluation document in the medical record prior to disposition...The patient will be treated according to physician’s orders and/or protocols which will be written on the ED record...Those patients with emergency conditions are treated immediately according to protocols and/or as required by the ED physician. Those patients who need consultation by specialty physicians and/or services for stabilization will have specialty care rendered within the capability of this facility...” Review of the hospital’s “Copy of LL.026 EMTALA [Emergency Medical Treatment and Active Labor Act]- Medical Screening and Treatment of Emergency Medical Conditions” policy effective 9/2023 revealed, “...Purpose: To ensure that individuals coming to an affiliated Hospital’s Dedicated Emergency Department [DED] seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act (“EMTALA”)... and, if an Emergency Medical Condition is determined to exist, such individuals are offered stabilization treatment within the capabilities and/or are transferred if appropriate...Emergency Medical Condition means: 1. A medical condition manifesting itself by acute symptoms of sufficient severity (inkling severe pain, psychiatric disturbances and/or symptoms of substance about) such that the absence of immediate medical attention could reasonably by expected to result in...Placing the health of the individual...in serious jeopardy...Serious impairment to bodily functions; or...Serious dysfunction of any bodily organ or part...Medical Screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists or a woman is in labor...The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred. Triage does not constitute a Medical Screening Examination...Policy: Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. If an Emergency Medical Condition is found to exist, the Hospital will...provide (a) stabilizing treatment within the capabilities of the hospital and its staff...and/or (b) an appropriate transfer to another medical facility...The Hospital should utilize the Triage Process to determine the order in which patients receive a Medical Screening examination and further treatment as necessary. Triage does not determine the presence or absence of an Emergency Medical Condition...In general, when an individual...comes to a Dedicated Emergency Department and requests assessment or treatment for a medical condition (whether or not the individual believes it to be an emergency), or the request is made on the individual’s behalf...The Hospital must provide for an appropriate Medical Screening Examination conducted by a physician or other Qualified Medical Professional...If the Medical Screening Examination reveals an Emergency Medical Condition, then the Hospital must provide stabilizing treatment within its capacity and capabilities...necessary to stabilize the patient or must appropriately transfer the patient to another facility...” Review of the hospital’s “Potentially Violent Individuals (Code Violet), 835-1063” policy approved 6/2025 revealed, “...The purpose of this policy is to outline the necessary steps to take when dealing with a patient, visitor, co-worker or any other person who is showing signs of violence and/or aggressive behavior...Security and/or all able bodied “Handle with Care” - trained staff male employees shall respond to the area. Security and/or “handle with Care”-trained staff members shall respond and along with nursing, take control of the situation. 4. If the subject refuses to calm down and the potential for physical injury is possible the response team may restrain the individual in order to reduce or eliminate the threat to the subject, our staff and other patients...” Review of the hospital’s ED Log revealed Patient #4 was taken to the ED via law enforcement on 9/4/2025 at 6:11 PM with chief complaint of “Psych Problem.” Medical record review revealed Patient #4 arrived in the ED at 6:12 PM. ED Provider #1’s physician’s order revealed, “18:14 [6:14 PM] MSE Initiated by Provider...Dispensed Medications...18:23 [6:23 PM] CANCELED (Other): ziprasidone IM [intramuscular] 20 mg [milligrams] IM once...” Review of a note written by RN #1 revealed, “Presentation: 09/04 [2025] 18:13 [6:13 PM] Acuity: Emergent (2) [the patient is at high-risk of a potentially life-threatening condition]. 18:24 [6:24 PM] Presenting complaint...Pt [patient] came in by [local law enforcement]. Pt was belligerent on arrival unable to calm or redirect. Pt was aggressive was threatening to “punch the nurses here.” Pt was yelling and screaming at me to not touch her, states I did not have consent to touch her. Pt states she refuses to undress “in front of this bisexual bitch.” Pt screaming for head nurse, states she is going to punch staff here. Unable to calm patient, refusing for vitals to be taken. Placed BP cuff on pts arm she removed it. Pt did punch me, hit left forearm. [local law enforcement] at bedside as well as hospital security. Pt was escorted to jail by [local law enforcement]. [Named law enforcement officer] escorted pt to cop car all belongings were sent with pt. Pt screaming during entire stay unable to calm...Vital Signs...18:24 [6:24 PM] unable to obtain...18:37 [6:37 PM] Discharged to police custody. Pt taken to jail by law enforcement, no instruction given to pt...18:53 [6:53 PM] Patient left the ED...Disposition Summary...Left Against Medical Advice...Condition: Unknown...” Review of an addendum written by ED Provider #1 on 9/20/2025 at 7:28 AM revealed, “This patient left before evaluation. No provider encounter...” There was no documentation a MSE was completed to determine if an Emergency Medical Condition existed, no documentation the Patient’s condition was stabilized, and no documentation to indicate the Patient’s condition when Patient #4 left the hospital. Review of the police report narrative dated 9/4/2025 revealed officers were dispatched to perform a welfare check in the community. “Upon arrival...There were 2 females standing and 1 was sitting on the ground. The 2 standing...stated that the female on the ground [Patient #4] was having a manic episode. [Patient #4] was yelling for people to leave her alone and that people were attacking her. She was visibly shaken and crying frantically...” The officers informed Patient #4 they were taking her to the ED and allowed her to gather some of her belongings to take with her. The report indicated the 2 females that were standing were the Patient’s mother and sister and Patient #4’s mother had recently picked the Patient up from a group home out of town and brought her to her home. The report revealed, Patient #4’s mother informed the officer, “Since that time [Patient back from out of town], as long as [Patient #4] was taking her medication, there were no issues. But recently [Patient #4’s mother] believes that [Patient #4] was either refusing to take her meds or had run out, the result was what we were currently witnessing...” The report indicated Patient #4 “was originally very against the transport...After some coaxing...she did agree to go...” The report indicated the Patient was transported to the ED by 2 of the officers that were onsite, and Law Enforcement Officer #1 stayed behind at the residence and was informed Patient #4 had bitten her sister when they “were attempting to hold her down ([Patient #4] wanted to drive off)...I [Law Enforcement Officer #1] left the residence and headed to the ER [Emergency Room]...Once I arrived I opened the doors to the ER and heard a lot of screaming and yelling coming from room 5 [ED room considered a safe room for psychiatric patients]. As I approached [named law enforcement officer] said that [Patient #4] was being very uncooperative with the nurses and security. She was refusing to let the nurses put her in a gown stating that “all women in [named town where Hospital #1 was located] were Bi-sexual” and she didn’t feel comfortable undressing in front of them. This banter went back and forth for a few seconds, before I decided to tell her that if she continued to act out, I would simply take her to jail. This statement worked for roughly a minute before she became irate and struck a nurse with a closed fist on the nurse’s right arm. At this point I [Law Enforcement Officer #1] decided to place [Patient #4] in custody for assault and transported her to jail. While at jail she did verbally resist the jailers numerous times, and was placed in the observation cell. I did contact mobile crisis and advised them of the situation. They stated they would respond back in less than 2 hours with a counselor. At no point was force used against [Patient #4] by [named local law enforcement] deputies, she was compliant with verbal commands.” During a telephone interview on 9/23/2025 at 10:20 AM, RN #1 verified she recalled Patient #4. The RN stated the Patient was brought into the ED by local law enforcement. The RN stated she was explaining she had to remove the Patient’s belongings and clothes, put her in a gown and check her vital signs, the Patient “absolutely refused everything. I told her I have to take her belongings and put her in a gown and explained I had to make sure she was safe. She ripped everything off I put on her [blood pressure cuff]. I couldn’t calm her down. I was genuinely afraid she was going to hurt me; I was trying so hard to help her. It was unsafe for myself, herself, and us; they [law enforcement] took her back to jail.” RN #1 was asked if ED Provider #1 assessed the Patient. The RN stated, “I don’t remember.” RN #1 was asked if there was any indication Patient #4 was acutely psychotic or intoxicated. The RN stated, “not intoxicated or under the influence. She was just so riled up I couldn’t do a true assessment.” During a telephone interview on 9/23/2025 at 1:35 PM, ED Provider #2 verified he was the ED Medical Director. The ED Provider was asked how ED Provider #1 determined the Patient was not acutely psychotic or experiencing an emergency medical condition. The Provider stated, “I can’t answer that. I wasn’t there and didn’t witness it. Typically, the evaluation happens concurrently when the patient arrives. I was told when the Patient arrived, police were involved.” ED Provider #2 continued and stated Patient #4’s condition deteriorated to a violent encounter, so it became a “legal matter, not a medical matter.” During a telephone interview on 9/23/2025 at 2:47 PM, ED Provider #1 stated Patient #4 “didn’t want to be seen and she was rude.” ED Provider #1 was asked if he assessed Patient #4. The ED Provider stated, “Unfortunately no. The nurse [RN #1] was with her and when I got ready to see her, she was gone. She didn’t want to be seen and was very rude.” ED Provider #1 was asked why he documented he initiated the MSE at 6:14 PM. The ED Provider stated, “I clicked it [initiated the MSE] because the Patient is in the ED, it doesn’t mean I’ve seen the Patient.” ED Provider #1 was asked if Patient #4 had a psychiatric or emergency medical condition. The Provider stated, “I don’t know, but she had a psychiatric history.” The ED Provider was asked why he ordered ziprasidone for the Patient since he hadn’t evaluated her. ED Provider #1 stated, “We usually give patients something to help calm them down.” The ED Provider stated he had written an addendum (9/20/2025; 15 days after Patient #4 presented to the ED) stating he never saw the Patient. ED Provider #1 continued and stated, “I don’t know how they let her go; that was a problem.” During an interview on 9/23/2025 at 3:00 PM, the hospital’s Director of Quality and Risk Management (DQRM) stated she had spoken with local law enforcement, and they informed her mobile crisis evaluated Patient #4 at the jail and the Patient was taken to Hospital #2, a psychiatric facility, for inpatient treatment, then was sent back to jail after she was discharged. The DQRM stated the hospital had met with law enforcement personnel and informed them they don’t have to send everyone to the ED. The DQRM continued and stated the hospital was “working with them on that. We or they can call mobile crisis who then refers them to [Hospital #2] for evaluation and treatment.” During a telephone interview on 9/24/2025 at 3:02 PM when the surveyor attempted to reach Law Enforcement Officer #1, the phone call was accidentally routed to RN #2 instead. The RN informed this surveyor she recalled Patient #4 was taken to Hospital #1’s ED and “when they tried to remove her clothes, she swung at one of the nurses so they [ED staff] sent her back here. When I talked to her [Patient #4] she told me she has a fear of being raped, so she felt threatened when they tried to remove her clothes. After she got back with us, we called mobile crisis. They [mobile crisis] evaluated her, and she was taken to [Hospital #2] and admitted.” RN #2 continued and stated law enforcement personnel now “have to call mobile crisis because the hospital won’t treat for mental illness or mental crisis. We’ve had meetings with hospital staff and some of the higher ups. They’ve told us to just call mobile crisis because that’s all they’re going to do anyway. I used to send patients that were on suicide watch to them after they bonded out to make sure they were safe to go home. We were told not to do that anymore because the only thing they’re going to do is call mobile crisis and we can do that here.” RN #2 stated Patient #4 informed her she swung at one of the nurses [RN#1] when she tried to remove her clothes so the ED “called to have her arrested. They [Hospital #1] can’t handle anybody that gets combative because they don’t have enough security for that.” During a telephone interview on 9/25/2025 at 8:31 AM, Security Officer (SO) #1 verified he was present in the ED when local law enforcement brought Patient #4 in. The SO stated Patient #4 was “somewhat combative and upset. Me and the nurse [RN #1] went in to get the Patient’s blood and urine and she was yelling, and she hit the nurse in the arm and was going to hit her again, but I stepped in between them. The [law enforcement officer] was standing outside the door. She was getting louder so the [law enforcement officer] decided he was going to take her to jail.” The SO was asked if the law enforcement officer was present in the room during the alleged altercation. The SO stated, “the only time he [law enforcement officer] came into the room was when he decided to take her to jail. He gave me the handcuffs, so I handcuffed the Patient and escorted her out to the police car.” The SO was asked if the (ED staff) requested the law enforcement officer’s assistance with Patient #4. The SO stated, “No, I stepped in.” The SO was asked if ED Provider #1 ever saw Patient #4. The SO stated, “I don’t think so, the whole thing only lasted about 4 or 5 minutes.” Patient #4’s medical record from Hospital #2 revealed the Patient was involuntarily admitted on 9/6/2025 from jail with diagnoses which included Unspecified Schizophrenia Spectrum and Other Psychotic Disorder and Unspecified Mood (Affective) Disorder. The Psychiatric Evaluation completed on 9/6/2025 revealed Patient #4 was in a manic state, delusional, aggressive, hyperverbal, with rambling speech, uncooperative and had allegedly assaulted a nurse at the ED and was subsequently sent to jail. The evaluation revealed, “multiple attempts at conducting a comprehensive interview were met with resistance, bizarre behavior and delusional themes...” Patient #4 was considered at risk for elopement and violent behaviors. Hospital #1 failed to complete a Medical Screening Examination to determine if Patient #4 had an emergency medical and/or psychiatric condition. The hospital’s failure to complete a Medical Screening Examination resulted in a delay of treatment for Patient #4 who spent 2 days in jail in a manic state and psychosis while awaiting assessment and stabilizing treatment.”

“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: 19001 Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s emergency department (ED) were listed on the ED central log and were provided an appropriate medical screening exam within the hospital’s capabilities for 1 of 22 (Patient #21) sampled patients in order to determine if an emergency medical condition existed. The Hospital failed to fully implement its corrective actions for training and education to ensure compliance with EMTALA requirements and prevent further occurrences. The findings included: 1. On 12/25/2023 gun shot wound (GSW) Patient #22 presented to the ED with a gang related gun shot wound. Nursing staff notified the Registration Clerk to limit visitor access to the ED due to safety concerns since the shooter had not been apprehended by law enforcement. Security Guard #1 initiated a lockdown of the ED based on nursing request, without authorization of Administration. Patient #21 presented to the ED on 12/25/2023, while Security had the ED on lockdown. Security Guard #1 and Registration Clerk #3 advised the Stepmother of Patient #21, (who brought the Patient to the ED), that the hospital ED was on lock down for safety concerns. Patient #21 was not provided a medical screening exam for her emergency medical condition. The hospital self reported the incident and submitted a Corrective Action Plan (CAP) to CMS on 2/12/2024; however the hospital failed to fully implement the CAP by training ED Registration staff and was determined to be out of compliance with EMTALA requirements. Refer to 2405 and 2406.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 30070 Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s emergency department (ED) seeking medical attention were listed on the central log for 1 of 22 (Patient #21) sampled patients. The Hospital failed to fully implement its corrective actions for training and education to ensure compliance with EMTALA requirements. The findings included: 1. Review of the hospital’s “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions” policy last revised 8/2023, revealed, “Definitions: E. Central Log is a log that a Hospital is required to maintain on each individual who comes to its emergency department or any location on the Hospital Property or Premises seeking assistance and that contains the disposition of each individual, whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged. The purpose of the central log is to provide a listing of each individual who comes to the Dedicated Emergency Department seeking examination or treatment for a medical condition, or who comes to the Hospital Property or Premises seeking care for an Emergency Medical Condition.” 2. Review of the hospital’s ED central log revealed no documentation Patient #21 had presented to the hospital’s ED on 12/25/2023. 3. On 4/1/2024 at 10:30 AM, when questioned as to why Patient #21 was not on the hospital’s ED central log, the Chief Nursing Officer (CNO) stated that on 12/25/2023 a gun shot wound (GSW) Patient (Patient #22) had presented to the ED with a gang related gunshot wound, the shooter was still at large and the hospital ED was put on high alert. The CNO stated the nursing staff directed the ED Registration staff to limit visitors into the ED due to possible safety concerns. The CNO stated the Security guard on duty interpreted the direction from the nurses to initiate lockdown of the ED. The CNO stated about one hour later the nursing staff realized the Security staff had misinterpreted the nurses’ instructions and had placed the ED on lockdown and not allowing anyone ED access. The CNO verified the Risk Manager initiated an investigation and self-reported the potential violation to CMS. 4. In an interview on 4/1/2024 at 1:17 PM, the CNO stated there was no video footage of the 12/25/2023 incident. 5. In a telephone interview on 4/2/2024 at 10:11 AM, Patient #21’s stepmother verified she did bring one of her stepdaughters to the hospital ED in December of 2023, but she could not recall the exact date. Patient #21’s stepmother stated, “I can’t recall the reason I brought her in.” Patient #21’s stepmother stated when she entered the hospital ED entrance she was informed by a female (name unknown) that the hospital was on lockdown and the patient could not be seen. When asked if the patient received any care, she stated she took her stepdaughter to taken her to a urgent care clinic the following day. In a subsequent telephone interview on 4/3/2024 at 4:17 PM, Patient #21’s stepmother stated she had spoken with her 20-year-old stepdaughter (Patient #21) and confirmed her 20-year-old stepdaughter was taken to the Hospital’s ED in December 2023 for treatment of a fever and vomiting, and verified they were advised to leave the ED premises due to safety concerns and denied treatment. The hospital failed to ensure all individuals presenting to the ED were placed on a log, as required by EMTALA regulations. In addition, the hospital failed to fully implement its CAP to address the EMTALA violation, by failing to fully educate the ED Registration staff on EMTALA requirements as it related to the hospital lockdown policy and in doing so was determined to be out of compliance. Refer to 2406.”

“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: 19001 Based on policy review, document review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital’s emergency department (ED) were provided an appropriate medical screening exam within the hospital’s capabilities for 1 of 22 (Patient #21) sampled patients in order to determine if an emergency medical condition existed. The Hospital failed to fully implement its corrective actions for training and education to ensure compliance with EMTALA requirements. The findings included: 1. Review of the hospital’s “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions” policy last revised 8/2023, revealed, “PURPOSE: To ensure individuals coming to an affiliated Hospital’s Dedicated Emergency Department seeking assessment or treatment for a medical condition...receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act ...42 U.S.C Section 1395...DEFINITIONS: ..Medical Screening Examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists...POLICY: Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitled to and shall be provided an appropriate Medical Screening Examination provided by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exits...” 2. Review of the hospital’s Plan of Correction submitted to CMS on 2/12/2024, after the investigation into Patient #21 being refused medical treatment on 12/25/2023, revealed, Corrective Actions: [Named Hospital #1] will provide education to all contracted Security Guards and Registration/ Patient Access Staff on the following: 1. EMTALA and the responsibilities of the Hospital 2. Lockdown Policy Review and Implementation Instructions- Completion date 1/26/2024. [Named Hospital #1] will update General Hospital Orientation for all staff members to include a review of EMTALA and the Responsibilities of the Hospital- Completion Date 1/8/2024. [Named Hospital #1] has updated its lockdown policy. Specifically, the new policy requires either the house supervisor, Emergency Room (ER) charge nurse, or designee to be stationed at the entrance to the ER along with security personnel to provide medical assistance and appropriate direction for emergency medical services. It also clarifies that no patients should be refused care or treatment- Completion Date 1/26/2024. [Named Hospital #1] will perform auditing and monitoring of the EMTALA log, which reflects each individual who presents to the ER, to ensure no individuals are turned away from the ER. It will also conduct a review of any diversions and lockdowns to ensure EMTALA compliance. 3. Review of the hospital’s ED central log revealed there was no documentation Patient #21 had presented to the hospital’s ED on 12/25/2023. There was no documentation of a medical record for Patient #21. Review of the central log revealed a gun shot wound (GSW) Patient #22 arrived to the hospital’s ED via private vehicle on 12/25/2023 at 11:28 PM with a gunshot wound to his right shoulder. The record revealed the gun shot wound was gang related. Patient #22 was treated in the hospital’s ED. 4. In an interview on 4/1/2024 at 10:30 AM, the Chief Nursing Officer (CNO) stated on 12/25/2023 GSW Patient #22 presented to the ED with a GSW, was triaged and taken into the ED for treatment. The CNO stated the nursing staff were notified the shooter had not been secured and the staff were informed it could have been gang related. The CNO stated the nursing staff directed the ED Registration staff to limit visitors into the ED due to possible safety concerns. The CNO stated the Security guard on duty interpreted the direction from the nurses to initiate lockdown of the ED. The CNO stated about one hour later the nursing staff were notified by the Registration clerk that Patient #21 had presented to the hospital’s ED for treatment and had been advised by Security and Registration the ED was on lockdown for safety concerns and Patient #21 was denied entry, care and treatment. The CNO verified the Risk Manager initiated an investigation and self-reported the potential violation to CMS. 5. In an interview on 4/1/2024 at 1:17 PM, the CNO stated there was no video footage of the 12/25/2023 incident. 6. In a telephone interview on 4/2/2024 at 10:11 AM, Patient #21’s Stepmother verified she did bring one of her stepdaughters to the hospital ED in December of 2023, but she could not recall the exact date. Patient #21’s stepmother stated, “I can’t recall the reason I brought her in.” Patient #21’s stepmother stated when she entered the hospital ED entrance she was informed by a female (name unknown) that the hospital was on lockdown and the patient could not be seen. Patient #21’s stepmother stated she left the premises with her stepdaughter. When asked if the patient received any care, she stated she took her stepdaughter to taken her to a urgent care clinic the following day. In a subsequent telephone interview on 4/3/2024 at 4:17 PM, Patient #21’s stepmother stated she had spoken with her 20-year-old stepdaughter (Patient #21) and confirmed her 20-year-old stepdaughter was taken to Hospital #1’s ED in December for treatment of a fever and vomiting. The Stepmother verified she was advised to leave the premises due to safety concerns and denied treatment. 7. In an interview on 4/1/2024 at 3:25 PM, ED Registration Clerk #4 stated she was not sure about the specifics of the Lockdown policy and further stated she did not recall any re-training on the lockdown protocols since December 2023. 8. In a telephone interview on 4/2/2024 at 10:31 AM, ED Registration Clerk #1 verified she worked from 4:00 PM until 11:00 PM on 12/25/2023, when GSW Patient #22 presented to the ED with a GSW. ED Registration Clerk #1 stated the Security Guard #1 locked the ED down after talking with the nursing staff about potential safety concerns. ED Registration Clerk #1 stated she was not aware any patient was turned away as she left her shift at 11 PM and was relieved by ED Registration Clerk #3. When asked if she had additional training on the lockdown policy and what the expectations were of ED Registration staff, she stated, “No, I don’t really know what to do.” ED Registration Clerk #1 stated she was not sure of the process to follow if it ever happened again. 9. In a telephone interview on 4/2/2023 at 10:39 AM, ED Registration Clerk #3 verified she was working on 12/25/2023 when GSW Patient #22 patient was being treated in the ED. ED Registration clerk #3 stated she was present when the Security Guard #1 informed Patient #21 on 12/25/2023 that the ED was being secured for safety and they were not accepting patients. ED Clerk #3 stated at the time she did not know that was an EMTALA violation, but she had since been educated. 10. In an interview on 4/2/2024 at 10:56 AM, Registration Clerk #2 stated she was not clear on the expectation of ED Registration staff for a lockdown, and she felt she needed additional training. 11. In an interview on 4/2/2024 at 11:09 AM, the Registration Team Coordinator, direct Supervisor of ED Registration staff, stated the registration staff would do as directed by the nurses or security staff during a lockdown. When asked if her ED Registration staff had been re-trained since the incident on 12/25/2023, the Registration Team Coordinator stated, “I don’t think everyone [all registration staff] has been reiterated on it [policy], No...” 12. In a telephone interview on 4/2/2023 at 2:01 PM, Nurse #1 verified she was working on 12/25/2023 in the hospital ED when GSW Patient #22 presented with the GSW injury. Nurse #1 stated there was a lot of traffic in the ED after GSW Patient #22’s arrival, and based on law enforcement reports that the perpetrator had not been apprehended. Nurse #1 instructed the Registration Clerk assigned to the ED to restrict patient only admittance into the ED, from the ED waiting room. Nurse #1 stated she did not instruct her to limit patients from entering the ED seeking treatment, she only asked them not to allow visitors into the ED treatment area with patients, due to safety concerns. Nurse #1 stated “There was never a decision to lockdown.” Nurse #1 stated Security made the decision to lockdown without nursing knowledge. 13. In a telephone interview on 4/2/2024 at 2:25 PM, Security Guard #1 verified she was working on 12/25/2023, and nursing staff directed her and the Registration Clerk to limit traffic into the ED due to GSW Patient #22. Security Guard #1 stated she initiated a lockdown and verified she was present with ED Registration Clerk #3 when Patient #21 presented for treatment on 12/25/2023. Security Guard #1 verified she did tell Patient #21’s Stepmother the ED was on lockdown and they were not accepting patients. Security Guard #1 stated she was now aware that EMTALA requirements and during a lockdown, patients seeking treatment would be provided care. 14. In an interview on 4/3/2024 at 9:13 AM, the Risk Manager (RM) verified the training for ED Registration staff/clerks had not been completed. The RM stated she had requested to attend a staff meeting of the ED Registration staff but had not completed the training as outlined in the corrective action plan submitted to CMS on 2/12/2024. The hospital failed to provide Patient #21 an appropriate medical screening examination after she presented to the ED and a request was made for an evaluation. In addition, the hospital failed to fully implement its CAP to address the EMTALA violation, by failing to fully educate the ED Registration staff on EMTALA requirements as it related to the hospital lockdown policy and in doing so was determined to be out of compliance.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to provide an appropriate medical screening exam and transfer for 1 of 3 (Patient #1) sampled patients requiring a higher level of care, out of 20 total patients reviewed. The findings included: 1. Review of the facility’s, “EMTALA - Medical Screening and Treatment of Emergency Medical Conditions” policy (11/16/2023) revealed, “ ...Medical Screening Examination is the process to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists ...Such screening must be done within the facility’s capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred ...” Review of the facility’s “EMTALA -Transfer Policy” (9/25/2023) revealed, “ ...The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility... The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual... The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment... The transferring hospital must send copies of all available medical records pertaining to the individual’s emergency condition to the hospital where the patient is being transferred... If the hospital offers to transfer a patient to another hospital for services the hospital does not offer and informs the patient or the legally responsible person of the risks and benefits to the person of the transfer but the patient or the person acting on the patient’s behalf refuses to consent to the transfer, the facility must take all reasonable steps to secure a written refusal from the patient or the person acting on the patient’s behalf. The written refusal should indicate the person has been informed of the risks and benefits of the transfer and state the reasons for such refusal...” 2. Medical record review revealed Patient #1 presented to the Emergency Department (ED) on 11/18/2023 at 5:07 PM with a chief complaint of back abscess with nausea and general malaise. A Medical Screening Examination (MSE) was initiated on 11/18/2023 at 5:45 PM by Physician #1. Physician #1 documented Patient #1 had a history of type 2 diabetes mellitus and presented to the ED with an abscess on his back with increased pain, swelling, fever, and chills causing him to feel sick to his stomach. Physician #1 documented Patient #1 reported he saw his primary care physician two days prior (11/16/2023) and was placed on Bactrim (antibiotic). Physician #1 documented the abscess was approximately 3 centimeters (cm) but was now almost 10 cm. Physician #1 documented Patient #1 had a past medical history of diabetes mellitus and hypertensive disorder. Physician #1 documented Patient #1 needed a higher level of care not available at Facility #1. Physician #1 discharged Patient #1 from the Facility #1 ED, and Patient #1 left the ED on 11/28/2023 at 6:09 PM. While at Facility #1 ED, there was no fingerstick glucose performed to assess if Patient #1 was hyperglycemic and at risk for diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids [ketones]) since Patient #1 presented with a history of abscess, fevers, and chills in a diabetic patient. Physician #1 documented Patient #1 needed admission and surgical evaluation for the worsening abscess. Physician #1 did not order admission or a transfer for the surgical evaluation but ordered discharge home. There was no lab work ordered or drawn to further assess Patient #1’s condition. The MSE was not complete or appropriate. Refer to A2406 3. Medical record review revealed Physician #1 documented the abscess would require intravenous (IV) antibiotics and surgical evacuation (removal). Physician #1 documented Patient #1 would need to be transferred to a higher level of care due to the facility (Facility #1) did not have surgical coverage. Patient #1 and spouse chose to expedite care and go directly to another hospital (Facility #2) by private vehicle. Physician #1 discharged Patient #1 from the ED. Patient #1 left Facility #1 on 11/18/2023 at 6:09 PM. There was no documentation Facility #1 reached out to Facility #2 to inquire if surgical coverage was available, or if another physician was willing to accept Patient #1 at Facility #2. There was no documentation Facility #1 obtained a written refusal from Patient #1 regarding refusal of transfer by ambulance. Refer to A2409”

“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: 30070 Based on policy review, medical record review, and interview, the facility failed to provide a complete or appropriate medical screening exam (MSE) for 1 of 20 (Patient #1) sampled patients who presented to the facility’s Emergency Department (ED) seeking medical care. The findings included: 1. Review of the facility’s, “EMTALA - Medical Screening and Treatment of Emergency Medical Conditions” policy (11/16/2023) revealed, “ ...Medical Screening Examination is the process to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists ...Such screening must be done within the facility’s capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient’s needs and must continue until the patient is either stabilized or appropriately transferred ...” 2. Medical record review revealed Patient #1 presented to the ED on 11/18/2023 at 5:07 PM with a chief complaint of back abscess with nausea and general malaise. Patient #1’s vital signs at 5:19 PM were: temperature 99.1 degrees Fahrenheit, pulse 97, respirations 18, blood pressure 134/82, and oxygen saturation 97%. Patient #1 reported a pain level of 7 on a 0-10 pain scale (10 being the most severe pain). A Medical Screening Examination was initiated on 11/18/2023 at 5:21 PM by Physician #1. Physician #1 documented Patient #1 had a history of type 2 diabetes mellitus and presented to the ED with an abscess on his back with increased pain, swelling, fever, and chills causing him to feel sick to his stomach. Physician #1 documented Patient #1 reported he saw his primary care physician two days prior (11/16/2023) and was placed on Bactrim (antibiotic). Physician #1 documented the abscess was approximately 3 centimeters (cm) but was now almost 10 cm. Physician #1 documented Patient #1 had a past medical history of diabetes mellitus and hypertensive disorder with home medications of Novolog insulin (medication injection given beneath the skin to help control blood sugar spikes) and Lexapro (medication which can be used to treat depression and generalized anxiety disorder) 20 milligrams 1 tablet daily. Physician #1 documented upon physical exam, Patient #1, “...appears alert, awake, anxious, obviously ill, in obvious pain, uncomfortable ...Skin: abscess, that is large, approximately 12 cm(s), of the Mid and lower thoracic area, with fluctuance [a tense area of skin with a wave-like or boggy feeling upon palpation], that is marked, with surrounding cellulitis, that is moderate ...” Physician #1 documented the ED course for Patient #1, “...He is diabetic and already been on Bactrim for couple of days. He is feeling worse now. He definitely need [sic] IV [intravenous] antibiotics and surgical evacuation of this deep abscess on his back. I told him we will start the workup and finally had to transfer him for higher level of care because we do not have a surgeon here. Him and his wife decided to go directly to the ER [emergency room] to expedite the care. He is stable to go by POV [privately owned vehicle]. I am giving him oral antibiotic for pain relief ...” Physician #1 documented in the Disposition Summary for Patient #1, “ ...11/18/2023 17:53 [5:53 PM] ...Discharge Ordered ...Location: Home ...Symptoms: have worsened ...Diagnosis ...Deep abscess of back wall thorax ...” 3. In an interview on 11/28/2023 at 10:30 AM, the ED Director verified Patient #1 was discharged from the ED and was to go by private vehicle to the next facility. The ED Director stated, “...but how do you know they actually go is always my concern ...” In an interview on 11/28/2023 at 1:25 PM, Physician #1 stated he informed Patient #1 and his wife that he would order lab work and a computed tomography (CT) scan (imaging test that helps healthcare providers detect diseases and injuries), but Patient #1 would need to transfer elsewhere afterwards for surgeon coverage. Physician #1 stated Patient #1’s wife asked why they couldn’t just go to another hospital with a surgeon, and Physician #1 told them Patient #1 was okay to go to the other facility per their vehicle, if that was their choice. Physician #1 stated he screened Patient #1, and there was no reason he could not be driven per private vehicle to the other facility. In an interview on 11/30/2023 at 11:00 AM, the ED Medical Director stated he reviewed Patient #1’s medical record. The ED Medical Director stated he felt there was an urgent medical condition present but not an emergent condition. The ED Medical Director stated Patient #1 was in stable condition at the time of discharge, and Patient #1 was apparently undecided where exactly he wanted to go and wanted to consider that decision further. Patient #1 presented to the Facility #1 ED on 11/28/2023 at 5:07 PM and was discharged home on 11/28/2023 at 6:09 PM (1 hour 2 minutes). Patient #1 needed a higher level of care not available at Facility #1. While at Facility #1 ED, there was no fingerstick glucose performed to assess if Patient #1 was hyperglycemic and at risk for diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids [ketones]) since Patient #1 presented with a history of abscess, fevers, and chills in a diabetic patient. Physician #1 documented Patient #1 needed admission and surgical evaluation for the worsening abscess. Physician #1 did not order admission or a transfer for the surgical evaluation but ordered discharge home. There was no lab work ordered or drawn to further assess Patient #1’s condition. The MSE was not complete or appropriate.”

“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: 35244 Based on policy review, medical record review and interview, the facility failed to appropriately transfer a patient requiring a higher level of care for 1 of 3 (Patient #1) sampled patients requiring a higher level of care, out of 20 total patients reviewed. The findings included: 1. Review of the facility’s “EMTALA-Medical Screening and Treatment of Emergency Medical Conditions” policy (11/16/2023) revealed, “ ...PURPOSE: To ensure that individuals coming to an affiliated Hospital’s Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act ...and, if an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment within the Hospital’s capabilities and/or are transferred if appropriate ...” 2. Review of the facility’s “EMTALA -Transfer Policy” (9/25/2023) revealed, “ ...PURPOSE: To ensure that a patient requesting or requiring a transfer for further medical care and follow-up in connection with treatment for an Emergency Medical Condition (“EMC”) is transferred appropriately ...The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility ...The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual ...The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment ...The transferring hospital must send copies of all available medical records pertaining to the individual’s emergency condition to the hospital where the patient is being transferred ...If the hospital offers to transfer a patient to another hospital for services the hospital does not offer and informs the patient or the legally responsible person of the risks and benefits to the person of the transfer but the patient or the person acting on the patient’s behalf refuses to consent to the transfer, the facility must take all reasonable steps to secure a written refusal from the patient or the person acting on the patient’s behalf. The written refusal should indicate the person has been informed of the risks and benefits of the transfer and state the reasons for such refusal ...” 3. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Facility #1 on 11/18/2023 at 5:07 PM via “walk-in”. A triage assessment beginning at 5:19 PM documented the chief complaint for Patient #1 was a back abscess with nausea and general malaise. Further triage assessment revealed Patient #1’s skin was hot, with an abscess located on the thoracic area, golf ball sized. Patient #1’s temperature during triage was 99.1 degrees Fahrenheit. A Medical Screening Exam (MSE) was initiated on 11/18/2023 at 5:21 PM by Physician #1 with documentation that revealed Patient #1 was a type 2 Diabetic that presented with increased pain and swelling to his mid-back area, that was associated with fever, chills and feeling sick to his stomach. Physician #1 documented Patient #1 saw his personal physician two days prior to coming to the ED. The personal physician started Patient #1 on Bactrim (antibiotic) by mouth. Patient #1 told Physician #1 the swelling was 3 centimeters (cm), but was now almost 10 centimeters. Patient #1 also complained of throbbing pain, spiking fevers and chills. A continuing MSE on 11/18/2023 at 5:47 PM by Physician #1 revealed Patient #1’s skin was positive for cellulitis (common and potentially serious bacterial skin infection), erythema (superficial reddening of the skin), and swelling to the middle of the lower thoracic area. Physician #1 also documented, “The patient appears alert, awake, obviously ill, in obvious pain, uncomfortable. Skin: abscess, that is large, approximately 12 cm(s), of the Mid and lower thoracic area, with fluctuance, that is marked, with surrounding cellulitis, that is moderate”. Physician #1 documented the ED course as Patient #1 had a large, deep abscess over the mid and lower thoracic area, with associated fever and chills. Patient #1 was diabetic, and had been on an antibiotic for a couple of days. Further documentation stated, “He is feeling worse now. He definitely need IV [intravenous] antibiotics and surgical evacuation of this deep abscess on his back. I told him we will start the workup and finally had to transfer him for higher level of care because we do not have a surgeon here. Him and his wife decided to go directly to the ER to expedite the care. He is stable to go by POV [privately owned vehicle] ...” Review of the Disposition Summary on 11/18/2023 at 5:53 PM revealed, “Discharge Ordered. Location: Home. Problem: new. Symptoms: have worsened. Condition: Stable. Diagnosis: Deep abscess of back wall of thorax. Follow-up: With: Emergency Department. When: Today. Reason: Recheck today’s complaints, Continuance of care, you opted to go by POV to [named facility #2] to expedite care since we do not have surgeon on call. You should go directly their [there] ...” Review of Patient #1’s Discharge Instructions revealed, “SPECIAL NOTES ...So you have a large deep abscess in the back wall of thorax associated with possible sepsis. We have offered you initial workup and then transferred by ambulance for a surgical consult since there is no on-call surgeon [at] your facility. You have opted to go by your own vehicle to expedite care. You should go directly to emergency room either in [named facility] or [named facility] where there is surgeon on-call”. Physician #1 discharged Patient #1 from the ED, and Patient #1 left facility on 11/18/2023 at 6:09 PM. In an interview on 11/28/2023 at 1:25 PM, Physician #1 stated he informed Patient #1 and his wife they could go ahead and get started on the work up needed for the abscess, which would include labs and imaging, but would still need to transfer to another facility afterwards for surgeon coverage. Physician #1 stated he explained how the transfer process worked. Patient #1’s wife asked why they couldn’t just go on to a hospital with a surgeon. Physician #1 stated he believed Patient #1 was stable and was okay to be discharged to go to another facility per vehicle, if that was their choice. Patient #1 was discharged from Facility #1 per private vehicle on 11/18/2023. Patient #1 needed a higher level of care not available at Facility #1. Patient #1 required transfer to another facility. There was no documentation Facility #1 reached out to Facility #2 to verify specialized services required (surgical services) were available, and if a physician was willing and able to accept Patient #1 at Facility #2. There was also no documentation of a written refusal for transfer by Patient #1, as specified per Facility #1’s policy.”