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Based on medical record review and interview, 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 (#15) of 20 (#1-#14, #16-#20) being transferred to another facility when the transferring hospital had the capability and capacity to provide services. (see findings tag A-2409).

Based on medical record review and interviews, the hospital failed to provide documented evidence to indicate an appropriate transfer was provided for 1 (#15) of 20 patients who presented to the hospital ED with an emergency medical condition. This failed practice was evidenced by Patient #15 being transferred to another facility when the transferring hospital had the capability and capacity to provide services.
Findings:

Review of hospital policy, "Treatment and Transfer of Individuals Requesting/In Need of Emergency Medical Services," last reviewed 04/19/2024, revealed in part: Patient Request: When a patient (patient representative) requests a transfer, the request must be documented. The transfer may then occur if the ... legal representative: (a.) makes a request for transfer to another medical facility ... (b) acknowledges his or her request and understanding of the risks and benefits of the transfer ... Physician Certification: Physicians who request to transfer a patient (non-patient request) from the Emergency Department to another healthcare facility will have the request reviewed by the House Manager and the Emergency Physician who requested the consult. If their review is in conflict with the physicians request to transfer, the Chief Medical Officer and the Administrator on Call review may preclude the actual transfer ... and other specialties/subspecialties not available at OLOLRMC are reviewed and approved by the attending physician. If medical treatment has been provided within available capabilities and it is determined to be in the best interest of the patient to transfer to another facility: * Patient condition will be stabilized to the point that within reasonable medical probability, no material deterioration will occur during or as the result of transfer.

Review of Patient #15 medical record revealed that the patient was a 3 year old with a history of short gut syndrome. Further review revealed the following nursing documentation:
Patient #15 arrived on 05/27/2024 at 7:14 a.m. with a chief complaint of a vascular access problem.
Bedside glucose was 62 at 7:25 a.m.
Dextrose 10% IV Bolus and Dextrose 10 IV infusion initiated by 8:18 a.m.
10:09 a.m. Surgery at bedside.
10:24 a.m. Nurses Note: Per surgery resident, "family has chosen to have their care done at Hospital "B," they can do the central line care there as well, we are no longer taking care of him." Surg at bedside. Provider notified.
11:23 a.m. Nurse free text note: Surgery refusing to repair central line after "popping" the line, S4EDMD at bedside explaining to father transfer to Hospital "B."
12:29 p.m. - Patient left Our Lady of the Lake Regional Medical Center Children's Hospital.

Review of the documentation by the ED provider revealed the following ED Course:
7:44 a.m. - On examination patient is awake and crying. Vital signs are stable. Afebrile. Heart is regular rate and rhythm. Lungs are clear. G-tube placed into anterior abdomen. Central line placement to the left side chest wall- no surrounding skin changes. Ostomy bag in place- no leakage present. Differential diagnosis consist of but not limited to hypoglycemia, dehydration, electrolyte abnormality, central line malfunction.
8:26 a.m. - Half of tPA placed in line- unable to flush. Will try again
8:49 a.m. - CBC does not show a leukocytosis. Hemoglobin is 15.4 higher than his baseline, could be from hemoconcentration/dehydration. CMP does not show any signs of acute kidney injury. Patients LFTs are slightly elevated-these are higher than his baseline. CO2 is 18- patient is receiving continuous fluids. On arrival patient's blood glucose was 62- patient received a D10 bolus and a D10 normal sodium drip.
9:02 a.m. - Able to insert remainder of tPA into the line.
9:32 a.m. - Unable to flush central line.
9:52 a.m. - Patient has had his central line replaced multiple times at our facility. General Surgery consulted.
10:48 a.m. - General surgery at bedside- resident attempted to flush the line and it popped. General surgery resident informed the nurse that father wants to go to Hospital "B" for their care and they will not replace the line here.
After speaking to the father- he states he never said he wanted to go to Hospital "B." States patient always has his central line replaced here along with receiving majority of his care at our facility.
11:21 a.m. - General surgery states that they will not replace patient's central line and that patient needs to be transferred to Hospital "B" where patient has received care in the past.
Patient was hypoglycemic from not receiving his TPN overnight- currently on a D10 drip.
11:27 a.m. - Will call Hospital "B" to initiate transfer.
11:37 a.m. - Accepted at Hospital "B."
Diagnosis: 1. Problem with vascular access 2. Clotted dialysis access, initial encounter (HCC) 3. Hypoglycemia. Disposition and Plan: Transfer to another facility.

Review of Patient #15's Plan of Care - Encounter Notes by S12GSMD (General Surgery) at 05/27/2024 10:42 a.m. revealed the following: Patient is a Ochsner short bowel multidisciplinary patient and has all care coordinated through GI and surgery in New Orleans. Patient does not require emergent intervention presently. Should be transferred to his primary care givers and primary surgeon who performed his recent intestinal surgery. Signed by S12GSMD at 10:45 a.m. on 05/27/2024.

Review of Patient #15's Transfer Record revealed the reason for transfer was service or qualified clinical personnel unavailable. Further review revealed the following: Patient condition: Patient is stable. Benefits of transfer: Clinical personnel of receiving facility are capable of providing the level of care needed; Hospital resources available at receiving facility.

Further record review revealed that during the 4 hours following the Dextrose bolus and the initiation of the Dextrose infusion, the blood glucose of the patient was not rechecked prior to departure from facility to ensure patient was stable for transfer. Initial documented bedside Blood Glucose of patient was 62 at 7:25 a.m. on 05/27/2024.

In an interview on 06/12/2024 at 1:54 p.m. with S4EDMD stated surgeon S12GSMD had capability of replacing and/or inserting central line at Our Lady of the Lake Regional Medical Center Children's Hospital.

In a phone interview on 06/12/2024 at 2:26 with S11EDRES revealed in part: She spoke with Surgeon who told the nurse the patient's father wants to go to Hospital "B." S11EDRES states, "I thought this was strange and when I spoke to the dad about it, he said that wasn't true." S11EDRES called surgeon back and said to send him Hospital "B" because that is where his specialist are and he should go there to get it done." S11EDRES stated patient was not stable because the patient was hypoglycemic and had to be put on a D10 drip to get blood glucose up.

In a phone interview on 06/12/2024 at 3:40 p.m. with S12GSMD revealed the following statements in part: "I did not see the patient. I was called about the patient and spoke to the ED provider/resident." S12GSMD stated the surgery resident saw the patient. S12GSMD stated he didn't remember which surgery resident saw the patient. S12GSMD stated that over the past month, they have had conversations regarding this patient with GI due to the patient being a "complex patient." "We decided that since this patient is so complex" and most of his procedures have been done with Hospital "B." "It is in the best interest for this patient to receive care at Hospital "B." S12GSMD stated, "If he had an emergency and was not stable, then we will care for him. He didn't have an issue that kept him from being transferred to Hospital "B." I'm not going to do simple minor things anymore for him, because he is more complex and his care has been shifted to Hospital "B." "Just about everyone in our group has done a procedure on him at some point, and every time we operate there is something else." "If he comes in for something that is not emergent, he will be transferred to Hospital "B" where his team is."

In an interview on 06/12/2024 at 1:28 p.m. S2VPPCS verified that on 05/24/2024 Our Lady of the Lake Regional Medical Center Children's Hospital was not at capacity and had the capability to care for patient #15. S2VPPCS also verified at this time that S12GSMD is credentialed for central line placement at Our Lady of the Lake Regional Medical Center Children's Hospital.