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Based on document review and interview, it was determined that the hospital failed to comply with 42 CFR 489.24.

Findings include:

1. The hospital failed to provide medical treatment to stabilize a patient's emergency medical condition. A-2407.

2. The hospital failed to ensure an appropriate, timely transfer for an unstable patient. A-2409 A.

3. The hospital failed to ensure the transfer form was completed, as required. A-2409 B.


The immediate jeopardy began on 5/24/2023, due to the hospital 's failure to provide the medical treatment required to stabilize a patient's (Pt #1) emergency medical condition and was identified on 8/9/2023. The IJ was announced on 8/9/2023 at 4:00 PM during a meeting with the Quality Manager, Chief Nursing Officer, Senior Director of Operations, Director of Nursing Education, Director of Nursing Services and Director of Emergency Department, and was not removed by the survey exit date of 8/9/2023.

Based on document review and interview, it was determined that for 1 of 1 Neurology Interventionist (MD #3) on-call on 5/24/2023, the hospital failed to ensure the on-call physician was available while on call to meet the needs of the patients requiring specialty services.

Findings include:

1. On 8/7/2023, the hospital's policy titled "City-Wide Call Policy" (dated 7/2020) was reviewed and indicated, "If the consulted physician is unable to provide appropriate care, he/she shall assist with obtaining additional consultation ...The physician On Call when the telephone call is first made is the responsible physician ... Any changes to the call schedules shall be communicated to the appropriate hospital department in a timely manner."

2. On 8/7/2023, Hospital A's "Intervention Neurologist list and schedule" (dated 4/2023 to current) was reviewed. MD #3 (neuro-interventionist) was scheduled as the "on call" neuro-interventionist on 5/24/2023.

3. On 8/7/2023, the hospital's policy titled, "Physician On-Call to the Emergency Department" (dated 4/2021) noted, "When a physician is scheduled to be on call to the ED, it is the physician's responsibility to respond to the ED ...Response times - Arrive at Hospital within sixty (60) minutes after notification that services are needed - neurosurgery ..."

4. On 8/7/2023, Pt #1's emergency department (ED) clinical record from Hospital A, dated 5/24/2023, was reviewed and included:

-2:40 PM -Pt #1 arrived in Hospital A's ED via ambulance with stroke symptoms.
-2:41 PM -orders placed by MD #1 for CT (CAT scan - specialized x-ray) stroke head and CTA (Cat scan angiogram - dye) ( head/neck
-2:42 PM Imaging (CT stroke head and CTA head/neck started)
-2:52 PM - Triage Nurse (E #2) - notes orders acknowledged - ED telemetry monitoring; draw blood for labs; CT stroke head; EKG (electrocardiography)12 lead; oxygen; IV; pulse oximetry
-3:05 PM - CT stroke head complete
-3:07 PM - Tenecteplase (TNKase- is a powerful blood thinning medication used to treat a stroke caused by a blood clot) injection 25 mg intravenous, vitals blood pressure 146/111
-3:41 PM - Pt #1 seen by neurologist (MD #2) - MD #2 noted "...Pt #1 is a candidate for endovascular therapy. Neuro-intervention was consulted at Hospital B and Pt #1 to be transferred to Hospital B."
-3:48 PM, MD #1's note - We (Hospital A) do not have interventional neurology thus Pt #1 transferred to Hospital B after our neurology team spoke to neurology team there for interventional care. Hospital B accepted Pt #1. Clinical impression - Cerebrovascular accident (CVA).
-5:11 PM - Pt #1 transported to Hospital B via critical care ambulance.
Pt #1's clinical record did not include documentation of the attempt to/contact with (including time) the neuro-interventionist (MD #3) who was on-call on 5/24/2023.

5. On 8/8/2023 at 11:30 AM, an interview was conducted with the Neuro APN (Advanced Practice Nurse - E #4). E #4 stated that E #4 was not aware that Hospital A's neuro-interventionist (MD #3) was not available on 5/24/2023 until 5/24/2023 when a stroke alert was called for Pt#1 and MD #3 was not available to respond. E #4 stated that MD #3 was the neuro-interventionist on call for 5/24/2023, and MD #3 did not call the hospital to inform them that MD#3 would not be available.

6. On 8/7/2023 at 1:30 PM, an interview was conducted with the Manager of Quality (E #1). E #1 stated that MD #3 (neuro interventionist) was not available at Hospital A to see Pt #1 in the ED on 5/24/2023 when called (even though MD #3 was on the on-call schedule for 5/24/2023) due to a personal emergency. E #1 stated that it was up to MD #3 to find MD #3's own coverage for 5/24/2023.

7. On 8/8/2023 at 12:30 PM, an interview was conducted with Hospital A's ED Physician (MD #2). MD #2 stated that he did not know that Hospital A's neuro-interventionist (MD #3) was not available until E #4 informed E #4 on 5/24/2023 during the stroke alert for Pt #1.

8. On 8/8/2023 at 12:50 PM, an interview was conducted with the Neuro-Interventionist (MD #3). MD #3 stated that (MD #3) did not notify Hospital A that he was not available on 5/24/2023 prior to receiving the call about Pt #1.

Based on document review and interview, it was determined that for seven patients (Pt #2, Pt #3, Pt #4, Pt #5, Pt #8, Pt #17, and Pt #18) who presented to the hospital's emergency department (ED), the hospital failed to ensure the ED log included the discharge disposition of each patient.

Findings include:

1. The hospital's policy titled, "EMTALA Screening, Treatment and Transfer of Patients (revised 2/2020)" was reviewed on 8/8/2023 and included, "Emergency Log: The hospital will maintain the capacity to generate a central log of each individual who comes to the hospital seeking emergency assistance. The log will indicate ... transfer, admit and treated, stabilized and transferred or discharged."

2. The hospital's ED log from 02/24/2023 - 07/24/2023 was reviewed on 8/8/2023. The following patients (Pt #2, Pt #3, Pt #4, Pt #5, Pt #8, Pt #17, and Pt #18) identified on the log lacked documentation of the discharge disposition for the patients:
- Pt. #2 - presented to the ED on 3/24/2023 at 3:57 PM with the chief complaint of stroke alert.
- Pt. #3 - presented to ED on 3/24/2023 at 6:13 PM with the chief complaint of stroke alert.
- Pt. #4 - presented to ED on 3/24/2023 at 9:15 PM with a chief complaint of shortness of breath.
- Pt. #5 - presented to the ED on 4/24/2023 at 2:08 AM with a chief complaint of trauma - arm injury.
- Pt. #8 - presented to the ED on 4/24/2023 at 7:22 PM with a chief complaint of trauma - fall.
- Pt. #17 - presented to the ED on 6/24/2023 at 3:57 PM with a chief complaint of trauma.
- Pt. #18 - presented to the ED on 6/24/2023 at 5:56 PM with a chief complaint of trauma.

3. During an interview on 8/8/2023 at 10:15 AM, the manager of the ED (E#6) stated that the log should include the discharge disposition.

Based on document review and interview, it was determined that for 1 of 10 ED (emergency department) clinical records (Pt #1) reviewed for patients presenting with stroke symptoms, Hospital A [sending hospital] failed to provide the medical treatment required to stabilize Pt #1's emergency medical condition. Subsequently, Pt #1 was transferred in unstable condition to Hospital B [receiving hospital] where Pt #1 immediately underwent a thrombectomy and stent placement.

Findings include:

1. On 8/9/2023, the Hospital's policy titled, "EMTALA Screening, Treatment, and Transfer of Patients" (effective 5/2023) was reviewed and indicated, "...Stabilize the patient's condition - by providing such additional medical treatment as is within the capabilities of the staff and facilities of the Hospital, and is necessary to stabilize the medical condition. A. If the use of on-call physicians is appropriate for such stabilizing care, the physicians or other appropriate staff will call in such physicians. B. Once the patient is stable, this policy ceases to apply and the patient may be discharged or transferred without needing to meet any further obligations under this policy.

2. On 8/9/2023, Hospital A's "Neuro Specialty Procedure List" (undated) was reviewed and indicated that thrombectomy is a procedure that is a service provided by Hospital A and is performed by a neuro-interventionist.

3. On 8/7/2023, Hospital A's "Intervention Neurologist list and schedule" (dated 4/2023 to current) was reviewed. MD #3 (neuro-interventionist) was scheduled as the "on call" neuro-interventionist on 5/24/2023.

4. On 8/7/2023, Pt #1's ED clinical record from Hospital A, dated 5/24/2023, was reviewed and included:

-2:40 PM -Pt #1 arrived in Hospital A's ED via ambulance.
-2:41 PM -orders placed by MD #1 for CT (CAT scan - specialized x-ray) stroke head and CTA (CAT scan angiogram - dye) head/neck
-2:42 PM Imaging (CT stroke head and CTA head/neck started)
-2:52 PM - Triage Nurse (E #2) - notes orders acknowledged - ED telemetry monitoring; draw blood for labs; CT stroke head; EKG 12 lead; oxygen; IV; pulse oximetry
-3:05 PM - CT stroke head complete
-3:07 PM - Tenecteplase (TNKase- is a powerful blood thinning medication used to treat a stroke caused by a blood clot) injection 25 mg intravenous
-3:41 PM - Pt #1 seen by neurologist (MD #2) - MD #2 noted "Pt #1 was administered TNK in the ER, and Pt #1 is going to be transferred to Hospital B at the request of Pt #1's wife, for possible intervention. CT head shows a hyperdense left MCA indicating hyperacute thrombus (clot). No intracranial hemorrhage (bleed). CTA head/neck shows total occlusion (blockage) of left distal cervical ICA (internal carotid artery) and intracranial ICA. Total occlusion of left MCA(middle cerebral artery). I (MD #2 had a detailed discussion with Pt #1's wife regarding the assessment and plan, and she (Z1) verbalized understanding of and agreement to the plan. Pt #1 is a candidate for endovascular therapy. Neuro-intervention was consulted at Hospital B and Pt #1 to be transferred to Hospital B."
-3:47 PM - ED Disposition - set to transfer to another Facility per MD #1 note
-3:48 PM - ED Physician (MD #1) notes - Physician certification - Emergency Medical Condition Identified - Pt #1 unstable. Reason for Transfer: Emergency - Unstable. Risks - motor vehicle collision/crash; worsening of condition; permanent disability; death. Benefits; higher level of care; Individual's (Pt #1) condition at time of transfer; serious. Hospital/Facility
Pt #1 transferred to - Hospital B; Pt #1 to be transferred via: ALS (advanced life support)
-MD #1's note, also at 3:48 PM - We (Hospital A) do not have interventional neurology thus Pt #1 transferred to Hospital B after our neurology team spoke to neurology team there for interventional care. Hospital B accepted Pt #1. Clinical impression - Cerebrovascular accident (CVA).
-4:00 PM - Pt #1's blood pressure 116/92; spO2 90% oxygen 6 liters per nasal cannula
-4:26 PM -Ambulance company was dispatched to transfer Pt #1 from Hospital A to Hospital B.
-5:11 PM - Pt #1 transported to Hospital B via critical care ambulance.

5. Pt #1's clinical record from Hospital B was reviewed on 8/7/2023 and indicated that Pt #1 arrived at Hospital B on 5/24/2023 at 5:21 PM and included:
-Angio Neuro/Cerebral Intervention surgical procedure (performed by MD #4) on 5/24/2023 at 5:41.
Hospital B course: Pt #1 was transferred from Hospital A for stroke management and left MCA/ICA occlusion. Pt #1 was admitted with a diagnosis of stroke with left MCA/ICA occlusion on 5/24/2023. CT scan of the head was negative for any acute bleed at outside hospital. Pt #1 was given IV tPA. CT angiography of head and neck showed left ICA and MCA occlusions. Pt #1 was therefore transferred to assess at Hospital B and for thrombectomy. Pt #1 upon arrival was found to be lethargic with left gaze preference without any speech deficits. Pt #1 had hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs and facial muscles) on the left upper and lower extremities. Neurology (MD #4) was consulted and Pt #1 underwent successful carotid stenting and IA (intra-arterial) thrombectomy with near complete recanalization on 5/24/2023 (minimally invasive surgery for acute ischemic stroke patients with large vessel occlusion. During the procedure, the neurosurgeon will try to reestablish blood flow to the affected part of the brain by using catheters to reach the blocked brain vessels and remove the blood clot).

6. On 8/8/2023 at 11:30 AM, an interview was conducted with the Neurology APN (Advanced Practice Nurse - E #4). E #4 stated that E #4 was not aware that Hospital A's neuro-interventionist (MD #3) was not available on 5/24/2023 until 5/24/2023 when a stroke alert was called for Pt#1. E #4 stated that MD #3 was the neuro-interventionist on call for 5/24/2023. E #4 stated that MD #3 was called with the results of Pt #1's CT angiography results, and MD #3 stated that since MD #3 could not come to the hospital, Pt #1 needed to be transferred for treatment.

7. On 8/9/2023 at 11:00AM, an interview was conducted with the Senior Director of Inpatient Hospital Operations (E #8). E #8 stated that (Hospital A) has never had to make a lateral transfer and should not need to because (Hospital A) has the capability to treat our stroke patients. E #8 stated, "This is the first time we (Hospital A) even considered a transfer, because our physician on call (MD #3) was not available."

A. Based on document review and interview, it was determined that for 1 of 3 ED clinical records (Pt #1) reviewed for transfers, the Hospital failed to ensure an appropriate, timely transfer for an unstable patient.

Findings include:

1. On 8/8/2023, the Hospital's policy titled, "EMTALA Screening, Treatment, and Transfer of Patients" (dated 5/2023) was reviewed and indicated, "...Use qualified personnel and transportation equipment as required to effect the transfer safely, including using necessary and appropriate life support measures to minimize risks during the transfer. The transferring physician will determine the method of transportation and necessary accompanying personnel based on the patient's medical status."

2. On 8/7/2023, Pt #1's ED clinical record dated 5/24/2023 was reviewed and indicated:

-2:40 PM -Pt #1 arrived in Hospital A's ED via ambulance.
-2:41 PM -orders placed by MD #1 for CT stroke head and CTA head/neck
-2:42 PM Imaging (CT stroke head and CTA head/neck started)
-3:05 PM - CT stroke head complete
-3:07 PM - Tenecteplase (TNKase- is a powerful blood thinning medication used to treat a stroke caused by a blood clot) injection 25 mg intravenous, vitals blood pressure 146/111
-3:09 PM - blood pressure 151/100
-3:41 PM - Pt #1 seen by neurologist (MD #2) - MD #2 noted "Pt #1 was administered TNK in the ER, and Pt #1 is going to be transferred to Hospital B at the request of Pt #1's wife, for possible intervention. CT head shows a hyperdense left MCA indicating hyperacute thrombus (clot). No intracranial hemorrhage. CTA head/neck shows total occlusion of left distal cervical ICA (internal carotid artery) and intracranial ICA. Total occlusion of left MCA(middle cerebral artery). I (MD #2 had a detailed discussion with Pt #1's wife regarding the assessment and plan, and she (Z1) verbalized understanding of and agreement to the plan. Pt #1 is a candidate for endovascular therapy. Neuro-intervention was consulted at Hospital B and Pt #1 to be transferred to Hospital B."
-3:47 PM - ED Disposition - set to transfer to another Facility per MD #1 note
-3:48 PM - ED Physician (MD #1) notes - Physician certification - Emergency Medical Condition Identified - Pt #1 unstable. Reason for Transfer: Emergency - Unstable. Risks - motor vehicle collision/crash; worsening of condition; permanent disability; death. Benefits; higher level of care; Individual's (Pt #1) condition at time of transfer; serious. Hospital/Facility
Pt #1 transferred to - Hospital B; Pt #1 to be transferred via: ALS (advanced life support)
-3:48 PM MD #1's note - We (Hospital A) do not have interventional neurology thus Pt #1 transferred to Hospital B after our neurology team spoke to neurology team there for interventional care. Hospital B accepted Pt #1. Clinical impression - Cerebrovascular accident (CVA).
-4:00 PM - Pt #1's blood pressure 116/92; spO2 90% oxygen 6 liters per nasal cannula
-4:26 PM -Ambulance company was dispatched to transfer Pt #1 from Hospital A to Hospital B.
-5:11 PM - Pt #1 transported to Hospital B via critical care ambulance.
Pt #1's clinical record did not include documentation the timeline of arrangements made for transportation to facilitate the transfer of Pt #1 to Hospital B.

3. On 8/9/203, Hospital A's ambulance log from RockCom Dispatch Center (located at Mercyhealth Rockton campus [other campus of Hospital A] - provides dispatch and coordination for Hospital A's patients' transfers/ambulance requests) timeline (for Pt #1 being transferred from Hospital A ED to Hospital B) dated 5/24/2023 noted the following:
-3:48 PM - Pt #1 will be going to Hospital B
-3:50 PM - ambulance will be at Hospital A in 15 minutes
The log did not include any additional communication with the ambulance service to indicate why the ambulance did not arrive to Hospital A until 5:11 PM (1 hour and 6 minutes past the 15-minute arrival time documented on the log).

4. On 8/8/2023 at 11:30 AM, an interview was conducted with the Neuro APN (Advanced Practice Nurse - E #4). E #4 stated that the neuro-interventionist from Hospital B stated that Hospital B would handle the tranport. E #4 stated that after about 30 minutes, there was no ambulance arriving for transport. E #4 stated that E #4 communicated with the transfer service for Hospital B for Pt #1's transfer from Hospital A to Hospital B. E #4 stated that the transfer service told E #4 that E #4 needs to handle that transportation for Pt #1's transfer from Hospital A to Hospital B. E #4 stated that the delay (approximately 2 hour) was due to arranging an ALS (advanced life support) transfer for Pt #1.

5. On 8/9/2023 at 11:00AM, an interview was conducted with the Senior Director of Inpatient Hospital Operations (E #8). E #8 stated that [Hospital A] has never had to make a lateral transfer and should not need to because we (Hospital A) has the capability to treat our stroke patients. This is the first time we (Hospital A) even considered a transfer, because our physician on call (MD #3) was not available.

6. On 8/9/2023 at 2:40 PM, an interview was conducted with the EMS Coordinator (E #9). E #9 stated that E #9 had communications with [name of ambulance service] to have an ambulance within 15 minutes on 5/24/2023 for Pt #1. There was no further communication with the ambulance service regarding why the ambulance was delayed on 5/24/2023.

7. On 8/9/2023 at 4:00 PM, an interview was conducted with the ED Director (E #10). E #10 stated that Hospital A does not have a process in place on what to do if an ambulance does not show up in a timely manner.

B. Based on document review and interview, it was determined that for 2 of 3 emergency room clinical records (Pt #1 & Pt #19) reviewed for transfers, the Hospital failed to ensure the transfer forms were completed, as required.

Findings include:

1. On 8/8/2023, the Hospital's policy titled, "EMTALA Screening, Treatment, and Transfer of Patients" (dated 5/2023) was reviewed and indicated, "The transferring physician signs a certification before transfer stating that, based on information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the risks to the patient. The certification must contain a summary of the specific risks and benefits on which it is based..."

2. On 8/8/2023, the clinical record for Pt #1 was reviewed. Pt #1 was seen in Hospital A's emergency department on 5/24/2023 with a diagnosis of stroke. Pt #1 was transferred to Hospital B for neuro intervention on 5/24/2023. Pt #1's transfer form, dated 5/24/2023 and signed by Hospital A's ED Physician (MD #2), lacked documentation of the medical benefits expected from Pt #1's transfer from Hospital A to Hospital B.

3. On 8/8/2023, the clinical record for Pt #19 was reviewed. Pt #19 was seen in Hospital A's ED on 6/24/2023 with a diagnosis of sepsis. Pt #1 was transferred to Hospital B per Pt #19 request for inpatient wound care/sepsis. Pt #19's transfer form, dated 6/24/2023, was blank. Pt #19's transfer form did not include a MD signature or documentation of medical benefits expected from Pt #19's transfer to Hospital B.

4. On 8/8/2023 at 11:00 AM, an interview was conducted with the Manager of the ED (E #6). E #6 stated that the transfer forms should be filled out completely.