Tyler County Hospital

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 10135 Based on observations and interview, the facility failed to ensure sanitary practices when storing patient supplies and sterilizing patient equipment in 2 of 2 supply storage areas in the Emergency department (obstetric (OB)cart and clean utility room). The facility failed to: A. ensure patient equipment was sterilized in a manner to prevent recontamination. B. ensure patient sterile and non-sterile supplies were stored in a manner to prevent cross contamination. This deficient practice had the likelihood to cause harm to all patients presenting to the emergency department (ED). Findings include: During an observation on 06/02/2025 after 3:01 p.m., the following was found: OB cart Sterile packages of obstetric instruments were stored in an OB cart in the hallway. One of the sterile packages had 6 plus hemostats, scissors and tweezers in it. The hemostats were in a closed position and the instruments were stacked in the sterile package. Two pair of ring forceps was in a peel packet with the hinges in a closed position. There was no way all surfaces of the instruments could be properly sterilized. Clean utility room There was a Pyxis machine which contained medical supplies stored inside it. Across from the Pyxis was a covered cart which contained linen and splinting supplies. There was a water/ice machine on the counter in the same room. Underneath the water/ice machine area were cabinets which contained lab supplies needles, alcohol pads, bandages, and trays of blood collection tubes. The inside hinges of the cabinets were covered in rust and a black build-up. There was a cabinet above the sink in the same area which contained bins of 15 plus peels packets of patient instruments. The instruments were ring forceps, hemostats, female urethral dilators, stop cocks, J guidewire, magnet and laryngoscope blades. There was no humidity being monitored in the room. There were ring forceps and hemostats in sealed peel packets with the hinges in a closed position. There was no way all surfaces of the instruments could be properly sterilized. Staff #2 confirmed the condition of the supplies. During an interview on 06/03/2025 after 10:17 a.m., Staff #3 provided temperatures that were being taken in the ED but stated that humidities were not being monitored. According to the Association of perioperative Registered nurses (AORN) facility reference center with copyright dates 2012-2025, https://aornguidelines.org/guidelines/content?sectionid=173737249&view=book Guidelines for Perioperative Practice: Packaging Systems the following was found: “ ...3.9 Position items to be sterilized within packages in a way that facilitates sterilant contact with all surfaces and aseptic presentation of the package contents at the point of use.9 [Recommendation] ... Sterilant contact is necessary for sterilization to be achieved, and incorrect packaging can prevent sterilization from occurring. Inappropriate handling can lead to loss of package integrity. Incorrect packaging can make aseptic delivery of the contents to the sterile field challenging.15 3.9.2 Place items to be sterilized in an open or unlatched position within the sterilization package. [Recommendation] The open or unlatched position facilitates sterilant contact of all surfaces of the item.9,43 3.9.3 ...” “ ...Storage of Sterile Items 4.1. Store sterile items in a controlled environment.11 [Recommendation] Limiting exposure to moisture, dust, direct sunlight, handling, and temperature and humidity extremes decreases the potential for contamination and degradation of sterilized items.11 Factors that contribute to contamination include handling,11,36 air movement, humidity, temperature, location of storage, dust, presence of vermin, open or closed shelving, and properties of the sterile barrier system.1 For additional guidance on temperature and humidity parameters, see the AORN Guideline for Design and Maintenance of the Surgical Suite.10 ... 4.1.7. Do not store sterile items under sinks or in other locations where they can become wet.1,11,36 [Recommendation] ...””

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure the Emergency department was directed in a manner to provide documentation of complete assessments and discharges on 2 of 21 (Patient #’s 11 and 12) sampled Emergency department (ED) patients. The facility failed to: A. ensure Patient #’s 11 and 12 received complete assessments to determine the severity of complications they were having related to their pregnancies. B. ensure there was a policy in place addressing assessment of pregnant females who were not in active labor. This deficient practice had the likelihood to cause harm on all pregnant patients presenting to the emergency department (ED). Findings include: Patient #11 Review of the ED record of Patient #11 revealed she was a 19 -year- old female who presented to the ED on 02/12/2025 at 9:03 p.m.. Review of the triage assessment timed 9:05 p.m. revealed she was assessed as having an emergency severity index of 4 (semi-urgent). Patient #11 reported being 10 weeks pregnant and cramping. The initial vital signs documented at 9:05 p.m. were 125/85 (blood pressure), 90 (pulse), 18 (respirations), 98.5 (temperature), pain level of 5 and an oxygen saturation of 100 percent. Patient #11 reported that she was having pain in her lower abdomen that shot down her legs. Now she was hurting on the left lower side, supra pubic area. At 9:46 p.m. 1000 milliliters of normal saline was given and at 9:52 p.m. Tylenol 500 milligrams was administered. Review of an untimed physician screening revealed that Patient #11 was seen and examined. “I discussed with the patient that OB ultrasound or even regular ultrasound is not available at this facility after 5 p.m. She was given 1-liter normal saline bolus and Tylenol 500 mg oral in the ED with resolution of her symptoms. Patient #11 was discharged home at 11:35 p.m. Nursing failed to document another set of vital signs or follow-up pain assessment after administration of the Tylenol. During an interview on 06/03/2025 after 10:23 a.m., Staff # 2 confirmed there were no other vital signs taken and no follow-up pain assessment. Patient #12 Review of the ED record of Patient #12 revealed she was a 19 -year- old female who presented to the ED on 03/20/2025 10:40 p.m. with complaints of vaginal bleeding, cramping and being pregnant. Review of the triage assessment timed 10:40 p.m. revealed she was assessed as having an emergency severity index of 3 (urgent). Patient #12 reported the onset of the bleeding was at 9:30 p.m. Patient #12 had a pain level of 5 and was having supra pubic cramps. The initial vital signs documented at 10:42 p.m. were 124/85 (blood pressure), 95 (pulse), 16 (respirations), and 97.9 (temperature). There was no documentation of what the oxygen saturation was. According to nurses’ notes Patient #12 reported “finding out today while going for an insertion of an IUD (intrauterine device) that she was pregnant.” Patient #12 reported cramping on and off all day and that she started bleeding at 9:30 p.m. Patient #12 reported possible small clot and spotting. There was documentation in the notes that no vaginal exam was done. According to the nurses notes Patient #12’s last menstrual period was 02/12/2025. There was no documentation by nursing of the gestational age, gravida, para, abortions, and a description of the vaginal bleeding. Review of the physician’s untimed medically screening revealed Patient #12 was classified as being emergent/urgent. The physician documented Patient #12 was gravida 2 para 1 and she had vaginal spotting and cramping today. Documentation in the physician’s medical decision-making criteria revealed the following: “This pregnant patient presents with vaginal bleeding in the first trimester. Differential includes ectopic, IUP (intrauterine pregnancy), threatened /inevitable abortion, along with completed abortion. Patient without history of coagulopathy or infectious symptoms. Doubt alternate acute emergent pathology. Patient is RHO+ so Rho gam is not indicated BHCG only 2.5 so TVUS (transvaginal ultrasound) not indicated will dc with strict return precautions and plan to fu with OB within the next few days for repeat HCG.” Patient #12 was discharged home on 03/21/2025 at 12:15 a.m. There was no documentation of a reassessment of pain, vital signs or vaginal bleeding prior to discharge. During an interview on 06/03/2025 after 10:23 a.m., Staff # 2 confirmed there were no other vital signs taken and no follow-up pain assessment. During an interview on 06/03/2025 after 12:00 p.m., Staff #’s 1 and 2 confirmed they did not have a policy to address the assessment of pregnant females. The only policy they had was the one addressing a patient in active labor. Review of a facility policy named “Patient Documentation Emergency Department Presentation” revised 06/2024 revealed the following: ...”PROCESS STANDARDS.. 3) The triage documentation will be noted on the patient record. Chief complaint, narrative note, vital signs, allergies, immunizations, past medical/surgical history, GCS, basic head to toe assessment, & pain assessment..””

“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: 10135 Based on interview and record review, the facility failed to comply with §489.24. The facility failed to: A.) Ensure 1 of 21 sampled patients were appropriately medically screened (Patient #1). The facility failed to ensure the ED (emergency department) physician provided a pelvic exam and a human chorionic gonadotropic (hCg) test to determine pregnancy in Patient #1 who presented to the facility with vaginal bleeding and a positive home pregnant test. Refer to tag A2406 for additional information. B.) Ensure 1 of 21 sampled patients was appropriately transferred (Patient #1). The facility failed to: Ensure Patient #1 who was deemed as having an emergency medical condition was stabilized and provided with a safe transfer. Patient #1 was allowed to drive herself to another hospital and there was no documentation to indicate that the risk and benefits were discussed with the patient. Ensure the receiving hospital was notified and agreed to accept Patient #1. Ensure medical records related to the emergency medical condition on Patient #1 was sent to the receiving hospital. Refer to tag A2409 for additional information.”

“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: 10135 Based on interview and record review, the facility failed to ensure 1 of 21 sampled patients were appropriately medically screened (Patient #1). The facility failed to: Ensure the ED (emergency department) physician provided a pelvic exam and a human chorionic gonadotropic (hCg) test to determine pregnancy in Patient #1 presented to the facility with vaginal bleeding and a positive home pregnant test. This deficient practice had the likelihood to cause harm to all pregnant patients presenting to the ED. Findings include: Review of the medical record on Patient #1 revealed she was a 39-year-old female who presented to Hospital A on 05/01/2025 at 12:53 p.m. Patient #1 presented with complaints of vaginal bleeding and having a positive pregnancy test. The triage was performed upon presentation and Patient #1 was given an emergency index number of 3 (urgent). The initial vital signs documented were 124/74 (blood pressure), 76 (pulse), 18 (respirations), 98.1(temperature) and oxygen saturation of 99 percent on room air. The patient reported having low back pain, but there was no documentation of the severity of the pain. There was documentation that Patient #1’s last menstrual period was 03/07/2025, gestational age was 8 weeks, gravida one, para two, and vaginal bleeding was light. There was no documentation of how much bleeding and the color or consistency of the blood. The physician who medically screened Patient #1 documented that the case was Emergent/urgent condition possible immediate attention was required. The differential diagnoses listed were ectopic pregnancy, urinary tract infection, threatened abortion and positive pregnancy test. There was no documentation of any radiology test being done. There was documentation under the medical decision-making criteria that read: Patient #1 “is pregnant with benign exam and normal VSS c/w (Vital Signs Stable consistent with) ruptured ectopic, however we have no US (ultrasound here). Discussed the need for Emergent US. Pt expressed understanding and wants to drive herself to” Jasper hospital now. Patient #1’s condition was listed as fair. There was no documentation of a pelvic exam being performed by the physician. There was documentation in the record that the physician deferred the genital urinary exam. According to the medical record Patient #1 was discharged at 2:29 p.m. Review of the medical record from Hospital B revealed that Patient #1 was ordered to have a “US (ultrasound) OB (obstetric) transvaginal” at 4:19 p.m. and the first labs were ordered at 4:21 p.m. At 5:14 p.m. the HCG (human chorionic gonadotropin) level was 249. A history and physical exam signed off Staff #5 was dated 05/01/2025 and timed for 5:04 p.m. According to the history and physical Patient #1 presented with hematuria. There was documentation that Patient #1 stated she had a positive pregnancy test at home on yesterday and this morning she began having abdominal cramping with pain radiating to her back. She also had light vaginal spotting. Patient #1 reported that she went to Hospital A today and had a positive urine pregnancy test. Patient #1 reported that they discharged her and told her that she should come to Hospital B emergency room and have an ultrasound to rule out ectopic pregnancy. According to the history and physical Patient #1 was positive for abdominal cramping and back pain. She had previous diagnoses of cesarean section and fibroid tumors. She was currently having mild vaginal bleeding. An ultrasound was done and showed no intrauterine pregnancy seen and this correlated with the serum beta-HCG levels. There was thickened hyper vascular endometrium and there was the question of a small uterine fibroid. Patient #1’s lab test showed that she was anemic with a hemoglobin of 10 and hematocrit of 32.7. Patient #1 stated she was chronically anemic, and these numbers were not worse than her usual. The final disposition was a threatened spontaneous abortion in early pregnancy. There was documentation that Patient #1 was stable for discharge home. During an interview on 05/28/2025 at 10:46 a.m., with Staff #5 (Hospital B) revealed she works as a Nurse practitioner at Hospital B. Staff #5 (Hospital B) said that Patient #1 came to their facility around 5 pm in the evening on 05/01/2025. She had just been at Hospital A and was told to come there for an ultrasound to rule out an ectopic pregnancy. The patient said she went to Hospital A with abdominal cramping and spotting. They did an urinalysis and pregnancy tests. Staff #5 (Hospital B)said she checked the patient, and she did have some vaginal bleeding. Two hours after coming to their facility she received an ultrasound. They had to call someone into to perform the ultrasound because they only provide that service full-time, Tuesday through Friday from 8:00 a.m.-4:00 p.m., otherwise they must call someone in. Staff #5 stated they received no notification from Hospital A that Patient #1 was coming there. When the ultrasound was done it showed no intrauterine pregnancy seen. The patient’s quantitative hCG (human chorionic gonadotropin) hormone pregnancy blood test was 249 which was indicative for a positive pregnancy. Staff #5 (Hospital B) reported Patient #1 did not have any pain and they discharged her home with instructions for close monitoring and follow up there if needed and to follow up with her OB GYN physician. Staff #5 (Hospital B) stated they had no record of the patient returning to their hospital after the 05/01/2025 encounter. She concluded there was no ectopic pregnancy, and that Patient #1 may have had a miscarriage. Staff #5 said she was concerned because Hospital A told the patient to come there, and they were suspicious of an ectopic pregnancy, and they knew that Hospital B did not have obstetrics services there. During an interview on 06/02/2025 at 2:44 p.m., Staff #7 (Hospital A physician) confirmed he medically screened Patient #1. He stated that Hospital A does not do transvaginal US or pelvic cavities. There was no way to decide if there was an ectopic pregnancy. He stated he told the patient to go down the street to Jasper and that we could transfer her, but she wanted to drive. Staff #7 stated he does not work at Hospital A anymore because of atypical things occurring and this is one of those things. Staff #7 said he texted the physician at Hospital B and told him about the case and to be expecting her. Staff #7 said he was currently on vacation, and he would find the text and send that to the surveyor. Staff #7 said he felt like the patient’s condition was emergent. He said that the facility tells them when discharging a patient like this to have them sign out AMA. That is the culture around here and its pretty routine. During an interview on 06/02/2025 at 3:58 p.m., Staff 12 (Hospital A staff) revealed that the hours for ultrasounds were 8:00 am-4:30 pm Monday through Friday. There are no ultrasounds offered for Saturday, Sunday or after hours. During that timeframe the emergency room (ER) physician makes the call on what to do during these timeframes. They can do an emergency transfer, see if on call are available from another hospital or prescribe it for a non-emergency on the days they offer the service. During an interview on 06/02/2025 at 4:35 p.m., Staff #11(Hospital A staff) revealed she was the triage nurse on 05/01/2025 who assessed Patient #1. She remembered Patient #1 was 8 weeks pregnant and Staff #7 wanted her to go Hospital B to rule out an ectopic pregnancy. Normally when we are concerned about a miscarriage or ectopic pregnancy, we always let the patient know we will transfer. When they do not want to be transferred most physicians will say get an AMA. Staff #11 said she did not know if Patient #1 went AMA. Usually, they send patients out to Lufkin, Livingston and Jasper. She stated that Hospital B has ultrasound, but no obstetrics (OB) services. Staff #11 stated that fetal heart tones are assessed at 20 weeks, but they are not able to pick them up at 8 weeks. They normally document if the patient is cramping in the medical record. If the patient is having vaginal bleeding they should be documenting the number of pads, color, odor, and how long it has been going on. They are not allowed to do ultrasounds at all at their facility on OB patients and that is by radiology protocol. During an interview on 06/03/2025 at 9:40 a.m., Staff #14 (Hospital A staff) revealed they did not do OB ultrasounds, and she really did not know the reason. The documentation for OB patients should be vitals, last menstrual period, what is going on currently, and pain. Assessment of any bleeding should include number of pads, when it started, if any clots, and color. During an interview on 06/03/2025 at 12:00 p.m., with the Staff #’s 1 and 2 (Hospital A staff members) revealed there was no policy on assessment of OB patients. They only have the policy for dealing with active labor. Review of a facility’s policy named “Patient Documentation Emergency Department Presentation” dated 06/2024 revealed the following: “ ...PROCESS STANDARDS:.. ...4) The ED Physician, will medically screen all presenting patients to determine the emergent status. 5) All emergent patients will be treated and stabilized where at all possible ...””

“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: 10135 Based on interview and record review, the facility failed to ensure 1 of 21 sampled patients were appropriately transferred (Patient #1). The facility failed to: A. Ensure Patient #1 who was deemed as having an emergency medical condition received education regarding the risk and benefits of driving herself to another hospital. B. Ensure the receiving hospital was notified and agreed to accept Patient #1. C. Ensure medical records related to the emergency medical condition on Patient #1 was sent to the receiving hospital. This deficient practice had the likelihood to cause harm to all pregnant patients presenting to the emergency department ( ED). Findings include: Review of the medical record on Patient #1 revealed she was a 39-year-old female who presented to Hospital A on 05/01/2025 at 12:53 p.m. Patient #1 presented with complaints of vaginal bleeding and having a positive pregnancy test. The triage was performed upon presentation and Patient #1 was given an emergency index number of 3 (urgent). The initial vital signs documented were 124/74 (blood pressure), 76 (pulse), 18 (respirations), 98.1(temperature) and oxygen saturation of 99 percent on room air. The patient reported having low back pain, but there was no documentation of the severity of the pain. There was documentation that Patient #1’s last menstrual period was 03/07/2025, gestational age was 8 weeks, gravida one, para two, and vaginal bleeding was light. There was no documentation of how much bleeding and the color or consistency of the blood. The physician who medically screened Patient #1 documented that the case was Emergent/urgent condition possible immediate attention was required. The differential diagnoses listed were ectopic pregnancy, urinary tract infection, threatened abortion and positive pregnancy test. There was no documentation of any radiology test being done. There was documentation under the medical decision-making criteria that read: Patient #1 “is pregnant with benign exam and normal VSS c/w ruptured ectopic, however we have no US (ultrasound here). Discussed the need for Emergent US. Pt expressed understanding and wants to drive herself to” Jasper hospital now. Patient #1’s condition was listed as fair. There was no documentation of a pelvic exam being performed by the physician. There was documentation in the record that the physician deferred the genital urinary exam. There was no against AMA (against medical advice) form or documentation in the chart to indicate that the risk and benefits were discussed with the patient. According to the medical record Patient #1 was discharged at 2:29 p.m. Review of the medical record from Hospital B revealed that Patient #1 was ordered to have a “US (ultrasound) OB (obstetric) transvaginal” at 4:19 p.m. and the first labs were ordered at 4:21 p.m. At 5:14 p.m. the HCG (human chorionic gonadotropin) level was 249. A history and physical exam signed off Staff #5 (Hospital B staff) was dated 05/01/2025 and timed for 5:04 p.m. According to the history and physical Patient #1 presented with hematuria. There was documentation that Patient #1 stated she had a positive pregnancy test at home on yesterday and this morning she began having abdominal cramping with pain radiating to her back. She also had light vaginal spotting. Patient #1 reported that she went to Hospital A today and had a positive urine pregnancy test. Patient #1 reported that they discharged her and told her that she should come to Hospital B emergency room and have an ultrasound to rule out ectopic pregnancy. According to the history and physical Patient #1 was positive for abdominal cramping and back pain. She had previous diagnoses of cesarean section and fibroid tumors. She was currently having mild vaginal bleeding. An ultrasound was done and showed no intrauterine pregnancy seen and this correlated with the serum beta-HCG levels. There was thickened hyper vascular endometrium and there was the question of a small uterine fibroid. Patient #1’s lab test showed that she was anemic with a hemoglobin of 10 and hematocrit of 32.7. Patient #1 stated she was chronically anemic, and these numbers were not worse than her usual. The final disposition was a threatened spontaneous abortion in early pregnancy. There was documentation that Patient #1 was stable for discharge home. During an interview on 05/28/2025 at 10:46 a.m., with Staff #5 (Hospital B) revealed she works as a Nurse practitioner at Hospital B. Staff #5 (Hospital B) said that Patient #1 came to their facility around 5 pm in the evening on 05/01/2025. She had just been at Hospital A and was told to come there for an ultrasound to rule out an ectopic pregnancy. The patient said she went to Hospital A with abdominal cramping and spotting. They did an urinalysis and pregnancy tests. Staff #5 (Hospital B) said she checked the patient, and she did have some vaginal bleeding. Two hours after coming to their facility she received an ultrasound. They had to call someone into to perform the ultrasound because they only provide that service full-time, Tuesday through Friday from 8:00 a.m.-4:00 p.m., otherwise they must call someone in. Staff #5 (Hospital B) stated they received no notification from Hospital A that Patient #1 was coming there. When the ultrasound was done it showed no intrauterine pregnancy seen. The patient’s quantitative hCG (human chorionic gonadotropin) hormone pregnancy blood test was 249 which was indicative for a positive pregnancy. Staff #5 (Hospital B) reported Patient #1 did not have any pain and they discharged her home with instructions for close monitoring and follow up there if needed and to follow up with her OB GYN physician. Staff #5 (Hospital B) stated they had no record of the patient returning to their hospital after the 05/01/2025 encounter. She concluded there was no ectopic pregnancy, and that Patient #1 may have had a miscarriage. Staff #5 (Hospital B) said she was concerned because Hospital A told the patient to come there, and they were suspicious of an ectopic pregnancy, and they knew that Hospital B did not have obstetrics services there. During an interview on 06/02/2025 at 2:44 p.m., Staff #7 (Hospital A physician) confirmed he medically screened Patient #1. He stated that Hospital A does not do transvaginal ultrasound (US) or pelvic cavities. There was no way to decide if there was an ectopic pregnancy. He stated he told the patient to go down the street to Jasper and that we could transfer her, but she wanted to drive. Staff #7 stated he does not work at Hospital A anymore because of atypical things occurring and this is one of those things. Staff #7 said he texted the physician at Hospital B and told him about the case and to be expecting her. Staff #7 said he was currently on vacation, and he would find the text and send that to the surveyor. Staff #7 said he felt like the patient’s condition was emergent. He said that the facility tells them when discharging a patient like this to have them sign out against medical advice (AMA). That is the culture around here and its pretty routine. During an interview on 06/02/2025 at 3:58 p.m., Staff 12 (Hospital A staff) revealed that the hours for ultrasounds were 8:00 am-4:30 pm Monday through Friday. There are no ultrasounds offered for Saturday, Sunday or after hours. During that timeframe the emergency room (ER) physician makes the call on what to do during these timeframes. They can do an emergency transfer, see if on call are available from another hospital or prescribe it for a non-emergency on the days they offer the service. Review of a facility’s policy named “Patient Documentation Emergency Department Presentation” dated 06/2024 revealed the following: “ ...PROCESS STANDARDS:.. ...5) All emergent patients will be treated and stabilized where at all possible. When transfer is medically determined, transfer will be made in a manner consistent with the transfer policy ...” Review of a facility’s policy named “Hospital Patient Transfer Policy “dated 06/07/2024 revealed the following: “ ...DEFINITIONS: Appropriate Transfer - The transferring hospital: 1. Provides treatment within its capacity to minimize the risks to the individual’s health and in the case of a woman in labor, the health of the unborn child:and 2. Sends all record relating to the emergency condition: a. Observations of signs and symptoms; b. Preliminary diagnosis; c. Treatment provided; d. Results of any tests; e. The informed written consent or certification;and f. The name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. The receiving hospital has agreed to accept transfer of the individual and to provide appropriate medical treatment. The physical transfer must be accomplished through qualified personnel and transportation equipment, as required by the transferring physician, including the use of necessary medically appropriate life support measures during the transfer. The hospital will use the county’s 911 Emergency Services for patient transfer transportation services since the hospital does not provide its own patient transfer transportation services....” “... 11. The hospital may not transfer a patient with an emergency medical condition which has not been stabilized or when stabilization of the patient’s vital signs is not possible because of the hospital or emergency treatment area does not have the appropriate equipment or personnel to correct the underlying process, evaluation and treatment shall be performed and transfer shall be carried out quickly without the physician certification waiver reference in Section G. I. The Hospital may not transfer a patient with an emergency medical condition which has not been stabilized unless the patient or legally responsible person acting on the patient’s behalf, after being informed of hospital obligation to provide further examination and treatment to stabilize the emergency medical condition and risk and benefits of transfer in writing, requests transfer to another facility. To request the transfer, the patient legally responsible person acting on the patient’s behalf must sign the “Request for Transfer” form and indicate the reason for the request. The transfer must be an appropriate transfer...” “ ...”