Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 530033 (X3) Date Survey Completed 03/21/2018
Name of Provider or Supplier Mountain View Regional Hospital Street Address, City, State 6550 East 2nd Street, Casper, WY
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A2409 APPROPRIATE TRANSFER
CFR(s): 489.24(e)(1)-(2)

(1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual's behalf) requests the transfer, after being informed of the hospital's obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital's files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer.


This STANDARD is not met as evidenced by:
Based on medical record review, receiving hospital record review, staff interview, and policy review, the facility failed to ensure the receiving hospital accepted transfer for 1 of 1 sample patients (#2) who had an emergency medical condition and then experienced cardiac arrest. The findings were: Review of the emergency department (ED) record showed patient #2 was admitted to the ED on 10/1/17 at 11 AM with a complaint of fever and cough. The review showed the patient received a medical screening examination, and treatment which included lab tests and x-rays. Further review showed the ED physician contacted physician #1 at a local hospital on 10/1/17 at 12:20 PM and received acceptance to transfer the patient with a diagnosis of sepsis. Physician #1 was not the ED physician, and the plan was to admit the patient to the intensive care unit. The review showed EMS (emergency medical services) was contacted for transport. Review of the "Memorandum of Transfer" form showed the patient's risks were "worsening sepsis." The review showed the patient was stable for transfer via EMS and had vital signs which included a temperature of 98.8 degrees Fahrenheit, pulse of 144 beats per minute, respirations of 44, blood pressure of 92/54, and an oxygen saturation of 72%. The following concerns were identified: a. Further review of the ED record for patient #2 showed the patient had a significant change in status on 10/1/17 at 12:35 PM. At that time the respiratory therapist called the registered nurse to the patient's room. The assessment showed the patient was cyanotic and unresponsive, was not breathing, and had no pulse. By 12:40 PM the ED team had called a "code blue" and CPR (cardio-pulmonary resuscitation) was in progress. The code continued, and at 12:53 PM the physician was able to insert an endo-tracheal tube for assisted respirations. At 12:55 PM the team applied a Lucas device (device to perform mechanical compressions for the heart). PEA (pulseless electrical activity) was noted as the patient's heart rhythm at that time. At 1 PM a member of the arriving EMS team reinserted an endo-tracheal tube for assisted respirations. At 1:07 PM PEA was still noted. At 1:09 PM the patient was being transferred to the ambulance for transport and was noted to still be receiving mechanical compressions with the Lucas device. At 1:10 PM another pulse check was performed and the patient had no pulse. At 1:13 PM the ambulance left the facility parking lot with the patient. b. Review of the ED record showed the ED physician failed to document any contact with a physician #1 concerning the patient's change in status. The review showed the ED nurse contacted the receiving ED and gave report on 10/1/17 at 12:45 PM. Review of the "Memorandum of Transfer" form showed the facility failed to update the patient's risks from "worsening sepsis" to include cardiac and respiratory arrest. Further review of the "Memorandum of Transfer" form showed the facility failed to update the vital signs to reflect the status of no pulse, no respirations, and the patient being unresponsive. c. Review of the receiving hospital "ED Provider Note" dated 10/1/18 and not timed showed "after initial evaluation" the sending physician contacted physician #2 at the receiving facility ED and gave a report, which included the patient's code status. The note showed the patient was coded for 52 minutes at the receiving facility and the code was stopped "due to futility." Review of the entire receiving facility medical record showed no indication the sending ED physician had spoken to any physician at the receiving facility after the patient's significant change in status prior to transport. d. Interview with the sending ED physician by phone on 3/22/18 at 8:37 AM confirmed the transfer documentation had not been updated to reflect the patient's significant change in condition. He further confirmed he had failed to document any contact with physician #1 after the patient's change in condition, and could not remember if he had contacted her after the patient's significant change in status. e. Review of the facility "Emergency Services" policy titled, "EMTALA: Medical Screening Examination and Stabilizing Treatment," showed the following, "...B. Stabilizing Care. i. If the MSE demonstrates that an EMC (emergency medical condition) exists, [the facility] will provide Stabilizing Treatment within [the facility's] Capabilities, even if [the facility] must transfer the Patient....ii. A Patient with an EMC is stabilized when the physician/QMP (qualified medical practitioner) determines that: ...2. The Patient is stable for transfer (i.e., when the physician or QMP has determined, within reasonable clinical confidence, that the Patient is expected to leave [the facility] and be received at the second facility with no material deterioration of his/her medical condition and the treating physician reasonably believes the receiving facility has the Capability to manage the Patient's medical condition and any reasonably foreseeable complications of that condition)...H. Transfer requirements for the Patient: iv. Transfer of the Patient who is not Stable for Transfer is accomplished as follows: ...3. The Transfer is affected through appropriate means consisting of the necessary, qualified personnel and transportation equipment including the use of life support measures. In all cases a physician to physician conversation must occur prior to acceptance and initiation of the transfer process."