North Big Horn Hospital District

“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: 16146 Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure a mid-level practitioner consulted with a physician at the time of transfer who agreed with, and subsequently countersigned, the certification for 2 of 2 patients who were transferred (#8, #10). The findings were: 1. Review of the medical record showed patient #8 presented to the emergency department (ED) on 12/28/25 with complaints of a fall after passing out. Review of the note by the provider, family nurse practitioner (FNP) #1, showed a CT (computed tomography) scan showed a fracture of C7 (cervical) vertebra. A consultation was done with a physician at another hospital who agreed to accept the patient as a transfer. The following concerns were identified: a. Review of the transfer certification dated 12/28/25 showed it was signed by FNP #1. There lacked a countersignature by a physician. b. During an interview on 1/24/26 at 10:19 AM FNP #1 stated they do not have a physician sign the transfer certification. He stated they consult with a physician at the receiving facility. 2. Review of the medical record showed patient #10 presented to the ED on 12/26/25 with a complaint of a severe headache. Review of the note by the provider, physician assistant (PA) #1, showed a consultation was done with a neurologist at another hospital. The neurologist reviewed the CTA (computed tomography angiography) and was concerned about the basilar artery with possible occlusion (blockage) or stenosis (narrowing of artery). The neurologist recommended transfer. The following concerns were identified: a. Review of the transfer certification dated 12/26/25 showed it was signed by PA #1. There lacked a countersignature by a physician. b. During an interview on 1/22/26 at 11:09 AM PA #1 stated the facility did not have any physicians who worked in the ED. He stated they do not have a physician countersign the transfer certification. He stated they consult with a physician at the receiving facility. 3. On 1/22/26 at 11:12 AM the medical director of the ED stated physicians do not countersign the transfer certifications. He stated there were no physicians who took call in the ED. 4. Review of the EMTALA policies provided by the facility showed they did not include having a provider consult a physician at the time of transfer who would agree with, and later countersign, the transfer certification.”

“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: 37603 Based on observation, medical record review, staff interview, review of the central log, the admission/emergency room video recording, the emergency medical services reports, and policy and procedure review, the facility failed to ensure C-2405 and C-2406 were met. The findings were: 1. Refer to C-2405 for details on the facility’s failure to ensure patient #1 was included on the emergency room log. 2. Refer to C-2406 for details on the facility’s failure to provide an appropriate medical screening examination to patient #1.”

“EMERGENCY ROOM LOG CFR(s): 489.20(r)(3) [The provider agrees,] in the case of a hospital as defined in §489.24(b) (including both the transferring and receiving hospitals), to maintain a central log on each individual who comes to the emergency department, as defined in §489.24(b), seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged. §489.24 The provisions of this regulation apply to all hospitals that participate in Medicare and provide emergency services. This Standard is not met as evidenced by: 37603 Based on medical record review, staff interview, review of the admission/emergency room entry lobby video recording, review of the central log, and policy and procedure review, the facility failed to ensure 1 of 20 sample patients (#1) was included on the emergency room log. The findings were: 1. Observation of the admission/emergency room entry lobby video recording showed on 4/16/25 at 11:02:03 AM patient #1 arrived with staff from a long-term care facility via wheelchair. The admission clerk had placed the patients arm band on at 11:04:16 AM. At 11:08:42 AM, the director of nursing talked with person in the lobby and took the patient out of lobby via wheelchair towards the nursing home. 2. Review of the April 2025 Emergency Department log showed the facility failed to include patient #1 when s/he presented to the emergency room on 4/16/25. 3. Review of patient #1’s “Encounter Search” showed the 11:03 AM registration on 4/16/25 for “Emergency” was a canceled visit. Further, it showed the discharge date was 4/16/25 at 11:10 AM. 4. Interview with the chief nursing officer on 4/23/25 at 4 PM revealed he had asked admissions to cancel the patient’s admission. 5. Review of the policy and procedure “EMTALA Guidelines” reviewed on 2/14/23 showed “...6. This facility will maintain a Central Log for each individual who comes to the emergency department seeking assistance...””

“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: 37603 Based on observation, medical record review, staff interview, review of the admission/emergency room video recording, and emergency medical services reports, and policy and procedure review, the facility failed to ensure an appropriate medical screening examination was completed for 1 of 20 sample patients (#1) who presented to the emergency department. The findings were: 1. Observation of the admission/emergency room entry lobby video recording showed on 4/16/25 at 11:02:03 AM patient #1 arrived with staff from a long-term care facility via wheelchair. The admission clerk had placed the patients arm band on at 11:04:16 AM. At 11:08:42 AM, the director of nursing talked with person in the lobby and took the patient out of lobby via wheelchair towards the nursing home. 2. Review of the “Encounter Search” for patient #1 showed on 4/16/25 at 11:03 AM the registration dated for “Emergency” was a canceled visit. Further, it showed the discharge date on 4/16/25 at 11:10 AM. There were no other emergency room records for the patient. 3. Review of the “Long Term Care/Swing Bed Documents” for patient #1 showed the following: a. Review of the progress note dated 4/16/25 at 10:40 AM showed “...inability to transfer and walk, ambulated via wheelchair back to room. Right sided weakness, drooling from the right side of mouth, complaint of neck and back to the right side...” b. Review of the “Facility Transfer LTC Form” entered on 4/16/25 at 11:24 AM showed “...Transfer Information. Medical Reason for Transfer LTC: Mental status change, Cardiac, Neurological. Medical Reason Comments LTC: Change of condition, with right sided weakness and increasing pain...” c. Review of the progress noted dated 4/16/25 at 12:54 PM showed “Resident [patient #1] was sent to the [hospital #2] ER via ambulance at noon...” The progress notes failed to show the patient was first sent to the North Big Horn Hospital emergency room. 4. Review of the emergency medical services “Patient Care Report” dated 4/16/25 at 11:14 AM showed “...Narrative: Dispatched to Care Center to take [patient #1] complaining of a headache that started at 1045 to hospital. Patient is a resident at [name of long-term care facility] and started complaining of headache while having a BM (bowel movement). Care Center staff decided patient was not acting right and took patient to NBHH [North Big Horn Hospital] ER [Emergency Room]. Due to NBHH CT scan being down, DON [name] and PA-C [name] told Care Center staff to take patient back to care center instead of checking in to ER and called 911 for transport to [hospital #2] ER the next closest facility.” The activities showed the patient was placed on 2 liters of oxygen, glucose was checked, IV - Saline Lock to left wrist, using a 22-gage catheter. 5. Interview on 3/24/25 at 10:33 AM with patient #1’s power of attorney revealed they had assumed they saw the patient in the Lovell hospital, but was not sure. The patient did go to [hospital #2] that day because the Lovell hospital did not have a CT machine. S/he was showing signs of dragging his/her right side. S/he probably had a mini stroke. 6. Interview on 4/23/25 at 4 PM with the chief nursing officer revealed he had found out the facilities CT scanner was already torn apart, and the mobile CT scanner was down. The long-term care facility was sending someone over with right sided weakness. He tried to stop the patient from coming over, so the long-term care facility could just send the patient to hospital #2. The patient was already checked in, so the patient was taken back to the long-term care facility and 911 was called. At that moment we just wanted to get him/her the help that they needed. We did not intentionally try and dump the patient. He further stated he did ask admissions to cancel the patient on the admission log. 7. Interview on 4/23/25 at 4:07 PM with the emergency room provider on duty for 4/16/25 revealed he was familiar with the patient. He had seen him/her before. However, on that date he did not see the patient and was unaware s/he came to the ED. 8. Review of policy and procedure “EMTALA Guidelines” review date of 2/14/23 showed “Policy: ...Any individual who comes to the hospital seeking or requesting examination or treatment of a medical condition, including women in active labor, will be given an appropriate medical screening exam.””