East Tennessee Childrens Hospital

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 51701 Based on review of facility policy, review of Medical Staff Bylaws Rules and Regulations, medical record review and interviews, the facility failed to provide an appropriate Medical Screening Examination and failed to provide an appropriate transfer for one patient (#8) who presented with behavioral and safety concerns of 21 medical records reviewed. The findings include: Patient #8, an 18-year-old nonverbal and autistic male, presented to the ED on 11/16/2024, accompanied by his mother, for behavioral and safety concerns. His mother stated about a week prior to the ED visit he started refusing his medications which included: Sertraline (increases serotonin levels/mood enhancing), Fanapt (schizophrenia in adults and the acute treatment of manic or mixed episodes associated with bipolar 1 disorder in adults), and Vyvanse (attention deficit disorder hyperactivity disorder). Since refusing these medications, the mother reported her son’s behaviors became more aggressive. He started hitting his head against the floor, attempted to attack his mother and tried to knock down a door on his mother. He was seen by the ED physician and no laboratory or imaging testing were completed. The ED physician telephoned an ED physician at Facility B and discussed the case with him. There was a discussion related to discharging Patient #8 and sending him to Facility B with his mother. The patient was discharged from Facility A. A Medical Screening Examination was not completed. There were no EMTALA form or documentation of risks and benefits of the transfer documented. Please see 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: 51701 Based on review of facility policy, Medical Staff Bylaws and Rules and Regulations, medical record review and interviews, the facility failed to provide an appropriate and ongoing Medical Screening Examination for 1 patient (#8) who presented to the Emergency Department (ED) with behavioral and safety concerns of 21 medical records reviewed. The findings include: Review of the facility policy, “Patient Transfer Policy and Procedure (Interinstitutional),” revised 4/14/2023, showed “... No patient shall be transferred from [Facility A] to another facility before completion of an appropriate medical screening examination and stabilization treatment of an emergency medical condition...” Review of the facility policy, “Patient Transfer Policy and Procedure (Interinstitutional), “ revised 12/21/2023, states the definition of Emergency Medical Condition is defined as “... A medical condition which manifests itself by acute symptoms of sufficient severity (including pain, psychiatric disturbances, and or symptoms of substance abuse) such that the absence of immediate medical attention could ... reasonably be expected to result in: placing the patient’s health in immediate jeopardy...” Review of Medical Staff Rules and Regulations, revised 12/21/2023, showed “...The hospital accepts patients up to the age of 21 years suffering from most types of diseases requiring inpatient or outpatient hospital services...” Medical record review for Patient #8 included a Nursing Triage Record dated 11/16/2024 at 12:10 AM, and showed the patient’s vital signs were as follows: Temperature 97.4° (degrees) Fahrenheit; Pulse 120 [normal 60 to 100]; Respirations 20; Blood Pressure 112/86; and Pulse Oxygen 97%. The patient’s Emergency Severity Index (ESI) score was 2, which indicated emergent needs. Medical record review of the ED physician’s record dated 11/16/2024 at 12:34 AM, showed Patient #8 was evaluated by the ED physician. The patient’s heart rate was 120 beats per minute (tachycardia-an abnormally high rate). The ED physician documented Patient #8 had several episodes of aggressive and bizarre behavior in the ED. There were no laboratory or imaging testing performed. No medication was administered. No medical workup was performed to evaluate the tachycardia or his change in behavior. The physician deemed Patient #8 to be in stable condition. Discharge records showed that Patient #8 was discharged to the care of his mother on 11/16/2024 at 3:40 AM. During an interview on 1/22/2025 at 9:20 AM, with the ED Medical Director, he stated the ED physician could not have given a thorough psychiatric assessment since the patient was autistic. During an interview on 1/22/2025 at 12:59 PM, with the Chief Medical Officer, she stated she was notified of a possible EMTALA violation.”

“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: 51701 Based on review of facility policy, Medical Staff Bylaws Rules and Regulations, medical record review and interviews, the facility failed to provide an appropriate transfer, failed to inform the patient of the risks and benefits related to the transfer, and failed to provide an Emergency Medical Treatment and Labor Act (EMTALA) transfer certification for 1 patient (#8) who presented to the Emergency Department (ED) with behavioral and safety concerns of 21 medical records reviewed. The findings include: Review of the facility policy, “Patient Transfer Policy and Procedure (Interinstitutional),” revised 4/14/2023, showed “...No patient shall be transferred from [Facility A] to another facility before completion of an appropriate medical screening examination and stabilization treatment of an emergency medical condition...” Review of the facility policy, “Patient Transfer Policy and Procedure (Interinstitutional),” revised 12/21/2023, showed the following documentation must be provided by the sending hospital “...(a) a chronology of events that have taken place; (b) measures taken or treatment implemented; (c) a description of the patient’s response to treatment; (d) the results of measures that have been taken to prevent further deterioration. For those patients in an “emergency medical condition” or labor who are appropriately transferred, hospitals should document the transfer in a manner which indicates each of the following: a. the identity of the facility accepting patient; b. the availability of space and qualified personnel for treatment of the patient at the receiving facility; c. agreement by the receiving facility to accept the patient and to provide appropriate medical treatment; d. transmittal of appropriate medical records of the examination and treatment of the patient to the receiving facility; the means of transportation to the receiving facility including a description of qualified personnel, equipment, and medically appropriate life support measures to be used...” Review of the facility’s Medical Staff Rules and Regulations, revised on 12/21/2023, showed “...Discharge shall be in accordance with [Facility A] policies and EMTALA requirements...” Medical record review for Patient #8 of an ED physician’s note dated 11/16/2024, showed the physician documented he was told further psychiatric services could not be provided for the patient since Patient #8 was 18 years old. The physician noted it would be best for the patient to be seen in an adult facility and he discussed this patient’s case with an ED physician, on staff at Facility B. The ED physician informed Facility B’s ED provider Patient #8 would be coming to Facility B for evaluation. Medical record review of the Discharge Disposition record showed Patient #8 was discharged in stable condition via private vehicle on 11/16/2024 at 3:40 AM, to his mother with a discharge diagnosis of Aggressive Behavior. The mother and patient were directed to Facility B. Medical record review showed there was no EMTALA form or risks and benefits of the transfer documented in the medical record. During an interview with the ED Medical Director on 1/22/2025 at 9:20 AM, he confirmed an EMTALA form was not completed. He stated the problem is not systemic but rather an issue with only one ED physician. During a telephone interview on 1/22/2025 at 9:50 AM, with Physician #2, he stated it was a stupid mistake on his part and it wouldn’t happen again.”