Sagewest Health Care

“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: 16146 Based on medical record review, staff, patient and friend interview, and review of outside surgical records, psychiatric evaluations, and policies and procedures, the facility failed to provide stabilizing treatment or transfer the patient to another medical facility for 2 of 20 sample patients (#4, #12). Patients #4 and #12 had emergency medical conditions that were not stabilized by the facility and both were discharged instead of transferred. The findings were: Refer to A-2407 for details on the facility’s failure to provide stabilizing treatment or transfer the patient to another medical facility for patients #4 and #12. Both patients had emergency medical conditions that were not stabilized by the facility and both were discharged instead of transferred.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 16146 Based on medical record review, staff, patient and friend interview, and review of outside surgical records, psychiatric evaluations, and policies and procedures, the facility failed to provide stabilizing treatment or transfer the patient to another medical facility for 2 of 20 sample patients (#4, #12). Patients #4 and #12 had emergency medical conditions that were not stabilized by the facility and both were discharged instead of transferred. The findings were: 1. Regarding patient #12: a. Review of the emergency department (ED) medical record showed patient #12 arrived on 2/7/25 at 1:28 AM with a complaint of penile pain after intercourse. The patient’s pain was documented as 8 on a scale of 0 to 10 at 1:47 AM. The record showed physician #1 evaluated the patient. The physician documentation showed the patient appeared uncomfortable and complained of penile pain. The penis was observed to be circumferentially swollen, discoloration entire penile shaft and markedly tender. At 2:10 AM the physician documented he was waiting for a callback from [Hospital A]. At 2:33 AM the physician documented that [name of physician] “...Happy to accept immediately, however pain is reasonably well controlled, & agreeable to the patient, reasonably safe for the patient to present to urology clinic when they open at 9:00 a.m. I discussed this with the patient. He is agreeable to DC from the ED and his GF at bedside will drive his reliable vehicle to [urology clinic A] in Casper.” The diagnosis was listed as “penile fracture” and the disposition was discharged. Further review of the medical record showed during the visit the patient received pain medication, anti-nausea medication, and an antacid, but no further treatment was provided. The discharge instructions to the patient informed him to not eat or drink until he spoke to [name of physician] or another urologist. The patient was instructed to go to [urology clinic A] in Casper at 9 am when they opened. The discharge information provided to the patient showed he was diagnosed with a penile fracture. Further, “...Penile fracture is a medical emergency that requires emergency surgery.” The patient was discharged at 3:40 AM. b. Further review showed the patient presented to the ED on 2/7/25 at 3:56 AM after falling in the parking lot after leaving the ED. Review of documentation from physician #1 showed the patient had just been discharged from the ED with a diagnosis of acute penile fracture and suffered a fall in the parking lot. “CT brain and face bones without contrast both without obvious urgent or emergent finding.” The patient received IV fluids in the ED. The physician further documented “He is still desirous of the original plan: Presenting to [urology clinic A] this morning. He, in his girlfriend at bedside, have a reliable friend who can drive them, since they have been up most of the night at this point... I again offered transfer but he declines.” The diagnoses included penile fracture and near syncope. The patient was instructed to proceed directly to [urology clinic A] in Casper. The patient was discharged at 7:03 AM. c. Review of the medical records for both ED visits on 2/7/25 showed no evidence the patient was educated on the risks of being discharged or the benefits of a transfer. There lacked evidence the patient was asked to sign a form indicating he did not want a transfer. d. During an interview on 4/15/25 at 6:19 PM the manager for the ED in Riverton confirmed patient #12 was discharged and went to Casper in a personal vehicle to go to a urologist for immediate care. She stated the patient was in a lot of pain. She further confirmed there was no signed “against medical advice” form for this patient. e. On 4/15/25 at 6:44 PM physician #1 was interviewed. He stated he diagnosed patient #12 with a penile fracture and stated the facility did not have urology services. Therefore he contacted [name of physician] at [hospital A] to consult. He stated because the patient’s pain was reasonably well controlled, it was reasonably safe for the patient to present to the urology clinic in Casper in the morning. Physician #1 stated at night the only ambulance service available was air ambulance, and the patient desired to go via personal vehicle instead. When asked if a penile fracture was an emergency medical condition, and if the patient should have been transferred instead, he stated he relied on the advice of the specialist. f. During an interview on 4/16/25 at 10:59 AM patient #12 stated he was diagnosed with a penile fracture in the ED and was told to go to the urologist later that morning in Casper. He stated he was told in the ED that his insurance would not pay for an air ambulance because his injury didn’t qualify, so he told them they would drive themselves. After the 2nd ED visit (after the fall), the ED staff stated they could get the air ambulance to be covered, but he stated he told them no, they would drive. He stated there was no discussion on the risks of not being transferred, and they didn’t ask him to sign anything. He stated he went to the urologist office in Casper and the urologist told him it “it was the worst he’d seen” and that the patient needed immediate surgery. He stated he went to a different building and had the surgery that same day. g. On 4/21/25 at 1:43 PM the friend of patient #12 stated she was in the ED with the patient and confirmed the patient was discharged and they drove to Casper in a personal vehicle. h. Review of a surgical note from [ambulatory surgical center A] showed patient #12 had “penoscrotal exploration with repair of penile fracture” performed on 2/7/25. i. Review of the facility’s ED on-call schedule for 2/7/25 showed urology was not an on-call service. 2. Related to patient #4: a. Review of the ED medical record showed patient #4 presented to the ED on 3/4/25 at 9:55 AM. The patient stated s/he took “10x 500 mg [milligrams] Gabapentin and 4-5x “cold medicine” to try and overdose and now regrets the decision and wishes to go to an inpatient facility.” Review of the Columbia suicide severity rating showed the patient was high for suicide risk. Review of the physician documentation from physician #2 showed the patient presented to the ED after a known overdose which was intentional. The exam showed “...Psych: Positive for anxiety, depression, suicide gesture” and “...patient having thoughts of suicide. Plan for suicide is taking pills.” In addition, patient “states that [s/he] needs some psychiatric help as [s/he] does feel suicidal...Patient had a discussion with [physician #3] who agreed the patient will need inpatient placement for suicidal gesture and ideation. Patient was medically cleared and will try an outpatient go to [mental health facility A] for further help.” The physician documented the diagnosis as suicidal ideations and stated transfer was ordered to [mental health facility A]. It was documented the patient was going by private vehicle voluntarily. There was no physician transfer certification in the medical record. Further review showed the patient was on frequent observation checks (every 15 minutes with a 1:1 sitter) for high suicide risk right up until the patient was discharged at 6:45 PM. b. Review of the psychiatry consult note from 3/4/25 at 11:49 AM by physician #3 showed the patient presented to the ED with a suicide attempt. This was the patient’s second lifetime suicide attempt and s/he has been hospitalized previously. The assessment/plan showed “patient seeking inpatient treatment. For now, okay to pursue voluntary admission. Patient requesting to go to [mental health facility A] in Worland. However, if patient declines admission and tries to leave, recommend involuntary hold/admission at that time.” c. Review of the medical clearance form for [mental health facility A] showed it said “...[mental health facility A] is NOT a medical facility and does not have an in-house pharmacy or 24 hour Nursing.” d. Review of documentation from [counseling service A] showed on 3/4/25 at 1:40 PM they were contacted by the ED to evaluate patient #4 after an intentional overdose. The patient did not meet criteria for involuntary detention as evidenced by his/her willingness and desire to admit himself/herself on a voluntary basis at [mental health facility A]. Another note dated 3/4/25 at 4:45 PM showed they spoke to the patient’s [wife/husband] who stated s/he could transport the patient to [mental health facility A] and could complete a safety plan for the interim between the ED and [mental health facility A]. e. Review of a “Personal Safety Plan” dated 3/4/25 by [counseling service A) showed the patient had suicidal thoughts and suicidal plans. The plan instructed the patient to check into [mental health facility A] that night around 9 PM. Further, it stated to call law enforcement if any issues arose during transportation. f. During an interview on 4/15/25 at 2:54 PM registered nurse (RN) #1 stated telepsych was called first for patient #4, and then [counseling service A] to determine if the patient needed to be involuntary held or could do a safety plan. The patient had a partner who stated s/he could drive the patient to [mental health facility A]. He stated this was a discharge and not a transfer, although they gave all pertinent records to the patient to give to the facility. g. On 4/16/25 at 11:12 AM physician #2 stated the patient was going voluntarily to [mental health facility A], but he wasn’t sure if it was inpatient or outpatient. He stated he would consider this a transfer since psychiatric issues were an emergency medical condition. He was unable to answer why there wasn’t a transfer certificate in the medical record. He stated the nurses would give him any appropriate forms and he would sign them. He confirmed the patient went to the other facility by personal vehicle. h. During an interview on 4/16/25 at 2 PM the ED manager for Lander stated [mental health facility A] was not a hospital. She stated it was a psychiatric facility that did both inpatient and outpatient. She stated if a patient was safe to go in a personal vehicle, then it was a discharge and not a transfer. i. Review of the Hospital/CAH database worksheet (Exhibit 286) completed 4/14/25 showed the facility did not provide psychiatric services. 3. Review of the facility’s policy “EMTALA- Medical Screening and Treatment of Emergency Medical Conditions,” effective 9/19/24, showed “...Any individual who comes to the Hospital Property or Premises requesting examination or treatment is entitle to and shall be provided an appropriate Medical Screening Examination performed by a physician or other Qualified Medical Personnel to determine whether or not an Emergency Medical Condition exists. If an Emergency Medical Condition is found to exist, the Hospital will (without regard for the patient’s insurance coverage or ability to pay) provide: (a) stabilizing treatment within the capabilities of the Hospital and its staff (including on-call physicians and diagnostic services), and/or (b) an appropriate transfer to another medical facility (if required for the patient’s treatment or requested by the patient).” In addition, “...For the purpose of discharging a patient with psychiatric condition(s), the patient is considered to be stable for discharge when they are no longer considered to be an imminent threat to themselves or others...” 4. Review of the facility’s policy “EMTALA- Transfer Policy,” effective 9/25/23, showed “...If the hospital offers to transfer a patient to another hospital for services the hospital does not offer and informs the patient or the legally responsible person of the risks and benefits to the person of the transfer but the patient or the person acting on the patient’s behalf refuses to consent to the transfer, the facility must take all reasonable steps to secure a written refusal from the patient or the person acting on the patient’s behalf. The written refusal should indicate the person has been informed of the risks and benefits of the transfer and state the reasons for such refusal. The patient’s medical record must contain a description of the proposed transfer that was refused by the patient or the person acting on the patient’s behalf...””