Shenandoah Memorial 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: 21229 Based on clinical record review, interviews and document reviews, the facility failed to ensure compliance with EMTALA requirements at 42 CFR 489.24: Special Responsibilities of Medicare Hospitals in Emergency Cases. The facility staff failed to accept a patient for a Medical Screening Examination (MSE) who had presented by EMS (Emergency Medical Services Ambulance) for evaluation after a motor vehicle accident. The hospital staff informed the EMS, after their arrival on hospital property that they could not accept the patient and the patient would have to be taken to a trauma center. Please refer to 2406 for further information.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) and 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: 21229 Based on clinical record review, interviews and document review, the facility staff failed to provide a Medical Screening Examination (MSE) for one patient (Patient #19) who presented to the Emergency Department (ED) Hospital campus requesting an evaluation after a motor vehicle accident (MVA). Patient #19 was transported to the facility via EMS (Emergency Medical Services) ambulance and upon arrival the EMS staff was told to take the patient to another trauma facility approximately 30 (thirty) miles away. The findings include: According to the information documented in the EMS “Prehospital Care report” dated September 26, 2024 at 3:01 a.m., the EMS had been dispatched and arrived on the scene of a motor vehicle accident (MVA). The document read, in part: “...complains of head pain...left hip aching a little...hit head in car but did not loose consciousness...could move feet and all extremities...does not complain of any neck or back pain...stated was wearing seatbelt...secondary exam found small bump on the top of patients head, no other injuries found...as (ambulance) began to transport to SMH (Shenandoah Memorial Hospital) priority 3 (non emergent condition that requires medical treatment but not on an emergency basis) reassessed vitals as noted. Called report to SMH as we were in the parking lot and was informed they (hospital ED) could not take and (patient) needed to go to a trauma center. (EMS Ambulance) redirected to (another hospital trauma center) pri (priority) 3...” There was no record of Patient #19 being seen in the facility’s Emergency Department on September 26, 2024. However, the Emergency Department of the “sister” facility (Trauma Center) had a record of Patient #19 receiving care following a MVA on September 26, 2024 at 4:04 a.m. On November 12, 2024 at 11:25 a.m. during a tour of the emergency Department (ED), Staff Member #3 indicated that when a call comes in from EMS regarding a patient in transport, the charge nurse takes the call and assigns a room. Staff Member #3 further explained that “according to EMTALA regulations” any person who comes on to the hospital campus seeking help must be seen in the ED. “The campus is the entire hospital buildings, clinics and parking lot.” Staff Member #3 indicated that EMS calls received over the radio were recorded, but if they came through the “CISCO portable phones” they would not be recorded. The surveyors requested to review recorded calls for the previous two (2) months. At 2:45 p.m. on November 12, 2024, the surveyors were provided and listened to recordings of calls to the ED in the past 2 months. There were no EMS calls related to the MVA for the dates November 25 or November 26, 2024. Staff Member # 9 indicated that the call must have come through the portable phone and was not recorded. Staff member #3 explained “there is not” a log of incoming calls to the ED kept. The facility policy and procedure “Transfer of Patients - EMTALA (Emergency Medical Treatment and Labor Act) last revised 04/2023” was reviewed and evidenced, in part: “...POLICY: A. Any person who comes to a VHS (Valley Health System) hospital requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening examination performed by a qualified provider to determine whether an emergency medical condition exists. B. Persons with emergency medical conditions will be treated with their condition stabilized within the scope of the facilities capability...C. Definitions...3. Comes to hospital a. refers to any individual requesting emergent examination and treatment arriving on any hospital property or premises. This includes sidewalks, driveways, parking lots and parking garages for the VHS hospital locations...5. Hospital Property a. Includes any facility that the hospital covers with its unique Medicare provider number, including the main hospital campus. the parking lot, sidewalk, and driveway of departments within 250 yards of the hospital...” According to information provided by the facility the “Prehospital Care Report” had been amended on September 28, 2024 to include the information that the EMS had been turned away by the facility when arrived “in the parking lot”. The surveyor interviewed OI #1 (Outside Interview/Non-Staff) on November 12, 2024 at 4:43 p.m. who explained that reports go through a “peer review” process as soon as possible after the event, “usually within twenty-four hours”. OI #1 indicated the crew who responded to this accident were relatively new at that time, and the incident was discussed and the documentation was reviewed by the captain (Fire and Rescue Captain). The crew was directed to edit the report and and include all pertinent information regarding the event that had not been included in the first report. “This is standard protocol because as you know, documentation is very important and must be accurate..” Both reports were available for review and evidenced the editing date. Review of an email statement by OI #2 (EMS) dated September 26, 2024 at 10:21 a.m. revealed, in part: “As we got off the exit I called SMH to give report. After sharing the patient’s info I was transferred to the charge and explained that I have a patient who was in MVC (motor vehicle crash) and only had head pain and minor hip pain. We parked in front of the hospital doors as I was still talking to the charge nurse which is when I heard (charge nurse) talking to someone in the background and then telling me they can’t take (patient). (Charge) said they don’t have the equipment and that (patient) needs to go to a trauma center. I explained that we are already at SMH but (charge) still said they can’t take, (patient) needs to go to a trauma center...We then diverted to (trauma center).” The surveyors requested to interview the ED Physician who was on duty at the time of the event. The surveyors were informed the physician was out of the country and could not be reached for an interview. The surveyors reviewed the ED schedule for charge nurse staff who were on duty on November 25 and November 26, 2024. Staff Member #11 (Registered Charge Nurse) indicated in an interview on November 12, 2024 at 3:00 p.m. that they were not aware of an EMS call in September in which a patient was turned away. “That has not happened when I was in charge”. At 3:15 p.m. on November 12, 2024, Staff Member # 12 (RN Charge) was interviewed and indicated they did not recall this incident, however stated, “if I told them that it would have been because I referred to the doctor and was instructed to give that message; but I do not recall this ever happening.” OI #3 was interviewed on November 13, 2024 at 12:00 p.m. (Emergency Medical Technician/Driver) and indicated they were the ambulance driver at the time of the incident and not aware the facility refused to take the patient until they had pulled outside the ED doors underneath the canopy. OI #3 recalled they had gotten out of the ambulance, went around to the back, opened the doors and were told by the patient that the facility refused to take them. OI #3 added that OI #2 was still on the phone with the ED and was telling them they were right outside the doors. OI #3 explained that after that they transported patient to the ED of the nearest trauma center. On November 13, 2024 at 1:30 p.m. OI #2 (Emergency Medical Technician) was interviewed and validated that they were in the back of the ambulance monitoring Patient #19. OI #2 indicated they had notified the ED that they were en-route with the patient who had stable vital signs and was only complaining of some head pain and mild side pain, possibly from the seatbelt. OI #2 recalled that they had pulled onto the hospital property and were getting ready to ark when the charge nurse in the ED told (OI #2) they “could not accept the patient because they did not have the resources for a patient with a possible major head trauma and the patient needed to be taken to a trauma center”. OI #2 further indicated that at they informed the charge nurse they were right outside the doors to the ED doors under the canopy with Patient #19 in ambulance. The charge nurse told them the ED could not take the patient and to take (patient) to a trauma center. OI#2 stated they had called their dispatch, explained the situation and transported the patient to the nearest a trauma center, 34 miles away. The surveyors made multiple attempts to contact Patient #19 on November 12 and 13, 2024, without success at the time of the report. The findings and concerns were discussed on November 12, 2024 at 3:45 p.m. with facility Administration in an exit conference.”

“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: 40084 Based on facility document review and staff interviews, it was determined the facility failed to conduct an appropriate transfer. After learning of the EMTALA violation through an internal report, the facility took the following action. The physician who refused Patient #12’s transfer request was terminated on August 1, 2024. An AMA escalation protocol was implemented to ensure the risks/benefits are discussed and the documentation is complete. Also, the request is escalated to the charge nurse who involves the supervisor to discuss - Is the patient requesting transfer? Is the patient going by private vehicle to another facility?; Does this put patient at potential risk of harm? - If the answers are no, a risk report is completed. If yes, escalation continues to clinical manager, and if needed to director and administrator on call. Leaders conducted rounds and discussion of EMTALA requirements with clinical staff. The emergency department’s (ED) lens board (an electronic touchscreen in the ED used by the facility for a communication and education) was updated with the link to the facility’s EMTALA policy. All clinical staff were enrolled in Emergency Care Research Institute’s (ECRI) digital training course titled, Emergency Medical Treatment and Labor Act, and required to pass with a 100%. As of September 16, 2024, all clinical staff had successfully completed the course with the exception of staff on extended leave. The ED providers, a contracted service, were instructed to complete the ECRI digital training course and required to pass with a 100%. The ED provider contract service has added the facility’s EMTALA training as a mandatory requirement when onboarding new providers. The facility was found in compliance, but previously out of compliance, with the EMTALA requirements at 42 CFR §489 (Rev. 7-19-19) regarding Responsibilities of Medicare Participating Hospitals in Emergency Cases. Please refer to tag A-2409 for details.”

“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: 42725 Based on document review and medical record review, it was determined the facility failed to facilitate an appropriate transfer by refusing one patient’s request to transfer and by sending incomplete physician’s certifications for two (2) of thirteen (13) transferred patients in the sample. Findings: The facility’s policy titled, Transfer of Patients - EMTALA (Emergency Medical Treatment and Labor Act) last revised 04/2023, was reviewed and partly reads: “... Individuals who do have an emergency medical condition will have that condition stabilized to the point where the individual is either stable for discharge or stable for transfer. b. Transfers of unstabilized individuals are allowed only pursuant to patient request or when a Physician or qualified medical person certifies that the expected benefits to the patient from the transfer outweigh the risks for transfer... D. Reasons for Transfer 1. Patients may be transferred to other acute care facilities, under a Physician’s order, for the following reasons. a. The transfer is medically indicated and the patient requires treatment that cannot be provided at the hospital. b. The patient or surrogate requests transfer... F. Completion of Physician Certification/Consent... 3. The [name of facility] Transfer Consent Form shall be completed for any patient with an emergency medical condition who is transferred to another facility...”. Patient #12 arrived by ambulance to the facility on July 27, 2024 at 5:57 PM complaining of left hip pain. After receiving an x-ray, Staff Member #14’s documentation revealed that the patient had a “closed mildly displaced left femoral neck fracture deformity fracture on XR”. Staff Member #14 documented the following: “I advised the patient and [patient’s] family that [patient] would need surgical intervention, and that {sic} stated that they wanted to be transferred. I assured them that we have a specialist here to take care of this issue and to transfer [patient] to be {sic} against EMTALA laws. [Patient] has elected to leave AGAINST MEDICAL ADVICE and I have explained to [patient] risk for doing this. [Patient] understood all the risk and still wanted to leave.” Staff Member #14 entered an AMA ED disposition at 11:49 PM on July 27, 2024. The discharge information revealed the patient departed the facility on July 28, 2024 at 12:24 AM; disposition documented as “Left Against Medical Advice” and the destination documented as “Home.” Patient #12 arrived at a second facility on July 28, 2024 at 2:27 AM via private vehicle. There was no documentation in the record to support the following: The patient was informed of the risks and benefits associated with the transfer; Staff Member #14 obtained or attempted to obtain the patient’s transfer request in writing; or that Staff Member #14 contacted the second facility to request and facilitate an appropriate transfer. Patient #20’s EMTALA form, dated January 1, 2024, did not contain documentation of the following: certification statement, expected benefits of transfer, potential risks of transfer, date, time or the certifying physician’s electronic signature. Patient #23’s EMTALA form, dated June 30, 2024, did not contain the certifying physician’s electronic signature.”