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Based on medical record review, policy review, and staff interview, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This had the potential for negative outcomes and life-threatening complications. Findings include:

Refer to A2406 as it relates to the failure of the hospital to ensure a medical screening examinations were performed within their capability.

Refer to A2409 as it relates to the failure of the hospital to provide an appropriate transfer.

The effects of these practices put all patients presenting to the ED for emergency medical treatment at risk of a negative outcome.

Based on policy review, medical record review, and staff interview, it was determined the facility failed to ensure patients received an appropriate medical screening examination prior to discharge for 1 of 22 patients (Patient #22) whose records were reviewed. This put all patients presenting to the ED for emergency medical care at risk for negative outcomes. Findings include:

A CAH policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy - Intermountain," last reviewed March 2025, stated the CAH shall, "Provide an appropriate Medical Screening Exam (MSE) to any individual who comes to the emergency department ... within the Hospital's Capability and Capacity, conduct and document an appropriate MSE reasonably conducted to identify an Emergency Medical Condition (EMC)." This policy was not followed. An example includes:

Patient #22 was an 8 week old female who presented to the ED on 12/11/24 at 11:05 AM with a chief complaint of shortness of breath. Documentation in the ED record under "History of Present Illness" stated, "8-week-old female presents to ED with parents for evaluation of turning blue episode when feeding earlier this morning. Reports having an episode about a week ago as well. Was seen recently and diagnosed with URI and congestion."

In the ED physician note under "Medical Decision Making/ED Course," Provider D documented, "While in the emergency department patient appeared well, was placed on pulse oximetry and observed for a few hours ... Patient was fed while in ED and did not have any repeat episodes ... Transfer considered but with lack of hard objective findings during ED obs [observations] will try close management with PCP."

No diagnostic tests were ordered or performed during Patient #22's ED visit. An ED discharge order was placed at 1:03 PM by Provider D with a disposition of "Discharge with close PCP follow-up this afternoon." The infant was observed for approximately two hours in the ED.

Later that same day, 12/11/24 at 5:03 PM, Patient #22 was evaluated by her PCP (Provider E) at the CAH's outpatient clinic. The PCP documented the need for hospital admission for observation, and Patient #22 was admitted to the medical floor.

Subsequently, on 12/11/24 at 8:17 PM, the CAH inpatient hospitalist documented, "7 days ago the infant developed a low-grade fever at 100.5 and was irritable ... 2 days later the infant had 2 different apneic spells ... Baby was seen in the ER twice with EMT transfer regarding those apneic events. Studies including Influenza RSV and COVID were negative. No other viral studies were done. No lab work was done. No blood cultures. No LP ... Since admission to the hospital the baby has had 2 apneic [not breathing] spells 1 for over 30 seconds with a rapid response and the second less than 10 seconds responding to stimulation. There were no efforts to breathe."

Due to observed episodes of apnea, a consultation was conducted with a physician at a higher level pediatric facility, who recommended the transfer of Patient #22. Life Flight was dispatched to facilitate the transfer via fixed wing air transport. The transport team arrived at the referring facility on 12/11/24 at 11:57 PM. According to Life Flight documentation, after evaluation by the transfer team RN and a telehealth critical care team member, it was determined, "given the frequency of apnea and duration of remainder transport time that it was in the best interest of this patient to intubate her prior to departure." Patient #22 was intubated at 12:54 AM on 12/12/24 and departed for the receiving facility at 1:37 AM.

An interview with Provider D was requested but he was unavailable.

The ED Medical Director was interviewed on 5/07/25 beginning at 9:40 AM regarding Patient #22. When asked if he would have handled the case differently, he said no. When asked if any tests or diagnostics should have been done during the ED visit, he responded, "I don't think I would have done anything different, each test has a risk vs benefit, I just can't think of a useful test you could do. It's easy to say in hindsight, but unnecessary tests can cause harm."

The lack of diagnostic evaluation and the decision to discharge Patient #22 based on observation, without further testing, represents a failure to provide an appropriate MSE per the CAH's policy.

Based on policy review and medical record review, it was determined the CAH failed to ensure a transfer to another hospital was effected through qualified personnel and transportation equipment for 1 of 22 patients (Patient #11) whose records were reviewed. Failure to ensure an appropriate transfer put the patient at risk for deterioration during the transport to another hospital. Findings include:

A CAH policy titled, "Emergency Medical Treatment and Labor Act (EMTALA) Policy - lntermountain" updated March 2025 stated, "Appropriate transfer. If an individual is to be transferred to another medical facility, the Hospital will: ... arrange for transfer by qualified personnel and appropriate equipment." This policy was not followed. An example includes:

Patient #11 was a 22 year old female who presented to the ED on 12/21/24 with a chief complaint of right upper quadrant pain. Her provider note from her ED visit stated, "This 22-year-old woman does not have a history of abdominal surgeries. She has had right upper quadrant pain for about a week. Pain is worse with eating. She had an ultrasound 1 week ago that showed gallstones without radiographic evidence of cholecystitis [gallbladder inflammation]. She has been advised to avoid fatty foods ... Unfortunately, the patient has developed choledocholithiasis [gallstones in the bile duct]. She was transferred via private vehicle to [area hospital] for ERCP and likely cholecystectomy [gallbladder removal surgery]."

Patient #11's provider note did not say what monitoring would be required during Patient #11's transfer. It did not say if an ambulance was offered and/or was refused by Patient #11. It did not include documentation of a discussion of the risks of transporting by private vehicle.

Patient #11's record included a transfer form dated 12/21/24. It was signed by the Provider A and Patient #11. It stated, "As indicated below, the patient will be transferred by qualified personnel and transportation equipment including the use of necessary and medically appropriate life support measures." The form included a checked box which said, "Private Vehicle." It was unclear what personnel and transportation equipment were required for Patient #11.

Provider A was interviewed on 5/06/25 beginning at 2:33 PM and Patient #11's record was reviewed. He confirmed he remembered Patient #11. He was asked what type of discussions were had with patients when they went by personal vehicle, and if risks and benefits were discussed. He stated patients are concerned about ambulance expenses, but he always offers an ambulance. When asked what risks and benefits he discusses with patients when driving themselves, he stated the ambulance knows where to take patients, and people driving themselves can get lost. When asked what he would document in these cases he stated, "the patient prefers to go by private vehicle. This request is reasonable."

The CAH failed to ensure transfer to another hospital was effected through qualified personnel and transportation equipment.