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Based on medical record review, policy review, and patient and staff interview, it was determined the facility failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24: Responsibilities of Medicare Participating Hospitals in Emergency Cases.

Refer to A - 2407 as it relates to the facility's failure to provide an appropriate stabilizing treatment for 1 of 20 patients (Patients #8) whose record was reviewed.

Refer to A - 2409 as it relates to the facility's failure to ensure an appropriate transfer for 5 of 18 patients (Patients #3, #4, #7, #9 and #13) who were transferred and whose records were reviewed.

Noncompliance with 42 CFR Part 489.24 had the ability to negatively affect all patients who presented to the ER seeking emergency care.

Based on medical record review, staff interview, and policy review, it was determined the hospital failed to provide stabilizing treatment to the best of their ability for 1 of 18 Patients (Patient #8) whose records were reviewed and required a transfer. This had the potential to delay treatment for this patient and other transfer patients. Findings include:

A hospital policy titled "Patient Transfer to Other Facility", approved 04/03/25, was reviewed. The policy stated, "If a patient's clinical condition requires resources and technical expertise not available within...transfer to a facility with the necessary resources and expertise may be indicated." "To the extent possible, based on the patient's condition, the risks and benefit associated with transfer to another facility should be discussed with the patient." This policy was not followed. An example includes:

Patient #8 was a 56 year old male who presented to the ED on 6/20/25 at 13:47 with a chief complaint of severe abdominal pain in all 4 quadrants with abdominal distension, pain rated at 10/10 with nausea and vomiting. Patient #8's past medical history included renal failure and renal transplant 4 years ago, colon resection and ostomy 2/2/25.

Patient #8 received a MSE at 13:52. The hospital was at that time on divert due to loss of power and subsequently no radiologic services. The ED Physician note stated patient was discharged 6/19/25 from an acute care hospital after abdominal surgery which resulted in an ileostomy.

The ED Physician ordered morphine 4mg IV and ondansetron 4mg IV for pain and nausea control. No other stabilizing treatment was performed. No labs were drawn. There was no documentation of communication with the surgeon at the acute care hospital where Patient #8 had discharged the previous day; that hospital was located 184 miles north of this hospital. ED physician noted, "his examination is concerning for acute abdomen including intra-abdominal pathology such as SBO, perforation or other serious infection or cause of pain."

Nearby hospital was contacted to confirm CT was available. The ED physician note stated their ambulance was not available. Patient agreed to transfer via private vehicle to nearby hospital for a diagnostic CT rather than wait for available ambulance to transport. Patient #8 travelled 16 miles south to nearby hospital for a diagnostic CT and labs.

Patient #8's disposition on the ED log was listed as "transfer." A request for the transfer form was requested. No transfer form was received prior to surveyor exit. Two more requests for the transfer form for Patient #8 were made via email without response.

Patient #8's medical record was reviewed in the presence of the DNS. The DNS confirmed in an interview on 6/24/25 beginning at 9:00 AM, that Patient #8 was driven to another hospital via private vehicle to obtain a diagnostic CT. She confirmed there was no documented discussion of other options or risks of private vehicle transport.

The hospital failed to ensure diagnostics and stablizing treatment were not delayed for Patient #8.

Based on policy review, record review, and staff interview, it was determined hospital staff failed to ensure the risks and benefits of a transfer were documented prior to transfer 6 of 18 patients (Patients #3, #4, #7, #8, #9 and #13) whose records were reviewed and were transferred out of the hospital. This failed practice placed patients at risk of unsafe or potentially inappropriate transfer route.
Findings include:

Hospital policy titled "EMTALA" with reviewed date of 7/11/2023 was reviewed. The EMTALA policy stated under the section "Appropriate Discharge or Transfer" "Appropriate transfer ... arrange for transfer by qualified personnel and appropriate equipment." This policy was not followed.
Examples Include:

1.Patient #3 was a 40-year-old female who presented to the ED on 6/07/25 at 16:35 with reason for visit listed as "Post surgery bruising." The patient was provided a MSE and transferred via private vehicle to an outside facility for a higher level of care.

Patient #3's medical record was reviewed, including her transfer form. The section on "Transport Agency/Equipment & Medical Personnel" had private vehicle marked. This section additionally stated, "The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures." The medical record did not document the risks and benefits of the transport via private vehicle.

The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #3's record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle.

2.Patient #4 was a 17-year-old male who presented to ED on 6/11/25 at 09:20 with reason for visit listed as "ABD pain." Patient #4 was provided an MSE as well as X-ray and CT scan and medical record documented an "acute appendicitis." Patient #4 was transferred via private vehicle to an outside facility for a higher level of care.

Patient #4's medical record was reviewed, including his transfer form. The section on "Transport Agency/Equipment & Medical Personnel" had private vehicle marked. This section additionally stated, "The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures." The medical record ED note dated 6/11/25 documented Patient #4 chose to go private vehicle with no documentation of the risks and benefits of transport via private vehicle.

The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #4's record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle.

3.Patient #7 was an 87-year-old male who presented to the ED on 5/19/25 at 15:12 with the reason for visit listed as "Stroke Symptoms." Patient #7 was provided an MSE and transferred to an outside facility for a higher level of care via private vehicle.

Patient #7's medical record was reviewed, including his transfer form. The section on "Transport Agency/Equipment & Medical Personnel" had private vehicle marked. This section additionally stated, "The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures." The medical record did not document the risks and benefits of the transport via private vehicle.

The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #7's record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle.

5. Patient #8 was a 56 year old male who presented to the ED on 6/20/25 at 13:47 with a chief complaint of severe abdominal pain in all 4 quadrants with abdominal distension, pain rated at 10/10 with nausea and vomiting. Patient #8's past medical history included renal failure and renal transplant 4 years ago, colon resection and ostomy 2/2/25.

Patient #8's medical record was reviewed. There was no trasnfer form documented.

The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #8's record was reviewed. The DNS reported there was no transfer currently in the chart but would review scanned in documents. Upon review DNS emailed surveyor and reported, "it does not appear there was a Transfer form filled out. Just the phone call to Syringa and the RN to RN phone call. Medical Records could not find a transfer form in his chart."

4.Patient #9 was a 60-year-old female who presented to the ED on 5/03/25 at 19:42 with the reason for visit listed as "injured right knee." Patient #9 was provided an MSE, her medical record documented a "fracture above of distal humerus above total knee prosthesis" and transferred to an outside facility for a higher level of care via private vehicle.

Patient #9's medical record was reviewed, including her transfer form. The section on "Transport Agency/Equipment & Medical Personnel" had ambulance/BLS and private vehicle both marked. This section additionally stated "The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures." The medical record did not document the risks and benefits of the transport via private vehicle.

The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #9's record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle.

5.Patient #13 was a 57-year-old male who presented to the ED on 6/16/25 at 11:45 with reason for visit listed as "SOB." Patient #13 was provided a MSE and medical record documented a "right lower lobe and perihilar infiltrate with increasing right sided pleural effusion: and transferred to an outside facility for a higher level of care via private vehicle. Patient #13's medical record documented, "he has O2 tanks for drive."

Patient #13's medical record was reviewed, including his transfer form. The section on "Transport Agency/Equipment & Medical Personnel" had ambulance/BLS and private vehicle both marked. This section additionally stated, "The patient will be transferred by qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures." The medical record did not document the risks and benefits of the transport via private vehicle.

The DNS was interviewed 6/24/25 beginning at 9:00 AM and Patient #13's record was reviewed. The DNS confirmed there was no documentation of the risks and benefits of the transfer via private vehicle.

The hospital failed to ensure complete and accurate transfer documentation was provided to the receiving facility. Failure to include essential documentation can lead to delays in treatment, medication errors and inadequate continuity of care, compromising patient safety and well-being.