Tamarack Health Ashland Medical Center

“PATIENT CARE POLICIES CFR(s): (1) The CAH’s health care services are furnished in accordance with appropriate written policies that are consistent with applicable State law. This Standard is not met as evidenced by: 44431 Based on record review and interview facility staff failed to document all elements of Nasogastric (NG) tube insertion per facility policy for 1 of 1 (Patient #1) patients requiring NG tube insertion in a total of 13 medical records reviewed. Findings: Review of facility procedure no date titled, “Inserting a Nasogastric Tube in Adults,” revealed, “ Documentation: Update patient’s plan of care and medical record...Include: Date/time of procedure, type and diameter of nasogastric tube, recorded length of tube inserted. Following initial placement, information about date/time position was checked, if aspirate was obtained, pH value, and external length of tube. Patient assessment information, including patient’s tolerance of procedure. Any unexpected patient events or outcomes, interventions performed.” A review of Pt. #1’s medical record revealed an NG tube with suction was placed on 12/24/2025 at 7:45 AM. Output of 700 ml of green drainage was noted at 08:00 AM. Ongoing review of Pt. #1’s medical record revealed no documentation of the number of attempts that were needed to insert the NG tube, the length of tube that was inserted, which nare (nostril) was used or how Pt. #1 tolerated the procedure. An interview was conducted with RN C on 02/11/2026 at 9:30 AM. When asked to describe how Pt. #1’s NG tube was inserted, RN C stated, “I told her what we were going to do, she had spilled water on her bedside table and I cleared that off. I explained the procedure...I lubricated the end of the tube and tried the left side, I met resistance and I stopped. [MD B] came in and I told him. I went to get water for her to swallow and had my back to [MD B], when I turned back with the water, he had inserted the tube. [Pt. #1] immediately felt better.” When RN C was asked why how Pt. #1 tolerated the procedure and the difficulty with the insertion of the NG was not documented in Pt. #1’s medical record, RN C stated, “I should have.””

“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: 44431 Based on observation, record review and interview the facility failed to follow policy and EMTALA (Emergency Medical Treatment and Labor Act) regulations by not accepting 1 (Pt. #1) of 1 patients requesting a transfer in for specialized services, in a sample of 20 medical records reviewed. Findings: Note: Facility A is the sending hospital and is located in a adjacent state, Facility B is the receiving hospital that declined transfer from Facility A. Patient #1 presented to the Facility B hospital after leaving Against Medical Advice (AMA) from Facility A. Upon presentation to Facility B, Pt. #1 received the necessary diagnostic imaging. Pt. #1 presented to Facility A on 05/13/2024 at 6:05 PM with a chief complaint of Pelvic Pain. Pt. #1 had a history of 2 previous ectopic pregnancies. Per review of Facility A medical record, Faciltiy A staff determined Pt. #1 required further diagnostic testing (Ultrasound) which Facility A was unable to provide. Facility B declined to accept the transfer of Pt. #1. Review of Facility B policy titled, “Antidumping Laws-EMTALA Compliance-Patient Transfer,” original date 1/1/1996 revealed, “[Facility Name] will accept appropriate transfers of individuals with emergency medical conditions if the hospital has the specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals, and a physician agrees to accept the individual...8. Physicians...shall follow all other EMTALA requirements as outlined in hospital policies and as required by regulatory entities.” Review of Facility B policy titled, “Ultrasound On-Call STAT Coverage After Hours, Nights, Weekends, Holidays,” original date of 10/01/1998 revealed, “To provide guidelines for night/weekend/holiday call-ins and emergency ultrasound imaging criteria to physicians....regarding the process and procedures to be followed- for STAT/emergency/critical ultrasounds....in Emergency Room (ER). These critical ultrasound examinations are those studies in radiology which, due to the indication, warrant performance of the exam....STAT Coverage Hours of Operation: A. Weeknights - Monday through Thursday: Ultrasound imaging staff are made available for STAT/emergency/critical ultrasounds, ONLY, as listed in the attached Critical Ultrasound Examinations section, during the following hours: 1900 to 07:00 hours (7:00 PM to 7:00 AM)....On Call Plan....A sonographer will be available via phone or beeper during weeknights, weekend and holidays hours for STAT/emergency/critical exams for in-patient (IP) and Emergency Room (ER) patients ONLY...” Review of Facility B Document titled, “Critical Ultrasound Examinations,” no date revealed, “The on-call sonographer will be available for the following critical tests/indications/criteria warranting ultrasound callbacks: 2. Early OB for ectopic Pregnancy.” Review of Facility B Incident report completed on 05/15/2024 regarding Pt. #1 revealed, “[Facility A] called and spoke with [MD A] concerning this patient. [MD A] denied transfer of pt with rationale given to [Facility A]. Pt. arrived to [Facility B] ED later in the night and stated that [she/he] did not want to be transferred 2 hrs from [Facility A]. Pt. informed primary nurse here at [facility B] that [Facility A] told [her/him] that the transfer via ambulance would be very expensive, and [she/he] left AMA from [Facility A] to come to [Facility B]...Manager Response: Risk Reviewed 05/16/2024. Potential EMTALA/Compliance Concern....No documentation about reason for declination of transfer.” Review of Facility B ultrasound schedule for 05/13/2024 revealed an ultrasound technician was scheduled in Facility B from 7:00 AM to 7:00 PM and an on call technician ws scheduled from 7:00 PM to 7:00 AM to provide on call coverage during that time. On 05/17/2024 at 3:20 PM in an interview with MD A when asked to explain the situation involving Pt. #1, MD A stated, “The ER MD called about ultrasound capability for a possible ectopic, it was after hours and we don’t have surgery coverage and I said I wasn’t going to accept.” MD A continued to say that they didn’t have a transfer agreement to accept patients, we don’t have to take someone just because they don’t have something and wasn’t going to call in ultrasound as ultrasound was on call for only certain things. MD A said, “We’re not here to do their ER work.” On 05/20/2024 at 8:40 AM in an interview with Radiology Director K when asked to describe the facility ultrasound services, Director K stated, “We have US coverage Monday through Friday from 7 AM to 7:30 PM in house and On Call after that based on our policy criteria. Any medical provider can call in ultrasound, it is available 24/7.” On 05/20/2024 at 10:30 AM in an interview with House Supervisor RN I, who was working on 05/13/2024, when asked if [he/she] could accept a transfer from another hospital; House Supervisor I stated, “I can’t accept or decline, it has to be provider to provider.” When asked what had happened with [Pt. #1] on 05/13/2024, House Supervisor I stated, I got a call from [Facility A] if we were fully staffed and could provide ultrasound services after normal business hours. They were looking for someone to do an US in house or on call. They said they were looking to rule out an ectopic, I told them I couldn’t accept that and they would have to talk to the ED provider about it and I transferred the call to the ED and don’t know anything more about it.” On 05/20/2024 at 10:15 AM in a follow up interview with MD A regarding the phone call received from Facility A, MD A stated, they called once, “I said NO!”, then they called a second time and I said, “Let me be clear to you, I’m not accepting this patient in a lateral transfer.” They then said something like what if they show up at your door and I said, “That’s a telling comment.” MD A continued, If it was an ectopic we would be transferring them out, they need to work within their system. This is not a new strategy for them. We didn’t have surgical services and I couldn’t provide complete care.”