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Based on interview and document review, the hospital failed to provide An Important Message from Medicare (IM) notice within two days of admission, and/or two days of discharge, for 6 of 10 Medicare beneficiary inpatient patients (P2, P33, P35, P37, P39, P40). This had the potential to impact all Medicare beneficiaries admitted to, and discharged from, the hospital.

Findings include:

The CMS Beneficiary Notices Initiative (BNI) website, dated 12/3/24, directed hospitals were "required to deliver the [IM notice] ...CMS-10065 to all Medicare beneficiaries ..." who were hospital inpatients. This notice informed patients of their hospital discharge appeal rights. CMS-10065 notice instructions, located in the Medicare Claims Processing Manual - Chapter 30, dated 8/1/24, section 200.3.3 - Hospital Delivery of the IM, directed the hospital "must ensure that the beneficiary or representative signs and dates the IM to demonstrate that the beneficiary or representative received the notice and understands its contents." The section 200.3.4 - Required Delivery Timeframes, directed the hospital to deliver an initial copy of the IM "at or near admission, but no later than 2 (two) calendar days following the date of the beneficiary's admission to the hospital." In addition, the section identified a follow-up IM was to be delivered "Two days before discharge" and no later than four hours prior to discharge. The section lacked identification for issuance exceptions.

On 2/13/24, during the abbreviated medical record review process, which started at 1:12 p.m., the following information was identified:
-P2 admitted on 12/11/24 and discharged on 12/19/24. P2's insurance was identified as Medicare. The Patient Contact section identified two sons as emergency contacts. P2's record identified an unsigned IM notice "Copy", effective 12/12/24. P2's record lacked documentation as to why the notice was placed into P2's record unsigned and/or if the notice was officially provided as required. In addition, P2's record lacked a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice.

An email, dated 2/13/25 at 4:04 p.m., from the accreditation and regulatory compliance manager (CM)-A, identified P2 was in isolation and thus a patient access registration staff member (PR) left the IM notice, and a copy, with the HUC (health unit coordinator) on P2's unit with the intent the HUC would obtain P2's signature on one of the IM notices and then the other copy would be left with P2. In response, PR staff entered an unsigned copy of the IM notice in P2's record and marked it 'received.' CM-A identified P2's chart lacked an admission signed IM notice. Additionally, the email identified, "It appears we missed delivering the IMM on day of discharge. Patient registration leadership acknowledges this, and that further staff education is needed."

In follow-up, additional investigation and record review was conducted, and the following information was identified:
-P40 was admitted on 1/15/25 and discharged on 2/13/25. P40's face sheet identified Medicare benefits. A Hospital Account History entry, dated 1/16/25, identified PR staff attempted to interview P40; however, they were unsuccessful. A Comment identified, "procedure." A follow-up account history entry, dated 1/17/25, identified the 1/15/25 unsuccessful interview; however, the Comments section identified P40 was oriented to self. An account history entry, dated 1/20/25, identified the admission IM was provided to P40. The Patient Contact section identified P40's son was her HCA, along with a significant other as an emergency contact and a daughter. P40's medical record lacked documentation to support attempt(s) to provide the admission IM notice to P40's contacts when P40 was unable to sign the IM notice within two days of his admission. Additionally, P40's medical record lacked evidence of a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P40, his son, or one of his other contacts.

-P37 admitted on 1/30/25 and discharged on 2/13/25. P33's face sheet identified Medicare benefits. A Hospital Account History entry, dated 1/31/25, identified P37 was provided the admission IM notice along with a copy of the IM signed notice. The Patient Contact section identified two daughters as emergency contacts. P33's medical record lacked evidence of a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P33 or one of P33's daughters.

-P39 admitted on 2/5/25 and discharged on 2/13/25. P39's face sheet identified Medicare benefits. A Hospital Account History entry, dated 2/6/25, identified P39 was provided the admission IM notice along with a copy of the IM signed notice. The Patient Contact section identified a son and daughter as emergency contacts. P39's medical record lacked evidence of a discharge provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P39 and/or P33's son or daughter.

-P35 admitted on 2/7/25 and discharged on 2/13/25 due to death. P35's face sheet identified Medicare benefits. The Patient Contact section identified P35's son was power of attorney (POA), along with three grandchildren as additional emergency contacts. A Hospital Account History entry, identified on 2/7/25, P35's son assisted with the registration process due to P35's "medical condition." P35's medical record lacked documentation the IM notice was provided at that time. A follow-up account history entry, dated 2/7/25, identified the IM was attempted with P35; however, P35 was "not waking." P35's medical record identified P35 was lethargic, and the son was not present with P35 at that time. An additional account history entry, dated 2/13/25, identified PR staff again attempted to visit with P35; however, staff identified P35 had passed away. P35's medical record lacked evidence of an admission provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P35's son or emergency contacts.

-P33 admitted on 2/8/25 and discharged on 2/14/25 due to death. P33's face sheet identified Medicare benefits. A Hospital Account History notes, identified P33's 2/8/25 registration process was "pushed through due to a code CVA (stroke)," and the registration process was not completed. A follow-up account history entry, dated 2/10/25, identified that due to P33's continued condition, registration again was not completed. The Patient Contact section identified P33's wife as his Health Care Agent (HCA), along with a sibling as an additional emergency contact. P33's medical record lacked evidence of an admission provided signed and dated IM notice, or documentation to support attempt(s) to provide the notice to P33's wife or emergency contacts.

When interviewed on 2/14/24 at 4:15 p.m., PR-A stated the IM notices were to be issued within the first two days of admission and a signature obtained on the notice, and then, up to four hours prior to discharge, they were required to provide a copy of the signed admission notice. If the patient was unable to sign when first approached for issuance, she was instructed to document the reason for the unsuccessful attempt, and then she was to continue to approach each day until a signature was obtained. All continued unsuccessful attempts were expected to be documented. PR-A stated that for someone else, other than the patient, to sign the IM notice, the patient needed to consent to the other person signing the notice and that person had to be the spouse or family. If the patient was unable to provide such consent, the signer needed to be a legal guardian or POA, in which she had to ensure the patient's medical record contained the necessary paperwork to provide evidence of such designations. PR-A explained she was to only call via the telephone for notice issuance "if it was clear" who she could talk to: "We cannot call the neighbor." If the patient was unable to sign, and there was no one present who could sign, they checked back with the patient the next "rotation" to see if the patient was able to sign, or if any of the above individuals were present, which could still be that same day or the next day, if it was reattempted within 24 hours. PR-A stated she overall was able to complete these processes "in house" without having to call. PR-A explained the patients' names stayed within the utilized system until the signatures were obtained, and thus each day this system was checked for workflows. Additionally, once the discharge date was entered into this system, the workflow would identify the need for a discharge IM notice process. For discharging patients, they ensured the copy was provided and documentation was entered to support this process. After the copy was provided, the copy, which was labeled "copy," was scanned into the medical chart as evidence this process was completed. PR-A stated, at times, depending on the patient's medical condition and/or situation, she left the IM notice with nursing staff for nursing staff to obtain the signature and/or to provide a copy to the patient. She explained this was what occurred with P2. PR-A explained she went to issue the admission IM notice to P2; however, P2 was not alert, and thus she was unable to give. She provided a copy of the form to the HUC, with instructions to provide to P2, in case P2 woke up enough and wanted the information on the form. PR-A denied she contacted anyone on P2's contact list. PR-A explained she missed the window for the admission notice issuance and because P2 did not sign the form, and the way the system worked and how she documented the copy provided to the nursing staff, P2 did not get a copy of a signed notice prior to discharge. PR-A stated she was never instructed to leave the notices with nursing staff, and she was unsure if nursing and/or the HUC provided P2 with the paperwork she left for P2.

During a telephone interview on 2/14/25 at 4:46 p.m., the patient access registration manager (PRM) stated an admission IM notice was expected within two days of admission and two days prior to discharge and there were no exceptions. She explained the PR staff worked out of the work cues and checked this daily for when admission and discharge IM processes were expected to be completed. She expected the admission IM notice contained a signature, and the discharge IM notice was a copy of this signed admission notice. If the patient was unable to sign, "anyone can sign" the notice on behalf of the patient. If the patient was unable to sign and there were no visitors present, a copy of the form was left with the HUC, or nurse, and they were asked to provide it when able, or the PR staff would continue to make attempts. The PRM was unsure if nursing staff and/or the HUC were trained to issue the notices, and she was unsure how often this practice occurred. Additionally, she was unable to verify these forms were returned when nursing and/or the HUC was asked to assist. If the patient had a POA or HCA, PR staff attempted to contact them via a telephone call. This was expected to be completed within the required timeframes of issuance and was to be documented. The PRM explained PR staffing was limited at this time and felt this was one factor that increased the risk of notice deliverance concerns; however, she was unaware of any current issues, prior to the abbreviated survey, with this process as there were no recent audits on this process. The PRM identified the PR staff required re-education as when she conducted record review on the six patients, she was unable to find evidence staff contacted the representative and/or followed the required processes for notice issuance.

On 2/14/25 at 5:08 p.m., CM-A, the senior director of hospital quality (DHQ), and the regulatory specialist (RS)-A were interviewed. CM-A was unaware of any recent education directed at PR staff related to IM processes. She identified their hospital system was working on system wide processes to unify the IM processes amongst all their hospitals, as another hospital in their system was identified to have concerns in this area. All were unaware of concerns with the IM processes within their facility, prior to the abbreviated survey; however, "some gaps" were identified this day, despite staff being expected to follow the process standards. CM-A identified there was no current policy related to IM notices; however, PR staff were to follow an IM workflow process.
An IMM: 1st and 2nd Letter Process procedural standard flowsheet, dated 4/28/24, identified the facility had determined due to staffing levels, these forms were not provided timely which potentially led to financial hardship of Medicare beneficiaries if Medicare did not pay, or if patients were not fully aware of their rights during their inpatient stay. After they investigated these concerns, they determined their current workflow was not sufficient to meet compliance requirements and a plan was put into place. The procedure directed the first IM notice was to be provided within two days (48 hours) of admission and the second IM letter copy was to be provided within two days (48 hours) of discharge. Going forward, staff were to work from the work cues and instructions on this process were provided on how to determine which patients required which letter and when. The procedure identified that anyone (spouse, children, etc.,) can sign the IM for the patient: it was not limited to the POA or guardian. If the patient was unable to sign and the POA was out of town, or unable to come to the hospital in a timely manner, a verbal consent was to be obtained, and the conversation documented.

The facility had an undated procedure outlining the process to issue the Important Message (IMM) from Medicare to patients identifying not giving the IMM timely can cause financial hardships for the patient if Medicare does not pay, or the patient is not fully aware of their rights during their inpatient say.

Based on interview, document, and audio review, the receiving hospital (HOSP)-A failed to collaborate with and/or accept transfers from transferring HOSP-B, when HOSP-A had capability to provide care and services for 2 of 2 (P31, P32) patients who required ophthalmology surgical care and treatment that HOSP-B was unable to provide.

The findings include:

P32's HOSP-B medical record identified P32 presented to the emergency department (ED) on 10/13/24 (Sunday) at 4:27 p.m. for evaluation of a high force eye injury. P32 experienced, about an hour before arrival, an incident where an air compressor's metal tubing, with a PSI of 100, hit him in the eye when he disconnected it from the air compressor. P32 was initially unable to see out of his right eye; however, when the eye was "forcibly opened," he could see. During the medical screening exam, performed by medical provider (MD)-A, P32's right upper and lower eye lids were edematous and crepitus was present. Anisocoria of the pupil appeared tear drop in share compared to the left. Additionally, there was chemosis of the right eye and some bubbles formed in the top portion. P32 had a positive Seidel sign. MD-A suspected P32 sustained likely facial fractures and an open globe eye injury. In addition, MD-A wanted retrobulbar hematoma to be ruled out.

P32's MD-A Emergency Department Course and Medical Decision Making entry, dated 10/13/24, identified MD-A contacted HOSP-A that evening and spoke to Health Partners Direct (HPD) staff, to coordinate an ED to ED transfer for management of an open globe injury that needed emergent ophthalmologic evaluation with likely operating room (OR) repair as P32 presented with a significant threat to his vision, and made it very clear they did not have ophthalmology services at that time. In response to the call, HPD staff communicated with their ophthalmologist, who in turn, declined the transfer because HOSP-B had the 'ability to care for this patient,' and HOSP-A did not accept out of system transfers for eye problems. Additionally, HOSP-A's trauma surgeon and ED provider also declined, based on ophthalmology's refusal. After this, MD-A was able to secure transfer acceptance to a different level 1 trauma center for P32's needed eye repair.

An Inter-Facility Transfer Form, dated 10/13/24, identified P32 required ALS (advanced life support) transfer for ophthalmologic trauma services as HOSP-B lacked the capability to render further examination and treatment.

On 10/13/24 at 6:36 p.m., P32's medical record identified he transferred out.

HPD call audio recordings, dated 10/13/24, identified the following relevant synopses of conversations:
-5:29 p.m., MD-A spoke to HPD-A and requested an ED-to-ED transfer as P32 required an ophthalmology eval for eye trauma and a globe rupture. HPD-A verified the hospital and asked if P32 was part of the HP system or if P32 was just a trauma transfer. MD-A reported trauma transfer.

-5:33 p.m., HPD-A relayed there were changes with their policy and questioned if the only injury was related to the eye. MD-A confirmed and explained again the nature of the transfer request. HPD-A asked if HOSP-B had ophthalmology trauma coverage. MD-A responded "no ophtho" and "certainly no ophthalmology trauma" coverage. MD-A requested to speak to an ED provider as they would know what type of coverage HOSP-A had. HPD-A explained changes in their ophthalmology policy, and they no longer provided consults out of the system and no longer accepted transfers from hospitals that had ophthalmology resources within their own systems. MD-A again stated HOSP-B did not have such services there and P32 required a level one trauma center.

-5:35 p.m., HPD-A requested additional P32 details and inquired if P32 required surgery that night. MD-A confirmed and asked to speak to someone to understand the coverage there that evening to understand what sort of coverage they had.

-5:41 p.m., HPD-A contacted ophthalmology (MD)-B and explained their new policy changes and the ED-to-ED transfer request for a global rupture. "Do we accept those from [HOSP-B]?" MD-B responded "No" and explained HOSP-B was supposed to consult within their own eye physicians first. "That is all I can say." "I am not accepting a transfer from [HOSP-B]." "If their ED physician talks to our physician and they decide that is what needs to be done, that is a course they can take. But [HOSP-A], we are not part of [their] system." HPD-B joined the conversation and questioned the response to MD-A if MD-A was to "push" the transfer and ended up stating they would just do an ED-to-ED transfer, as it was his understanding they were not supposed to do just an ED-to-ED transfer if ophthalmology declined the transfer. MD-B confirmed; however, he stated he could not tell MD-A or their ED physician what to do.

-5:47 p.m., HPD-A contacted MD-A and declined the transfer, and recommended MD-A speak to her system ophthalmologist. MD-A reiterated HOSP-B did not have ophthalmology coverage at that time. HPD-B joined the conversation and explained ophthalmology was spoken to and "they are unable to entertain transfer or consults for this patient." MD-A asked to speak to the ED physician. HPD-B stated, "Unfortunately the ED providers want ophthalmology consulted and when ophthalmology declines, they were unable to put them through to the ED." MD-A explained P32 sustained blunt facial polytrauma and needed a level 1 trauma. HPD-B inquired if this was an isolated eye injury. MD-A confirmed and stated they did not have the CT (computed tomography - type of x-ray scan) back to confirm P32's facial fractures. HPD-B stated if not polytrauma, then they did not involve the trauma surgeons, and being they already spoke with ophthalmology, this was something that needed to be addressed within their own system. MD-A again asked to speak to the ED provider for better understanding. HPD-B stated it did not matter as they went through their ophthalmology provider for these isolated eye injury situations, and they were not willing to do consults or transfers for outside services. HPD-B further stated if there was poly trauma they could connect with the trauma surgeon; however, they did their due diligence with ophthalmology and ophthalmology declined. MD-A asked to speak to the trauma surgeon.

-5:50 p.m., HPD-B contacted trauma surgeon (MD)-C and explained the situation and it sounded like an isolated eye injury. He identified they consulted with ophthalmology and explained the policy. HPD-B believed HOSP-B had ophthalmology services and thus ophthalmology wanted MD-A to go through HOSP-B's ophthalmology providers. Additionally, HPD-B stated MD-A was pretty persistent and wanted to talk with someone; however, their ED providers wanted ophthalmology consulted first on these cases as if they were not going to do anything, they did not want them sent to the ED. HPD-B asked MD-C if he wanted to talk with MD-A but again stated MD-A had her own ophthalmology within their network from his understanding. MD-C explained he prepped for surgery but would be happy to call MD-A back when able. HPD-B stated he did not want to bother MD-C and asked if it sounded reasonable to tell MD-A they could not take P32. MD-C responded if P32 had an isolated globe injury and their ophthalmologist were unable to see them, then trauma could not provide any additional services. If there were other injuries that trauma needed to address, then they would be happy to take the patient.

-5:53 p.m., HPD-B again spoke to MD-A and explained the trauma surgeon was unable to speak with her as he prepped for surgery, and would only talk with her if P32 experienced polytrauma as if ophthalmology declined the transfer there was nothing more trauma could provide. MD-A asked to speak to the ED physician to garner more information as P32 had a vision threat.

-5:57 p.m., HPD-B contacted the ED physician (MD)-D and updated on the situation. HPD-B explained ophthalmology was updated and due to a policy change, which he explained to MD-D, they were unable to accept. MD-D stated he tried to figure that process out; however, he stated if ophthalmology "cannot entertain this than I cannot either." HPD-B inquired into the process of the ED physicians wanting ophthalmology consulted first before ED-to-ED transfer was accepted, which MD-D confirmed. MD-D questioned trauma's response. HPD-B stated trauma was involved and because the situation did not appear to be polytrauma, and the ophthalmologist declined, then trauma declined also. MD-D stated, "I am kind of surprised that this is the case" as there was a traumatic globe rupture with threatening vision injury and they were a trauma hospital. MD-D followed up with, "This is kind of weird." HPD-B explained their policy used to entertain these sorts of traumas, but their ophthalmology went away from this practice as other hospitals called them when they had their own system ophthalmology. MD-D stated they simply could not accept patients who their specialists were not able to see: "That is something I cannot do." MD-D asked to have the director of trauma (MD)-E brought into the conversation as "this does not seem right."

-6:01 p.m., HPD-B contacted MD-E in which MD-E confirmed their current consult and transfer policy and thus there was nothing trauma was able to do.

-6:02 p.m., MD-E stated to MD-D the direction for HOSP-B was to utilize their own system resources first. MD-D questioned their policy if they were okay with them, being a level 1 trauma center, not taking this patient. MD-E recommended MD-A send P32 to where their own eye surgeons were as this was an isolated eye injury and thus it would not be an issue.

-6:03 p.m., MD-D conversed with MD-A and stated, "I am just clearly surprised as you;" however, his team did not take isolated traumatic eye injuries: "Apparently that is our policy." He was unable to further explain but commented, "Seems very strange to me because we are obviously a level one trauma center." MD-A questioned if this lack of acceptance was an EMTALA (Emergency Medical Treatment and Labor Act) violation as they lacked ophthalmology services and P32 required such. MD-D stated, "He needs to go to OR (operating room) clearly but this is something we do not accept." MD-D asked if there was ophthalmology surgery coverage at HOSP-C (within HOSP-B's system). MD-A denied. MD-D encouraged MD-A to contact HOSP-D and commented, "And frankly I am just as surprised as you," but if ophthalmology and MD-E stated they could not take, "I wish I had a better answer." MD-A verbalized it appeared HOSP-A did not want to transfer someone in from outside their system and she was quite sure if patients presented their ophthalmology would take them into the operating room. MD-D confirmed there was ophthalmology coverage there and MD-A responded they just did not take them from out of their system.

The 10/13/24 audio recording identified MD-A expressed, on multiple occasions to multiple HOSP-A employees, they were unable to manage P32's eye trauma due to the lack of ophthalmology and ophthalmology surgery services at HOSP-B and at HOSP-C. HOSP-A employees expressed to MD-A that due to their current policy they were unable to accept consults or transfers from outside hospitals that had ophthalmology services within their own system. Neither HPD-A or HPD-B, nor MD-B or MD-C or MD-D stated HOSP-A was unable to manage P32's care due to capacity and/or provider capabilities. All expressed that because HOSP-B's system had ophthalmology services, or that ophthalmology declined the transfer, MD-A needed to consult with her system resources or transfer to a different hospital. In addition, MD-E repeated this policy and process consensus; however, he also did not provide MD-A with information he was unable to take P32 related to the ED census at that time, and only declined the transfer as others within the team declined it.

A HOSP-B system Memorandum from the director of surgical services and the director of perioperative services, dated 12/6/24, identified system leaders and the ophthalmology team was updated that starting on 12/7/24, HOSP-C would "resume some support for urgent/emergent ophthalmology care on weekends. The memorandum listed the three weekends in December; however, did not reflect dates going forward. Additionally, the weekend hours were identified from 7:30 a.m. to 3:00 p.m. Weekday urgent/emergent availability was available from 12:00 p.m. to 3:00 p.m. Additional communication would be available when additional coverage could be provided.

Based on a summarized event word document, provided by HOSP-A's vice president and chief medical officer (CMO), following 10/13/24, HOSP-A and HOSP-B administration worked together to develop improved collaboration when it came to ophthalmology patients. The form identified that on 11/6/24, the HOSP-A team met and determined HOSP-B's system "had dozens" of ophthalmology doctors who were all trained in globe trauma. This was considered "bread and butter eye care," and thus the team was confused on why such treatment was not managed by HOSP-B's health system. A meeting on 1/9/25, held with both hospital staff, identified HOSP-B now had ophthalmology coverage from an outside eye group. An agreement was made that HOSP-A would "be happy to help with eye issues," but they preferred that an ophthalmology-to-ophthalmology phone consult occurred. MD-E was to work with HPD on protocols.

P31's HOSP-B medical record identified P31 presented to the emergency department on 1/26/25 (Sunday) at 8:45 a.m. for evaluation after a fall from bed where P31 hit her left eye on the nightstand which resulted in a left eye (OS) globe rupture, along with a closed nondisplaced fracture of the left radius head.

An Ophthalmology Consultation, dated 1/26/25, identified P31's was assessed by ophthalmologist (MD)-F. P31 had a history of retinal detachment and scleral buckle (retinal detachment) of the OS "a long time ago," where her vision had always been poor, but she was able to read an eye chart. Currently her visual acuity was only to light perception and her pupil was "2mm (two millimeters), irregular, and nonreactive. Eye pressure "appears soft" with an attempted check. The left eye anterior exam identified the adnexa had "mild edema and bruising on the upper and lower lids and she showed subconjunctival bleeding with additional scattered inferior subconjunctival bleeding and observed corneal plague buildup. The anterior chamber showed "deep, small layered hyphema (blood in eye) inferiorly and 3+ RBCs (red blood cells)." "POOR dilation both eyes (OU), No view OS 2/2 heme." A dilated fundus exam of the left eye identified there was "no view" for vitreous, nerve, vessels, macula, periphery with comment "B scan deferred given concern for applying pressure with c/f (closed or full thickness) ruptured globe."
-Head, Facial Bone, and Cervical Spine CT scans were completed and identified the ophthalmologist's assessment and plan were as follows: "Hyphema OS," concerns for ruptured globe OS as head and face CT scans revealed posterior medial flattening deformity of left globe in a patient with hyphema, lateral hemorrhagic chemosis (bleeding), and globe flattening deformity on CT. Recommendations were to transfer P31 to HOSP-D (level three trauma), HOSP-E (level one trauma), or a "level 1 trauma center" for surgical globe exploration given high concern for posterior ruptured globe.

An Emergency Department Staff Physician Note, dated 1/26/25, identified P31 was assessed by MD-A. P31's OS appeared "somewhat sunken" with chemosis of the lateral conjunctival. MD-A spoke with MD-F who came into the ED to examine P31; however, MD-F identified they do not repair traumatic open globes and recommended P31 be transferred to a trauma facility for exploration. MD-A contacted HOSP-A to initiate a transfer; however, when asked to speak with their ophthalmology staff, HPD-A refused to connect her due to HOSP-B having this type of coverage. MD-A verified they did not have coverage for traumatic open globe patients. MD-A additionally asked if MD-F could consult with HOSP-A's ophthalmologist; however, this also was refused.

An Inter-Facility Transfer Form, dated 1/26/25, identified P31 required BLS (basic life support) transfer for ophthalmologic trauma services as HOSP-B lacked the capability to render further examination and treatment and the benefits of transfer to another facility outweighed the benefits of remaining there.

On 1/26/25 at 3:05 p.m., P31 was transferred to HOSP-D.

HPD call audio recordings, dated 1/26/25, identified the following relevant synopses of conversations:
-2:31 p.m., Physician assist (PA)-A explained to HPD-B their ophthalmologist was there and wished to transfer P31 due to eye trauma and a fracture. HPD-B questioned if the transfer was specifically for the isolated eye injury. PA-A confirmed. After a brief hold, HPD-B stated, "Unfortunately the fact that you are out of network we are unable to facilitate any sort of consult or transfer for isolated eye injuries. You can probably try [HOSP-D] potentially." PA-A questioned this reason and HPD-A replied "They do not accept consults or transfers out of network eye injuries. Our ophthalmology department does not take those." After PA-A asked HPD-A to hold the line, HPD-A immediately stated, "We have had this conversation with your department before and that is the policy and that is kind of how it is so unfortunately I am not able to facilitate a transfer or consult for you. PA-A acknowledged this, and the call ended.

-2:35 p.m., MD-A explained to HPD-A the situation and that P31 was examined by their ophthalmologist and a transfer for a traumatic eye injury was requested.

-2:37 p.m., HPD-A inquired if this was an isolated eye injury. MD-A confirmed. HPD-A explained, "Health Partners, we are not able to provide ophthalmology consults or accept ophthalmology transfers for external sites with these services available in their health system at this time. So, we cannot accept a transfer." MD-A explained, "We do not have traumatic eye coverage. We have ophthalmology coverage, but they do not treat open globe so not a service we have in our health system. HPD-A stated, " [HOSP-B] is aware of this. This has been a concern, but we are unable to accept any transfers. MD-A asked to speak with the on-call ophthalmologist and identified their ophthalmologist was present who wanted to do "doc to doc on this case." HPD-A stated, "They do not accept them." MD-A again asked to do a physician to physician to confirm they do not accept. HPD-A stated, "No, they do not accept consults. MD-A questioned if this was an EMTALA violation and indicated this needed to be escalated. HPD-A stated that it would and were escalated in the past.

The 1/26/25 audio recording identified PA-A and MD-A attempted to transfer P31 to HOSP-A, where MD-A expressed they were unable to manage P31's need for surgical trauma services after their ophthalmologist had assessed the patient and confirmed such services were not available at that time. MD-A requested multiple times for a provider-to-provider consult; however, was repeatedly denied this request due to reasons HOSP-B had ophthalmology services in their network and thus HOSP-A ophthalmology would not consult with providers out of the HP network. Neither HPD-A or HPD-B explained the reason for the denied request was due to their current capacity and/or provider capabilities.

A summarized event word document, provided by the CMO, identified that on 1/26/25 a "New [HOSP-B] eye case" occurred. On 2/3/25, the CMO communicated with MD-E and MD-E explained he had connected with HPD's manager (HPDM) "last week" and "ensured that the direction of our HP team was to allow eye doc to eye doc connection for isolated eye trauma transfers."

An HPD Newsletter, dated 2/4/25, identified a section HP Direct Updates which indicated an agreement was made between the hospital ophthalmology and HOSP-B. HOSP-B now contracted with an outside eye clinic effective 1/1/25 and HOSP-B was expected to consult with this clinic prior to transfer requests. Effective immediately, if HOSP-B consulted with this clinic and the clinic provider continued to request the transfer, HPD staff were to take the patient. In addition, there was to be a "handoff" between the clinic provider and hospital ophthalmology for acceptance. The injured patient protocol was to be utilized. If HOSP-B attempted to consult with the clinic provider and was unsuccessful, the request was to be sent through.

An email, dated 2/5/25, from the HPDM to HPD staff, identified ophthalmology process changes. The following direction was provided: HPD was to determine if a transfer request was for an injured patient. If an isolated eye injury from an external site, HPD inquired if the patient was an HP patient, or if the patient received related specialty care within their system in the last two years. If the referring location was Mayo, Fairview, or Allina (health systems), HPD was to inquire if they consulted or attempted to consult with their local ophthalmology services. If consulted, HPD staff were to facilitate a provider-to-provider consult. If the receiving ophthalmologist accepted, the transfer continued. If declined, the transfer was declined. If attempted, a consult was to be facilitated between their ophthalmology and the ED provider. Then, if accepted, the transfer continued. If declined, the transfer was declined. If no consult or attempt, HP was not able to provide ophthalmology consults or accept ophthalmology transfers for external sites with these services available within their health system and HPD staff encouraged the caller to call back if the transfer was still needed once their local ophthalmology providers was contacted.

During a telephone interview on 2/11/25 at 10:39 a.m., MD-A identified both P31 and P32 experienced traumatic open globe injuries in which HOSP-A declined both transfer requests as they felt she had access to ophthalmology. MD-A stated she did not have ophthalmology covered services at HOSP-B for P32. MD-A explained HOSP-C had ophthalmology coverage; however, after she talked with the on-call trauma surgeon, she was informed HOSP-C was unable to manage traumatic open globes and they also were required to transfer these cases to a higher level of care. MD-A stated HOSP-B was able to secure ophthalmology coverage "mid-January." She had contacted this coverage for P31, and this provider presented to the ED and examined P31. The provider recommendation a transfer to a trauma center as the provider did not operate on open globe injuries, as those cases went to trauma centers. MD-A understood that when P31 presented to the ED and such a transfer was needed, once they consulted with their on-call ophthalmology, HOSP-B would allow a provider-to-provider consult.

When interviewed on 2/12/25 at 1:44 p.m., the ED director (MD)-G stated if a patient required services and the presenting hospital did not have the specialty to manage those services, a transfer to a facility that could manage would be expected. If a patient were to sustain polytrauma with an eye globe injury, there would be no issue with accepting that patient; however, if it was an isolated globe trauma, then the need for a level 1 trauma center was debatable. MD-G stated there was no special training for ophthalmologists to manage globe issues and thus any ophthalmologist would be able to manage. MD-G confirmed HOSP-A could manage an isolated globe patient; however, he believed HOSP-B also did and commented, "Maybe [the on-call staff] are not answering [the hospital provider's] phone call." MD-G explained HOSP-B's health system had many contracts with ophthalmology providers based on shared providers in both networks and thus they should call "their own people." MD-G provided an example if a call came into the call center for infectious disease - the call center would deny that transfer as the transferring hospital would have those services. If an eye issue was requested for transfer, he most likely would expect HPD to put that provider through to the trauma doctor; however, this was based on who the facility was: "If larger [hospital systems], may not go through." MD-G was aware of P31 and P32's and identified dialogues occurred over the past couple of weeks related to this. MD-G explained there were a lot of parts to this, but as far as he knew, the facility followed what they should have.

During an interview on 2/12/25 at 3:01 p.m., the CMO explained, prior to COVID-19, there was a 100 percent acceptance of all transfer requests; however, due to the impact of COVID-19 on their capacity, they became more "insular" in this acceptance; however, when it came to "trauma," which he questioned how this term should be defined, he explained, "As a level 1 [trauma center] we have to say yes if [the request was related to] trauma." For ophthalmology, the CMO stated their ophthalmology team told him that every ophthalmologist was knowledgeable, and able, to manage ruptured globe emergencies: "Primary globe rupture is just standard bread and butter [care];" but, if an ophthalmologist had not managed such emergencies in 10 years, and was not comfortable with this, then that provider would be in "over their head" and he would expect that ophthalmologist to confer with his ophthalmologist and they would accept the transfer. The CMO explained, his staff struggled with HOSP-B ophthalmology transfer requests as HOSP-B's health system had "38" ophthalmologists and thus there was a debate related to HOSP-B and their ability to not manage globe eye traumas. HOSP-B was thus expected to consult with their own ophthalmologists first, prior to contacting HOSP-A. He stated his preference was to manage care for those facilities that lacked ophthalmology consulting capabilities or if the ophthalmologist needed assistance. The CMO identified HPD utilized protocols and to ease their processes and understanding, their guidance was put on paper; however, due to the collaborative conversations with HOSP-B administration, this guidance was adjusted and all HPD staff were educated on the changes. Based on this guidance and education, HPD staff were expected to inquire if HOSP-B had consulted with their ophthalmologist before they requested transfer and if so, HPD were to initiate a provider-to-provider call.

When interviewed via telephone on 2/12/25 at 3:31 p.m., the HPDM stated she expected HPD staff to follow their directed work standard processes and protocols. These differed and were dependent on each call. Staff reviewed the reason for the call, the department specialty required for potential care, and hospital capacity. With this process, based on questions asked and information provided, there were instances where HPD was allowed to make the decision to not accept a transfer. Ophthalmology transfer requests followed the injured patient process and protocols. The HPDM identified HPD calls for ophthalmology transfers were mostly related to trauma. Based on that, those requests would always get put through to ophthalmologist for an acceptance or declined decision. For ophthalmology, recent changes were made and they attempted to determine when the appropriate time was for HRD to call them versus when not. If the call was related to an eye infection, not caused by injury, "we could potentially decline." Consults were not initiated for "external facilities unless they meet the injured patient criteria," which then was also dependent on other injuries potentially involved. The HPDM thought EMTALA training was provided during standard onboarding; however, was unable to state it was provided at the department level. The HPDM identified HPD staff were privy to which hospital in their system had specialty services; however, there were limited details on providers, thus one of the main reasons for a provider to provider consult for service capabilities. Over the past few months, there was "a lot of tension with [HOSP-B] and the ophthalmology group." Due to this, changes were made, and all staff were trained. When P32's transfer was declined, there was communication out that the hospital needed to connect with their own ophthalmology first and call back if services were still needed. That was what HPD staff followed. Since, HOSP-B now had ophthalmology coverage, and they were expected to collaborate with this coverage before they called. The HPDM was unsure of all the details surrounding P31's request and at what point the request was declined and/or if there was connection with their ophthalmology. Based on her knowledge, she felt HPD staff followed their work standard process and protocols, but maybe P31's event got "caught in the middle of the change," and maybe the work standard processes and/or protocols were not updated everywhere they needed to be.

During an interview via telephone on 2/13/25 at 11:55 a.m., MD-F stated she assessed P31 after P31 presented with concerns for a posterior left eye globe rupture where the integrity of P31's eye was no longer there, and she needed exploratory surgery. The rupture was unable to be found on the front part of the eye and thus the reason for the need for exploratory surgery. MD-F explained HOSP-B lacked an ophthalmology OR and it was difficult to get after hours and weekend ophthalmology at HOSP-C due to staffing shortages and limited time frames of when urgent surgeries were allowed. MD-F stated if this situation would have occurred during a weekday, it would not have been an issue; however, it was "near impossible.' after hours and on weekends. MD-F explained she performed surgeries, but HOSP-B did not have the OR capability for this repair process.

When interviewed via telephone on 2/13/25 at 12:19 p.m., the on call HOSP-B lead ophthalmologist (MD)-H stated there was a long-standing history on how to manage eye trauma, especially global eye ruptures. The bottom line however was the patient required surgical intervention. MD-H identified HOSP-B lacked OR resources and HOSP-C had limited availability with one room: only available during certain business hours, when not being utilized already. At other times, "there was nobody." MD-H stated if a call came into their company, the provider would see the patent to ensure appropriate treatment/care determination and if needed, would then consult with another ophthalmologist. He was aware of the 1/26/25 transfer denial and HOSP-A's lack of allowing such a consult. He stated, "If we would have had the place to do [the surgery], we would have."

During a telephone interview on 2/13/25 at 2:30 p.m., HPD-A stated she followed computer-based workflow protocols which were initiated based on dedicated questions and information obtained from the caller. During these calls, she followed a "script." if injury was identified, there was an injury protocol, and if information entered met the criteria, the call would be pushed through to the needed specialty for that specialty to accept or deny. Despite this, she explained there was one script for ophthalmology that indicated if the eye injury was isolated, and the caller was from another health system that had their own ophthalmologists on site, they did not accept those cases and did not have to coordinate a provider-to-provider consult. The only time she would coordinate this was when the patient was a HP patient and seen recently by ophthalmology. HPD-A explained she read this script verbatim when these calls came in. She was unable to clarify what "on site" meant and stated HOSP-B's health system had ophthalmology coverage. HPD-A identified processes were being reviewed and changed; however, she had yet to be updated on final changes, the script had yet to be changed, and if there was a call this day from an out of system provider for an isolated eye injury, and they had yet to connect with their own ophthalmologist(s), she would deny the transfer and would not pass the call onto her ophthalmologist. For P31 and P32, HPD-A stated she followed the provided scripts and collaborated with her coworkers for these calls. HPD-A was aware of EMTALA regulations based on education from past employers; however, she stated her hands were tied and she just followed the script.

When interviewed via telephone on 2/13/25 at 3:38 p.m., HPD-C stated she followed computer-based workflow protocols for determination on next steps. She explained as a broad rule, and based on bed availability, if the patient was an HP patient or the