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 531312 (X3) Date Survey Completed 03/20/2025
Name of Provider or Supplier Cody Regional Health Street Address, City, State 707 Sheridan Avenue, Cody, 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)
C2409 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, staff interview, and review of facility policies and procedures, the facility failed to ensure that a patient was not transferred unless the patient requested the transfer in writing or a physician signed a certification that the medical benefits outweighed the risks for 1 of 5 patients (#2) reviewed who had an emergency medical condition and was transferred to another facility. The findings were: 1. Review of the emergency room (ER) record showed patient #2 arrived on 2/27/25 at 10:37 PM. Review of physician notes showed the chief complaint was suicide attempt. The patient reported s/he had a gun to his/her temple, but was trembling prior to pulling the trigger and so the gun moved, missing him/her. The physician documented "Patient has been evaluated by [behavioral health agency]. I discussed the case with the evaluator. They agree with the plan to uphold the title [psychiatric hold] and seek placement for the patient." The physician later documented "...there is a bed available at [psychiatric facility] for [his/her] acute care and treatment. [S/he] agrees with the plan for transfer to that facility." Review of nursing progress notes showed on 2/28/25 at 6:03 PM the patient was transferred to a psychiatric facility via ambulance. The following concerns were identified: a. Further review of the ER record showed no evidence the patient requested the transfer in writing. Further, there was no certification by the physician stating the benefits outweighed the risks. In addition, there lacked documentation of the name of the person at the receiving facility who agreed to accept the transfer. b. During an interview on 3/19/25 at 11:48 AM the director of the ER and the director of quality confirmed there was no physician certification for the transfer of patient #2. They stated they didn't do a transfer certification if the patient was on a psychiatric hold (Title 25). They also confirmed the medical record of patient #2 lacked the name of the person at the psychiatric facility who agreed to accept the transfer. c. On 3/19/25 at 12:08 PM physician #1 (who arranged for the transfer for patient #2) stated the physician certification for transfers usually wasn't done for patients on Title 25 [involuntary hold]. 2. During an interview on 3/19/25 at 8:48 AM the medical director for the ER stated the physician certification for transfers should be completed, including for patients with psychiatric conditions who were on Title 25 [involuntary hold]. 3. Review of the facility's policy "EMTALA" (undated) showed "...An individual whose condition is unstable may be transferred for only one of two reasons: 1) The transfer is medically indicated. 2) The individual, or a responsible person acting on the individual's behalf, requests the transfer in writing and indicate the reasons for the request as well as indicate that he/she is aware of the risks and benefits of the transfer...Unstable patients may be transferred, and it is indicated, when CRH lacks the capability and resources, including physician expertise, necessary to stabilize or treat a patient's EMC [emergency medical condition]...When there is a medically indicated transfer or an unstable patient, the ED or WH&N [women's health and nursery] physician shall: 1) certify that the benefits to the patient from the transfer outweigh the risks of transfer. 2) Obtain the patient's informed consent 3) Arrange an appropriate transfer...The certification must be done in writing and must include the medical risks and benefits to the patient."