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Based on record reviews and interviews, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by:

1.) the hospital failed to have a working system in place to ensure the effective implementation of hospital approved policies/procedures relating to the responsibilities of on-call physicians. This deficient practice was evidenced by failing to consult with the on-call physicians of a potential transfer for 1 (#4) of 20 (#1-#20) sampled patients (see findings tag A-2404);

2.) the hospital failed to maintain a central log on each individual who comes to the hospital 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. This deficient practice was evidenced by failing to document in the Emergency Department (ED) Transfer Request log the reason for denial of a potential transfer in for 2 (#1, #5) of 20 (#1-#20) sampled patients (see findings tag A-2405); and

3.) the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient's condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department's physician who had requested services for 3 (#2, #3, #5) of 20 (#1-#20) sampled patients (see findings A-2411).

Based on record reviews and interviews, the hospital failed to have a working system in place to ensure the effective implementation of hospital approved policies/procedures relating to the responsibilities of on-call physicians. This deficient practice was evidenced by failing to consult with the on-call physicians of a potential transfer for 1 (#4) of 20 (#1-#20) sampled patients.

Findings:

Review of the hospital's policy titled "Physician Notification and Escalation Protocol", last revised 08/2019 with an effective date of 06/2024, revealed in part, "The purpose of this policy is to provide clinical employees and physicians with appropriate direction for the prompt handling of patient care issues. This policy makes available a formal line of communication for staff members who have concerns that a prescribed treatment plan (or the lack thereof) or a medical decision or other medical act might adversely affect the welfare of a patient or that of the hospital."

Review of Patient #4's emergency department (ED) record from hospital 'A' revealed Patient #4 presented to the ED on 12/31/2024 at 7:21 PM. Review of the provider note revealed in part, "Chief Complaint: weakness, vomiting, leg swelling, Patient to ED [room] via wc [wheelchair] with c/o [complaint of] bilateral leg swelling and cramping onset yesterday with accompanying weakness, intermittent SOB [shortness of breath] with exertion and vomiting onset this AM [morning] increasing in intensity to this evening. Patient denies CP [chest pain] in triage." "Clinical Impression: Final diagnoses: weakness; dyspnea [shortness of breath]; anemia [low number of red blood cells], unspecified type (primary); acute renal failure, unspecified acute renal failure type; cardiogenic shock; history of coronary angioplasty with insertion of stent; history of atrial fibrillation; elevated troponin."

Review of the transfer certificate dated 01/01/2025 revealed Patient #4 was transferred to hospital 'B' due to qualified clinical personnel unavailable, services unavailable at hospital 'A'. Further review of the document revealed "benefits of transfer: specialty services."

Review of Lake Charles Memorial Hospital (LCMH) ED Transfer Request Log revealed in part,
Date: 12/31/2024
Time: 10:01 PM
Patient #4
Requesting Facility: hospital 'A'
Requested Services/Reason for Transfer: Diagnosis: Cardiogenic shock Need: Cardiology/GI [gastrointestinal]
Reason for Denial: Doctors unavailable x2 / no call back

In an interview on 02/04/2025 at 3:48 PM S4UT stated they had two very critical patients in the ED at that time. S4UT stated they also had an inpatient in need of intubation as well. S4UT stated she went to both ED doctors twice. S4UT stated she told the ED doctors a "snip it" about Patient #4. S4UT stated neither ED doctor gave an answer to the transfer request. S4UT stated both ED doctors were too busy and could not come to the phone.

In a phone interview on 02/05/2025 at 8:33 AM S4UT stated she told the requesting hospital that she would get a doctor as soon as she could. S4UT stated she asked the requesting hospital to send the paperwork over so she could have the doctor review the paperwork. S4UT stated she did receive the paperwork from the requesting hospital. S4UT stated she left the paperwork on the desk in the doctor's lounge for the doctors to look at it. S4UT stated she assumed the doctors would look at it when she left the paperwork on the desk. S4UT stated some time went by and the requesting hospital called back. S4UT stated she went back to both doctors and asked if they had time to look at the paperwork. S4UT stated the doctors responded that they were too busy and the acuity was too high in the ED. S4UT stated the requesting hospital told her that hospital 'B' was on divert. S4UT stated the requesting hospital told her when hospital 'B' would come off of divert in the morning, hospital 'B' would have a bed available and able to take Patient #4. S4UT stated she did not contact the on-call doctors. S4UT stated she felt it was not her place to contact the on-call doctors. S4UT stated in this case, she did not have an ED doctor for the on-call doctor to talk to because they were busy. S4UT stated the ED doctor did not have time to speak to any doctor, the doctor from the requesting hospital or the on-call specialty doctor. S4UT stated when the requesting hospital called back, she told them that she was trying to get an ED doctor to look at it.

In an interview on 02/05/2025 at 8:52 AM, S1EDD verified the unit tech should have approached the charge nurse and explained the situation. S1EDD further explained the charge nurse should have then gone to the ED physician for direction on what to do. S1EDD verified if the charge nurse could not get a response from the ED physician, the hospital procedure would have been for the charge nurse to escalate the situation to the house supervisor. S1EDD verified if the house supervisor did not get a response, then the house supervisor should have escalated to the administrator on call. S1EDD stated ED staff should have followed the hospital's escalation policy.

In an interview on 02/05/2025 at 9:17 AM S2QD verified the ED staff should have followed the hospital's escalation policy when the ED physicians were busy.

Review of the Staff Manager Report dated 12/31/2024 revealed the hospital had beds available on 12/31/2024.

In an interview on 02/05/2025 at 9:48 AM S2QD verified the hospital had beds available on 12/31/2024.

Review of the physician on-call schedule revealed S5MD was on-call for Cardiology and S6MD was on-call for GI on 12/31/2024.

In an interview on 02/05/2025 at 9:55 AM S2QD verified S5MD was on-call for Cardiology and S6MD was on-call for GI on 12/31/2024.

Review of Patient #4's ED record from hospital 'B' revealed Patient #4 arrived on 01/01/2025 at 5:02 a.m. Review of the provider note revealed in part, "Chief Complaint: Patient is an [stated age] male with a PMHx [past medical history] of CAD [coronary artery disease], HLD [hyperlipidemia- high cholesterol], HTN [hypertension- high blood pressure], and stroke presents to the ED via EMS [emergency medical services] as a transfer from hospital 'A' for 'cardiogenic shock'. Per chart review from previous facility, patient initially presented to hospital 'A' ED for bilateral leg cramping and swelling with nausea, vomiting, generalized weakness, and dyspnea with exertion. Patient initially hypotensive [low blood pressure]. Labs from the outlying facility remarkable for profound anemia, mild elevation in troponin, elevated BNP [B-type natriuretic peptide], and renal insufficiency. He was typed and crossed for 4 units of blood, he is receiving the 3rd unit at this time. Blood pressure improved. He also received Bumex 1.5 mg [milligrams] and is currently on BiPAP [bilevel positive airway pressure]. Currently he still has mild shortness of breath, generalized weakness, and reports mild chest discomfort but states this is not similar to previous MI [myocardial infarction] in the past. He denies any black or bloody stool, no other signs of bleeding. Denies history of GI bleed. He was admitted here recently for MI s/p [status post] coronary stent placement 2 weeks ago. Patient is prescribed Eliquis, Brilinta, and is compliant with medications. Patient taking Eliquis for paroxysmal a-fib." Further review of the document revealed in part, "Clinical Impression: Final diagnoses: chest pain; NSTEMI [non-ST elevated myocardial infarction]; gastrointestinal hemorrhage, unspecified gastrointestinal hemorrhage type (primary); current use of long term anticoagulation; acute on chronic congestive heart failure, unspecified heart failure type; acute renal insufficiency." On 01/01/2025 at 6:31 a.m. Patient #4 was admitted to medical telemetry at hospital 'B'.

Based on record reviews and interviews, the hospital failed to maintain a central log on each individual who comes to the hospital 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. This deficient practice was evidenced by failing to document in the Emergency Department (ED) Transfer Request log the reason for denial of a potential transfer in for 2 (#1, #5) of 20 (#1-#20) sampled patients.

Findings:

Review of the hospital's policy titled "EMTALA Guidelines for Emergency Department Services and Transfer Policy", last revised and effective 07/2023, revealed in part, "The Emergency Department shall maintain a central log documenting the following information:
-Each individual presenting to the ED for assistance;
-If the individual refused treatment;
-If the individual was refused treatment; and
-If the individual was transferred, admitted and treated, stabilized and transferred, or discharged."

Patient #1
Review of Lake Charles Memorial Hospital (LCMH) ED Transfer Request Log revealed in part,
Date: 12/07/2024
Time: 11:20 PM
Patient #1
Requesting Facility: hospital 'C'
Requested Services/Reason for Transfer: Pedi
Service Available: No
Time Denied: 12:00 AM
Reason for Denial: blank (no documentation)
ER MD: blank (no documentation)

In an interview on 02/04/2025 at 1:02 PM S1EDD verified there was no documentation as to why the transfer of Patient #1 was denied.

Patient #5
Review of LCMH ED Transfer Request Log revealed in part,
Date: 01/26/2025
Patient #5
Requesting Facility: hospital 'D'
Requested Service/Reason for Transfer: Urology
Service Available: No
Time Denied: 11:00 AM
Reason for Denial: blank (no documentation)
ER MD: S12MD

In an interview on 02/06/2025 at 4:08 PM S2QD verified there was no rationale documented as to why the transfer of Patient #5 was denied.

Based on record reviews and interviews, the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide stabilizing treatment required by the patient's condition. This deficient practice was evidenced by failure to accept a patient transfer from the transferring hospital emergency department's physician who had requested services for 3 (#2, #3, #5) of 20 (#1-#20) sampled patients.

Findings:

Review of the hospital's policy titled "Admissions and Transfers", last revised 05/2015 with an effective date of 06/2023, revealed in part, "It is the policy of Lake Charles Memorial Health System to accept admissions and transfers into the hospital. Patient condition, bed availability, physician acceptance are to be obtained prior to the acceptance of any patient."

Patient #2
Review of Patient #2's emergency department (ED) record from hospital 'C' revealed Patient #2 presented to the ED on 12/12/2024 at 11:00 PM. Review of the provider note revealed in part, "History of Present Illness: Patient via EMS [emergency medical services] from casino where he is staying for work (He is from Beaumont). Pt complaint of SOB [shortness of breath] worsening x 3 days, 'chest tightness like I can't get a deep breath.' He denies specifically chest pain. Pt reports he was out of his medications (carvedilol, omesartan, eliquis, crestor, and spironolactone) for several days and only restarted them on Monday (3 days ago). He reports his legs are considerably more swollen than normal. He reports nausea with recent vomiting. He denies ever being told he had CHF [congestive heart failure]. Has never had an angiogram (or stents). He does admit to a stress test in past. He reports a Hx [history] of a-fib [atrial fibrillation] but it normally goes back into regular rhythm ....he denies knowledge of his a-fib ever being fast." Further review of the document revealed in part, "Diagnosis: atrial fibrillation with rapid ventricular response; congestive heart failure; elevated troponin; NSTEMI [non-ST segment elevation myocardial infarction]." "Disposition: Transferred."

Review of the nurse's notes revealed in part, "12:20 AM: MD decision to transfer for cardiology at this time, LCMH [Lake Charles Memorial Hospital] hse [house] sup [supervisor] called for transfer, spoke with [named], hse sup ok to call ER [emergency room]." "12:25 AM: called LCMH ER for doc [doctor] to doc for transfer acceptance for cardiology." "12:40 AM: [named] doctor to doctor with [named], recommends to call Patient #2's primary and cardiology services in Beaumont, Texas and transfer Patient #2 there."

Review of the Emergency Room Hospital Transfer form revealed in part, Patient #2 was transferred to hospital 'E' on 12/13/2024 for cardiology services.

Review of LCMH ED Transfer Request Log revealed in part,
Date: 12/13/2024
Time: 12:22 AM
Patient #2
Requesting Facility: hospital 'C'
Requested Services/Reason for Transfer: Cardiology
Service Available: No
Time Denied: 1:22 AM
Reason for Denial: Check with Beaumont hospital first. Around 1:22 AM Patient #2 got accepted to Beaumont.
ER MD: S7MD

In a phone interview on 02/06/2025 at 9:05 AM S7MD stated the transfer was not denied. He stated these nearby smaller facilities call requesting transfer. S7MD stated we are usually the only hospital they call. S7MD stated they will just call us first. S7MD stated sometimes the requesting hospital does not ask the patient if they have a specialist that they have already seen and are established with. S7MD stated he asked if Patient #2 had a cardiologist. S7MD stated the requesting hospital told him yes, Patient #2's cardiologist was in Beaumont. S7MD stated he asked the requesting hospital if Patient #2 was stable and asked if they wanted to ask Patient #2 if he wanted to go to Beaumont where his cardiologist was located and potentially go there for continuity of care. S7MD stated this hospital reached back out to the requesting hospital and they responded that Patient #2 was accepted to Beaumont.

Review of the physician on-call schedule revealed S8MD was on call for cardiology on 12/12/2024.

In an interview on 02/04/2025 at 1:35 PM S1EDD verified S8MD was on call for cardiology on 12/12/2024.

Review of the Staff Manager Report dated 12/12/2024 11:00 PM - 12/13/2024 7:00 AM revealed the hospital had inpatient beds available.

In an interview on 02/05/2025 at 10:54 AM S9DAS verified the hospital had inpatient beds available on 12/12/2024 11:00 PM - 12/13/2024 7:00 AM.

Review of Patient #2's ED record from hospital 'E' revealed Patient #2 arrived on 12/13/2024 at 4:37 AM. Review of the physician documentation revealed in part, "ED Course: Patient #2 is a [stated age] with history of CHF and AFib on Eliquis who presents with chest pain and shortness of breath. Patient presented to an outside facility today due to his chest pain. Patient admitted here as needed medications recently and restarted his medications on Monday. He is compliant with all his medications. He was found have an elevated BNP [B-Type Natriuretic Peptide] at the outside facility. He was also in AFib with RVR [atrial fibrillation with rapid ventricular response]. Patient was given diltiazem and Lasix prior to transfer. RVR improved. Patient had elevated troponin and was transferred here for NSTEMI. He received aspirin. No anticoagulation given. On interview patient states chest pain is improved. On exam, there is 1+ pitting edema bilaterally. Labs with sodium 145 potassium 4.3 Creatinine 1.7. BUN 40. Chest x-ray with left lower lobe infiltrate. EKG [electrocardiogram] with intermittent PVCs [premature ventricular contraction]. Patient has irregular rhythm. Patient is in AFib with 2-1 block. MD [named] contacted for admission. Will consult MD [named] with cardiology." Further review of the document revealed in part, "Diagnosis: pneumonia, unspecified organism; unspecified atrial fibrillation; chest pain, unspecified; acute congestive heart failure (systolic)." "Hospitalization status: inpatient admission" with a room assigned on 12/13/2024 at 6:43 AM.

Patient #3
Review of Patient #3's ED record from hospital 'F' revealed Patient #3 presented to the ED on 12/26/2024 at 4:03 PM. Review of the nurse's notes revealed in part, "Presenting complaint: Patient states: patient had hernia surgery 3 weeks ago in Houston. Patient states surgical incision started bleeding on Sunday. Patient called surgeon's office and they told him to just 'leave it uncovered during the day.' Today patient's incision is draining and patient states that his abdomen is 'hard and hot.' Transition of care: patient was not received from another setting of care." Review of the physician documentation revealed a diagnosis of "disruption of external operation (surgical) wound, not elsewhere classified."

Review of the nurse's notes revealed in part, "6:56 PM: Patient #3 requesting transfer to the Lake Charles area. Patient called friend/family member to discuss transfer and decided on Lake Charles." "7:03 PM: Phoned LCMH and spoke to [named] supervisor and he gave authorization to speak to ER [emergency room] MD to initiate transfer if accepted." "7:05 PM: Phoned ER to have ER to ER consultation. ER doctor denied transfer. Patient #3 needs to go to hospital 'G' in Houston."

Review of the Patient Transfer Out form revealed in part, "criteria/reason for transfer: for equipment or services not available at this facility. (list): General Surgery (Specialty)" with a "diagnosis: wound recheck, rule out intra-abdominal abscess." Further review of the document revealed Patient #3 was accepted to hospital 'I' on 12/26/2024.

Review of LCMH ED Transfer Request log revealed in part,
Date: 12/26/2024
Time: 7:07 PM
Patient #3
Requesting Facility: hospital 'F'
Requested Services/Reason for Transfer: General Surgery
Service Available: No
Time Denied: 7:03 PM
Reason for Denial: Recent procedure at hospital 'G', needs to go back to hospital 'G' for continuity.
ER MD: S10MD

In an interview on 02/04/2024 at 2:26 PM S2QD verified the documentation for reason of denial was recent procedure at hospital 'G', needs to go back to hospital 'G' for continuity.

In a phone interview on 02/06/2025 at 10:16 AM S10MD stated if he remembered correctly, Patient #3 had a recent hepatobiliary procedure. S10MD stated the procedure was done at hospital 'G'. S10MD stated the general surgeons here do not have the capability to do those procedures. He stated that was why the transfer of Patient #3 was denied.

Review of the physician on-call schedule revealed S11MD was on call for Trauma-General Surgery on 12/26/2024.

In an interview on 02/04/2025 at 2:24 PM S1EDD verified S11MD was on call for Trauma-General Surgery on 12/26/2024.

Review of the Staff Manager Report dated 12/26/2024 3:00 PM - 11:00 PM revealed the hospital had inpatient beds available.

In an interview on 02/04/2025 at 2:46 PM S9DAS verified the hospital had inpatient beds available on 12/26/2024 3:00 PM - 11:00 PM.

Review of Patient #3's ED record from hospital 'I' revealed, Patient #3 arrived on 12/27/2024 at 10:51 AM. Review of the emergency department provider note revealed in part, "In brief, [stated age] male with past medical history of hypertension [high blood pressure], hyperlipidemia [high cholesterol], small intestine rupture, inguinal and ventral hernia status post multiple repairs presents emergency department as a transfer from outside hospital for evaluation by general surgery after being found to have a large fluid collection within his superficial abdominal wall and intra-abdominal fluid collection. Initially noticed drainage on Sunday that has progressively worsened." Further review of the document revealed in part, "Plan: given unknown etiology of patient's fluid collection he was covered broadly in the event that this is an infection. On repeat lab work patient's left shift appears to have improved with neutrophil count of 7.10. Patient was consulted to general surgery who evaluated him at bedside and performed a drainage of his large fluid collection with thus far 700 mL [milliliters] of blood output." "Clinical Impressions: abscess of postoperative wound of abdominal wall, infected hernioplasty mesh, and abdominal fluid collection." On 12/27/2024 at 5:24 PM Patient #3 was admitted to trauma surgery at hospital "I".

Patient #5
Review of Patient #5's ED record from hospital 'D' revealed Patient #5 presented to the ED on 01/26/2025 at 8:43 AM. Review of the provider note revealed in part, "ED Course: [stated age] female with past medical history of nephrolithiasis [kidney stones] who presents with right-sided flank pain since the morning. Vitals with mild bradycardia [slow heart rate] but otherwise with normal limits. Labs showed urinalysis consistent with UTI [urinary tract infection]. CT [computed tomography]-abdominopelvic showed right renal calculi with moderate right hydroureteronephrosis [dilation of the ureter and kidney], but no obstructing stone noted. Treatment provided with analgesia, antiemetic and IV [intravenous] fluids. Patient will be transferred to hospital 'H' for urology services." Further review of the document revealed in part, "Diagnosis: hydronephrosis [upper urinary tract dilation]; stone in kidney" with a "final impression: nephrolithiasis with UTI."

Review of the nurse's notes revealed in part, "10:48 AM: While getting patient to sign transfer, family member requested to call Lake Charles due to him living in Sulphur. Spoke with [named] house supervisor, who states they have services. MD [named] speaking with MD who states will not accept Patient #5."

Review of the ED Summary report revealed in part, Patient #5 was transferred to hospital 'H' on 01/26/2025 for urology services.

Review of LCMH ED Transfer Request Log revealed in part,
Date: 01/26/2025
Patient #5
Requesting Facility: hospital 'D'
Requested Service/Reason for Transfer: Urology
Service Available: No
Time Denied: 11:00 AM
Reason for Denial: blank (no documentation)
ER MD: S12MD

In a phone interview on 02/06/2025 at 4:58 PM, S12MD stated Patient #5 had hydronephrosis and UTI with no stone, with an unchanged CAT scan and no need for surgical intervention. S12MD stated he consulted with the urology specialist and the specialist agreed. S12MD stated urology would not do anything with Patient #5. S12MD stated there was no need to transfer, no urological intervention would have been done. S12MD stated they were going off an old CAT scan. S12MD stated Patient #5 was not septic. S12MD stated Patient #5 needed antibiotics and to follow up outpatient.

Review of the physician on-call schedule revealed S13MD was on call for urology on 01/26/2025.

In an interview on 02/04/2025 at 3:35 PM S1EDD verified S13MD was on call for urology on 01/26/2025.

Review of the Staff Manager Report dated 01/26/2025 7:00 AM - 3:00 PM revealed the hospital had inpatient beds available.

In an interview on 02/04/2025 at 4:07 PM S2QD verified the hospital had inpatient beds available on 01/26/2025 7:00 AM - 3:00 PM.

Review of Patient #5's ED record from hospital 'H' revealed, Patient #5 arrived on 01/26/2025 at 1:46 PM. Review of the provider note revealed in part, "[stated age] female presents as transfer from hospital 'D' for moderate right hydroureteronephrosis with gross hematuria [blood in urine]. She reports urinary frequency recently but yesterday started with flank pain. Went to an urgent care and was noted to have large amount of blood in her urine. She was started on p.o. [oral] antibiotic and sent home. She presented to the ED today with findings as below. She was then transferred here for urology evaluation. Currently reports pain is starting to creep back up. Reports she just urinated in a sample cup and it was entirely blood. Denies fevers but does report some chills." Further review of the document revealed in part, "Diagnosis: gross hematuria; right flank pain; hydroureteronephrosis." "Disposition and Plan: admit." On 01/26/2025 at 4:04 PM Patient #5 was admitted to inpatient at hospital 'H'.