Memorial Hospital of Carbon County

“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 family interviews, and review of policies and procedures, the facility failed to ensure a transfer was effected through qualified personnel and transportation equipment for 2 of 6 sampled patients (#7, #9) who were transferred. The findings were: 1. Refer to C-2409 for details on the facility’s failure to ensure the transfers for patients #7 and #9 were effected through qualified personnel and transportation equipment.”

“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, patient and staff interview, and review of policies and procedures, the facility failed to ensure the transfer was effected through qualified personnel and transportation equipment for 2 of 6 sampled patients (#7, #9) who were transferred to other health care facilities. The findings were: 1. Review of the medical record showed patient #7 presented to the emergency department (ED) on 6/23/25 complaining of groin and scrotal pain. The patient described the pain as 4 or 5 on a scale of 1-10 (10 being worst). The physician’s exam at 10:38 PM showed the scrotum was swollen and eccymotic (bruised) and the testes were tender. There was a positive cremaster response (presence of this reflex can indicate lower likelihood of a testicular torsion) on the right and left. The physician transilluminated the scrotum, but was unable to see light through the scrotum (no light transilluminating through the scrotum can indicate a solid mass). The physician documented he spoke to a urologist at hospital B, located in another town about 108 miles away, who recommended transfer so he could evaluate. The assessment was documented as “scrotal trauma.” Review of the discharge instructions showed “Go to [town] ER now, they are expecting you.” The following concerns were identified: a. Review of the “COBRA Transfer Form” dated 6/24/25 showed the patient’s condition was “The patient may be at risk for deterioration from or during transfer.” The reason for transfer was “ultrasound” and the patient was being transferred to hospital B. The mode of transport was listed as “private auto.” b. Review of the ED disposition documentation dated 6/24/25 at 12:32 AM showed the patient was being transferred due to requiring specialty care. The mode of transfer was listed as “private vehicle.” c. Review of a nursing note dated 6/24/25 at 12:28 AM showed the patient stated he didn’t think he would be able to go to hospital B that night to see the urologist. He stated he was tired and thought he would fall asleep. The nurse reinforced to the patient the need and importance of being evaluated tonight “due to potential irreversible damage.” The patient verbalized understanding and stated he would have his father drive him. d. During an interview on 8/12/25 at 2:24 PM physician #1 stated the patient had scrotal pain, and the scrotum was swollen and eccymotic (bruised). His concern was for torsion (twisting of the testicle) or penile fracture (rupture of fibrous coverings on the penis; considered a urological emergency). He stated he called urology at hospital B and they said the patient needed to go there emergently. He stated the facility did not have ultrasound after 5 PM, therefore he needed to be transferred. He stated the patient had an emergency medical condition and needed further care. He stated the mode of transport was usually left up to the patient, but if the patient was unstable, they would be sent via ambulance. When asked if this patient was stable, he replied that his recollection was the patient didn’t want to go via ambulance and wanted to go in a private vehicle. When asked if patients who wanted to go in a private vehicle and not in an ambulance were asked to sign something to indicate they understood the risks, he stated not in this case. e. On 8/14/25 at 4:16 PM registered nurse (RN) #1 stated the patient was offered an ambulance. She stated the patient “waffled” about going to the other hospital and the doctor explained to him the importance of going. She stated when she talked to the patient at discharge, he stated he was tired and might go the next day. She explained the importance of going and he stated his father would take him. When asked if patients who declined an ambulance were asked to sign a form, she stated no. She stated the patient signed the transfer certification form (agreeing to a transfer). f. Further medical record review showed no documentation to show the patient was offered an ambulance but declined. There further lacked evidence the patient was educated on the specific risks associated with transport in a private vehicle. g. Review of the medical record from hospital B (recipient hospital) showed the patient arrived on 6/24/25 at 2:24 AM. Review of the ED note showed the patient was transferred from an outside facility with concerns for scrotal swelling and bruising and the need for urology evaluation. An ultrasound of the scrotum was obtained, which demonstrated scrotal thickening, minimal amount of right scrotal fluid, and otherwise normal. The urology consultation note showed the patient was evaluated for concern for penile fracture, but given the history and presentation the urologist did not think so. The scrotal ultrasound was without an acute finding or concern for trauma requiring surgical intervention. The diagnosis was a scrotal bruise. 2. Review of the medical record showed patient #9 presented to the ED on 7/9/25 complaining of left upper quadrant (abdominal) pain. The physician’s exam at 4:15 PM showed the physician received a phone call from another physician stating the patient was coming to the ED. The patient had severe upper abdomen pain and laboratory testing showed elevated AST (aspartate aminotransferase; shows liver health), ALT (alanine aminotransferase; shows liver health) and alk phos (alkaline phosphatase; shows liver health) and a lipase of over 900 (elevated levels shows problems with pancreas). In the ED, a CT (computed tomography) scan was done which showed gallbladder wall thickening with pancreatitis. The physician spoke with a gastroenterologist at hospital C (in a town about 117 miles away) who agreed to see the patient. He consented to the patient traveling by private vehicle. The assessment was documented as common duct stone and pancreatitis. The following concerns were identified: a. Review of the “COBRA Transfer Form” dated 7/9/25 showed the patient was being transferred by private vehicle to hospital C for gastroenterology. b. Review of the ED disposition documentation showed the patient was being transferred to hospital C by private vehicle with family. c. On 8/12/25 at 4:36 PM the patient stated the facility offered an ambulance but s/he wanted to go by private vehicle. The patient stated family was with him/her in the car. When asked if the facility had him/her sign something to show s/he understood the risks of transferring via a personal vehicle, s/he stated they signed “something” but s/he wasn’t sure if it was that. d. During an interview on 8/12/25 at 5:06 PM RN #2 stated the physician talked to the receiving physician and he was comfortable with the patient going by personal vehicle. The patient had an IV in place. She stated the facility did have an AMA form, but if the physician was comfortable with transfer via personal vehicle, then they wouldn’t have the patient sign it. e. During an interview on 8/13/25 at 8:46 AM physician #2 stated the patient had significant abdominal pain and the CT showed a common duct stone. He stated the patient needed ERCP (endoscopic retrograde cholangiopancreatography; used to diagnose problems in the bile and pancreatic ducts) which they didn’t have. He called hospital C and a physician accepted him. He stated the patient was offered an ambulance, but it was the patient’s choice to go via personal vehicle. When asked if the facility had patients sign a form indicating they were declining an ambulance for transport, he stated no. f. Further medical record review showed no evidence the patient was educated on the specific risks associated with transport in a private vehicle. g. Review of the discharge summary from hospital C showed the patient was admitted on 7/9/25 and discharged on 7/11/25. The patient went for ERCP and had a stent placed. General surgery was consulted and the patient had a cholecystectomy (removal of the gallbladder). 3. Review of the facility’s policy “Transferring of Patients,” (print date 11/5/2021), showed “...2. The transfer is an appropriate transfer in which: ...d. 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...” Further review of the policy showed it did not address procedures for when patients declined ambulance transport and wanted to go in a private vehicle.”

“ANESTHETIC RISK AND EVALUATION CFR(s): (1) A qualified practitioner, as specified in paragraph (a) of this section, must examine the patient immediately before surgery to evaluate the risk of the procedure to be performed. (2) A qualified practitioner, as specified in paragraph (c) of this section, must examine each patient before surgery to evaluate the risk of anesthesia. (3) Before discharge from the CAH, each patient must be evaluated for proper anesthesia recovery by a qualified practitioner, as specified in paragraph (c) of this section. This Standard is not met as evidenced by: 16146 Based on medical record review, staff interview, and review of policies and procedures and facility documentation, the failed to ensure a post-anesthesia evaluation was completed prior to discharge for 2 of 7 patients (#2, #4). The findings were: 1. Review of the medical record showed patient #2 had a laporascopic appendectomy on 8/21/24 under general anesthesia. The patient was discharged from the facility on 8/22/24. Further review of the medical record showed no evidence a post-anesthesia evaluation was completed. On 6/12/25 at 9:52 AM the director of nursing for inpatient confirmed she was unable to locate a post-anesthesia evaluation. 2. Review of the medical record showed patient #4 had surgery on 4/19/24 under general anesthesia. The procedure performed was an open diverting loop sigmoid colostomy. The patient was discharged on 4/24/24. Further review of the medical record showed no evidence a post-anesthesia evaluation was completed. On 6/12/25 at 8:52 AM the director of nursing for inpatient confirmed she was unable to locate a post-anesthesia evaluation. 3. During an interview on 6/12/25 at 9:09 AM the director of nursing for inpatient stated she called certified registered nurse anesthetist (CRNA) #1 who stated the post-anesthesia evaluation should be documented in the medical record under the consultation section. The director of nursing further stated there were no post-anesthesia evaluations for patients #2 or #4 in the medical record. 4. During an interview on 6/12/25 at 10:07 AM the director of risk stated post-anesthesia evaluations was not something that was being monitored in quality assurance. She stated some chart audits were done in the anesthesia department, but review of the audit forms she provided showed post-anesthesia evaluation was not included as a specific indicator. 5. Review of the facility’s policy “Postanesthetic Visits for Inpatients,” revised 8/31/12, showed “...Postanesthetic visits shall be made on all patients who have undergone anesthesia and at least one note shall be made describing the presence or absence of anesthesia-related complications...When the postanesthetic visit and chart entry by Anesthesia personnel is not feasible because of early patient release from the hospital, the physician or dentist who discharged the patient from the hospital shall be responsible for satisfying this requirement.””