Marshfield Medical Center

“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: 50646 Based on record review and interview, the facility staff failed to explain the risks and benefits of transfer to 2 of 4 patients (Patient #19 & Patient #20) transferred in a total universe of 20 medical records reviewed. Findings include: Review of facility’s policy 3-208 “EMTALA (Emergency Medical Treatment and Labor Act) Policy” dated 07/24/2023 revealed: “ ...Determining the appropriate receiving facility must be based on the physician’s sound clinical judgment. This requires an assessment of the expected risks and benefits of the transfer but may also include an evaluation of the continuity of care available to the individual, such as system affiliation or other aspects of clinical integration, specialist availability, or other relevant factors. While the proximity of the destination may be considered part of the clinical decision-making process and overall risk assessment, it need not be the determining factor in all cases...” Review of ED provider meeting minutes dated 07/24/2024 08:00 AM-09:00 AM revealed: “ ...EMTALA transfer-if voluntary psych admission to a hospital-put in for discharge, then don’t need the EMTALA transfer paperwork. If not voluntary-it’s transfer, and need the paperwork ...” Review of ED (Emergency Department ) staff meeting minutes dated 10/09/2024 revealed: “ ...We need to fill out forms (e-form or paper forms/packets) for all patient transfers. This includes involuntary behavioral health transfers, voluntary behavioral health transfers that are medically indicated (i.e. we don’t discharge them to go themselves the next day, we are arranging transfer), and medical transfers (i.e. to facility with higher level of care or to different facility per patient desire) ...” Patient #19 was a 13 year-old who presented to the ED on 04/14/2025 at 4:14 PM following a suicide attempt. Patient #19 was transferred to an inpatient psychiatric facility on 04/14/2025 at 11:30 PM via private vehicle. A review of Patient #19’s ED medical record revealed no documented evidence of a physician certification for transfer or that risks and benefits of transfer were discussed. During an interview on 05/06/2025 at 12:05 PM, the above findings were discussed with and confirmed by ED Manager B. Patient #20 was a 40 year-old who presented to the Emergency Department (ED) on 05/02/2025 at 12:23 AM for anxiety and suicidal ideation. Patient #20 was transferred to an inpatient psychiatric facility on 05/02/2025 at 6:20 AM via cab. A review of Patient #20’s ED medical record revealed no documented evidence of a physician certification for transfer or that risks and benefits of transfer were discussed. During an interview on 05/06/2025 at 12:05 PM, the above findings were discussed with and confirmed by ED Manager B.”

“RECIPIENT HOSPITAL RESPONSIBILITIES CFR(s): 489.24(f) A participating hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock-trauma units, neonatal intensive care units, or (with respect to rural areas) regional referral centers, which, for purposes of this subpart, means hospitals meeting the requirements of referral centers found at §412.96 of this chapter) may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. This requirement applies to any participating hospital with specialized capabilities, regardless of whether the hospital has a dedicated emergency department. This Standard is not met as evidenced by: 50646 Based on record review and interview, the facility staff failed to accept a patient (Patient #1) for transfer who required a higher level of care even though the hospital had the staff, beds, and specialty care needed in 1 patient reviewed for transfer out of 30 transfer request logs reviewed. Findings include: Review of facility’s policy 3-1199 “Patient Divert Process” dated 08/07/2023 revealed: “ ... [Facility service goal is to be open and accessible for all patients. In unusual cases, the hospital or a service may be at maximum capacity which results in a divert status being activated ...All efforts should be made to continue to accept patients from referral facilities ...” Review of facility’s policy 3-208 “EMTALA (Emergency Medical Treatment and Labor Act) Policy” dated 07/24/2023 revealed: “...A hospital with specialized capabilities or facilities ...or identified regional referral centers, may not refuse to accept an appropriate transfer of an individual who requires such specialized capabilities or facilities if the recipient hospital has the capacity to treat the individual ...” Patient #1 was a 62 year-old with a history of recent (date unknown) spinal cord stimulator placement at an outside hospital (Hospital #2). Patient #1 presented to another hospital’s Emergency Department (ED) (Hospital #1) on 03/28/2025 at 5:53 PM with symptoms of sepsis (severe infection). Review of Patient #1’s ED medical record from Hospital #1 revealed Hospital #2 was initially contacted for a request for transfer. Hospital #2 did not have the capability to accept the patient (no Neurosurgery available) and requested Hospital #1 contact Hospital #3 for transfer. Hospital #3 declined the transfer, and Patient #1 was ultimately transferred to another hospital (Hospital #4) for a higher level of care. A review of Hospital #3’s census for 03/28/2025 revealed 20 available Med-Surg beds and 4 available ICU Intensive Care Unit) beds. A review of Hospital #3’s Neurosurgeon call schedule for 03/01/2025 through 03/31/2025 revealed Neurosurgeon availability all shifts for the entire month. Review of “MC Cares” (Hospital #3’s transfer center) log dated 03/28/2025 at 10:33 PM revealed the following: 9:13 PM: Call made from Hospital #1 to Hospital #3. Bed availability confirmed. 9:40 PM: Neurosurgeon M was paged. 9:44 PM: Neurosurgeon M called MC Cares back. “ ...Pt (patient) info given, he is not the original surgeon as well, [Neurosurgeon M] asked for [Patient #1] to be discussed with [different outside hospital] neurosurgeon and hospitalist first.” 9:46 PM: Telephone call to Hospital #1 updating them on what Neurosurgeon M stated. 10:04 PM: “TC (telephone call) to [hospital #3] NS (nursing supervisor), updated on declination...” During an interview on 05/07/2025 at 09:20 AM with Service Line Administrator E, when asked about accepting patients in transfer, Administrator E stated they try and take patients if there is bed capacity, staffing and physician availability and if the patient needs a higher level of care. When asked if those criteria were present with Patient #1, Administrator E stated yes. When asked if there was a reason why Patient #1 was not accepted, Administrator E stated they were not sure, but that Neurosurgeon M had stated he did not feel Patient #1’s condition was related to a neurosurgery issue. During an interview with Neurosurgeon M on 05/07/2025 at 12:20 PM, Neurosurgeon M stated he would have accepted Patient #1 if Hospital #1 had called back and stated that Patient #1 needed a Neurosurgeon.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50646 Based on record review and interview, staff failed to perform pain assessment/reassessment, interventions or focused assessment in 4 of 10 medical records reviewed [Patient #4,5,6,&7], in a total of 10 medical records reviewed. Review of the facility’s policy 3-1616 “Pain Management Policy,” dated 09/25/2024 revealed: “ ...Upon patients entry into the [Facility} Ambulatory, Outpatient, Emergency and inpatient departments, the patients will have pain screened as a part of ongoing patient care and assessment expectations during qualifying RN level visits, Provider level visits or admissions. Information gathered during patients’ encounter may indicate the need for a more comprehensive assessment. A reassessment may occur depending on the course of the visit ...If the patient responds that they do not have pain, the screening is finished and results documented in the EHR. If the patient responds that they have pain, they will be asked to state their level of pain, if able, using one of the appropriate pain screening/assessment tools ...Support staff will take part in the collection which include but are not limited to; pain site, description of pain, frequency of pain, physiological and/or psychological effects of pain, ... and interventions attempted to alleviate pain. Results will be documented in the EHR (Electronic Health Record) and communicated to the provider/RN for the pain assessment process to be conducted.” Review of the facility’s policy 3-2854 “Standards of Nursing Practice Policy-Emergency/Urgent Care Department,” dated 11/09/2022 revealed: “ ...The RN will initiate accurate and ongoing assessments of physical and psychosocial components of the patient, utilizing a systematic approach. This is done timely and ongoing for duration of care ...The RN will assure vital signs are with-in normal limits or acceptable by provider for discharge/admission.” Patient #4 was a 29-year-old patient admitted to the ED on 02/07/2025 at 10:19 AM with abdominal pain. Patient #4 rated pain an 8 upon admission. No pain reassessment or pain interventions documented. Patient #4 was evaluated by provider with normal test results. Patient #4 given discharge instructions to follow up with her primary care provider. Discharged home on 02/07/2025 at 1:36 PM. Patient #5 was a 16-year-old patient admitted to the ED on 02/07/2025 at 10:23 AM with right lower quadrant abdominal pain. No pain assessment was completed on Patient #5 in triage. No focused assessment of gastrointestinal system documented by RN. Patient #5 was evaluated by physician and was admitted to the hospital with acute appendicitis. Patient discharged from the ED and admitted at 6:57 PM. Patient #6 was a 24-year-old patient admitted to the ED on 03/07/2025 at 11:33 AM after being physically assaulted and strangled. Patient #6 came in with a pain assessment of 10/10 in her left wrist. Patient #6 had no pain reassessments or pain interventions documented. Patient #6 was evaluated for injuries sustained, given a wrist brace, and given discharge instructions. Patient #6 was discharged home on 03/07/2025 at 2:01 PM. Patient #7 was a 25-year-old female admitted to the ED on 03/25/2025 at 10:30 AM with left lower quadrant abdominal pain and urinary urgency. No pain assessment or focal assessment on urinary system were completed by nursing on admission. Ultrasound and CT scan revealed ovarian cyst. Patient #7 received IV Ketorolac (Pain medication) on 03/25/2025 at 1:44 PM. No pain reassessment completed. Patient treated and discharged from the ED on 03/25/2025 at 4:49 PM. During an interview on 03/26/2025 at 09:25 AM ED Supervisors F and G stated that every patient should have pain assessed during their ED triage. If pain is present in triage a comprehensive pain assessment should be completed during the ED assessment. Both ED Supervisors F and G also stated that they would expect a nurse to conduct a focused assessment on the patient’s chief complaint.”