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Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the disposition of one of 21 patients presenting to the Emergency Department (ED) was not documented in the central log (MR1).

Findings include:

Review, at approximately 1:23 PM on August 30, 2016, of Policy #101.18, EMTALA Compliance Plan, effective December 2, 2009, revealed, "... Warren General Hospital shall comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) and all other federal and state laws governing the treatment of persons with emergency medical conditions. ... Central Log The Hospital shall maintain, in electronic form, a central log of all individuals who come to the hospital seeking care for an emergency medical condition. The log will include the patient's name, date and time of arrival, medical record number, whether he/she refused treatment, whether he/she was refused treatment, whether he/she was transferred, admitted, stabilized and transferred, or discharged. ..."

1. Review of MR1 revealed that the patient presented to the Warren General Hospital ED on July 23, 2016, at 2:21 AM for an alleged sexual assault. Review of the physician documentation for MR1 revealed, "... I discussed the case with the [Tertiary Hospital] Nurse OTH4 and it was agreed the patient would be sent to [Tertiary Hospital] for evaluation by the SANE nurse on call tonight. ... Primary Impression: Reported sexual assault. Transferred to Go to [Tertiary Hospital] and be evaluated by the SANE nurse on-call. Condition: Stable." The documentation was electronically signed by EMP1 on July 23, 2016, at 3:38 AM.

2. Review of nursing documentation (MR1) authored by EMP3, on July 23, 2016, at 3:34 AM revealed, "Reviewed discharge instructions with patient has had opportunity to read and ask questions about discharge instructions. Expressed understanding of discharge instructions. PT TRANSPORTED BY PRIVATE CAR TO [Tertiary Hospital]."

3. Review of the discharge instructions (MR1) provided to the patient revealed no documentation directing the patient to [Tertiary Hospital] for further evaluation by the SANE nurse or a physician.

4. Review of the ED log revealed no documentation of the disposition of MR1.

5. Between 8:50 AM and 9:30 AM on August 31, 2016, an interview was conducted with EMP10. When asked if the patient (MR1) was discharged or transferred, EMP10 stated that the patient was transported by private car. EMP10 added, "Generally, when they go by private car, it's not considered a transfer, it's considered a discharge and a readmission."

6. Between 10:07 AM and 10:30 AM on August 31, 2016, a telephone interview was conducted with EMP1. When asked if the patient was discharged or transferred to a higher level of care, EMP1 stated, "I called the SANE nurse on duty at [Tertiary Hospital], well the charge nurse on duty that night, was the SANE nurse on duty. ... I asked [him/her] if we should do some specimen collection tonight, or was it something that the pediatric gynecologist could do the following day. ... The recommendation was that [he/she] go to [Tertiary Hospital] that night. The patient was discharged, and arrangements were made for the patient to have a SANE exam that night, in the next couple of hours. ... I can't answer that [transfer versus discharge] any better than that."

Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to provide a medical screening examination within the capabilities of the hospital's Emergency Department (ED) for one of two patients presenting for alleged sexual assault (MR1).

Findings include:

Review, at approximately 1:12 PM on August 30, 2016, of the "Warren General Hospital Medical Staff Rules and Regulations & Allied Health Professional Rules and Regulations," updated March 27, 2015, revealed, "... I. Medical Staff Policies ... C. Transfer Orders. 3. To Other Healthcare Facility. ... No patient who presents with an emergency medical condition (including a woman in labor) shall be transferred who has not received a medical screening examination and appropriate stabilization."

Review, at approximately 1:23 PM on August 30, 2016, of Policy #101.18, EMTALA Compliance Plan, effective December 2, 2009, revealed, "... Warren General Hospital shall comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) and all other federal and state laws governing the treatment of persons with emergency medical conditions. Medical Screening Examination Warren General Hospital will provide an appropriate medical screening examination to any individual who presents to the hospital for emergency care. ... The medical record must reflect continued monitoring, according to the individual's needs, until it is determined whether or not the individual has an emergency medical condition, and, if the individual has an emergency medical condition, until the individual is stabilized or appropriately transferred. The medical screening examination must be conducted in a non-discriminatory manner. The individual shall not receive a different level of care based upon the patient's ability or inability to pay. The medical screening examination shall be performed by qualified medical personnel."

Review, at approximately 1:50 PM on August 30, 2016, of Policy #1207-d-R, Sexual Assault, revised December 9, 2005, revealed, "Policy: To provide victims of sexual assault with prompt, comprehensive, and professional treatment while respecting their need for privacy. Procedure: As soon after arrival as possible, a victim of sexual assault should be placed in a private examination room. The screening nurse should take a brief history to the events of the assault. History should be limited to a very brief description of the events surrounding the assault including date, time and location of assault. Medical history per screening policy #1202-R should be obtained. Patients should be screened for any injuries needing emergency treatment. ... Any individual who identifies herself/himself as a victim of sexual assault that occurred within the previous 120 hours should be asked if she/he wishes to be seen by a Sexual Assault Nurse Examiner (SANE). If the patient refuses, the ECC physician will see that patient. Patients identified with need for emergency treatment for injuries received as a result of a sexual assault will be evaluated by the ECC physician, initially. The SANE nurse will perform a detailed history and forensic exam with the intent of collecting evidence under the auspices of the ECC physician, and will document all findings thoroughly. ... The interview and the forensic examination will be done after the arrival of a police officer. A careful assessment will be done with particular attention to the events prior to and during the assault, the time of assault, the clothing worn, and any bathing since the event. ... Specimens will be collected in conjunction with the guidelines of the Tri-Tech Sexual Assault Evidence Kit, or a suitable alternative. After the examination is complete, all specimens are appropriately labeled, and the chain of evidence is transferred to the investigating officer. Initial testing will include serum pregnancy test for any female of childbearing age. Urine drug screen and Rohypnol testing may be done when appropriate. The Pennsylvania Department of Health or the primary care physician should do testing for sexually transmitted diseases, including HIV, on follow-up within 2 weeks. Preventative medical care will be provided through the offering of the following medication(s): Ceftriaxone 125-250 mg IM in a single dose Metronidazole 2 gm orally BID x 7 days Doxycycline 100 mg orally BID x 7 days Azithromycin 1 gm PO in a single dose Cipro 500 mg PO in a single dose Plan B one tablet PO STAT and repeat in 12 hours, if pregnancy test is negative HIV prophylaxis at discretion of the SANE/ECC physician ..."

1. Review of MR1 revealed that the patient presented to the Warren General Hospital ED on July 23, 2016, at 2:21 AM for an alleged sexual assault. Review of the record revealed no documentation of a SANE assessment or internal examination of the patient. The record further revealed no initial testing and preventative medical care as per facility policy.

2. Review of the physician physical examination revealed, "PHYSICAL EXAM ... No overt lacerations noted on external examination only. ... EMERGENCY COURSE Urinalysis was obtained as [MR1] had to urinate here in the ER. I discussed the case with the [Tertiary Hospital] Nurse OTH4 and it was agreed the patient would be sent to [Tertiary Hospital] for evaluation by the SANE nurse on call tonight. ... Education/Counseling provided: Patient, family Provided Edu/Counseling on: Diagnosis, Treatment, Prognosis, need for follow up ... Primary Impression: Reported sexual assault. Transferred to Go to [Tertiary Hospital] and be evaluated by the SANE nurse on-call. Condition: Stable." The documentation was electronically signed by EMP1 on July 23, 2016, at 3:38 AM.

3. Between 8:50 AM and 9:30 AM on August 31, 2016, an interview was conducted with EMP10. EMP10 confirmed that the ED used to have a SANE nurse, but no longer does. When asked the last time the facility had a SANE nurse, EMP10 stated, "I believe EMP11 was our last certified SANE nurse; and [he/she] left ... in July [2016] some time. ... We don't have anyone who is certified at this time." When asked if the ED is still capable of performing a sexual assault examination, EMP10 stated, "Yes." When asked if [he/she] has sat in on an examination as a second staff person in the past, EMP10 stated, "Yes." When asked if the examination typically includes an examination of exterior and interior damage, EMP10 stated, "Yes." When asked if the ED physician performs the external and internal examinations, EMP10 stated, "Yes ... I believe if the SANE nurse has that specific training and been through so many classes ... there are some SANE nurses that are able to do that." EMP10 confirmed that ED physician is able to perform both internal and external examinations. Upon identifying MR1 and asking about [his/her] recollection of the case, EMP10 stated, "Vaguely. I knew there was one [pediatric sexual assault case], but I don't believe I was here." When asked if [he/she] could identify, within the medical record, an internal examination of the patient, EMP10 confirmed there was an external examination only. EMP10 added, "I believe that according to this (MR1), an internal exam was not done. ... Actually, I do not believe that we have pediatric speculums. ... We have small adult [speculum], ... but I do not believe we have any pediatric ones. I don't believe we have the equipment for that [pediatric internal examination]." Upon reviewing the medical record, EMP10 stated, "This patient, looks like [he/she] had a UA [urinalysis] and a culture." When asked if there would typically have been testing for positivity of drugs and/or alcohol in the patient's system, EMP10 stated, "Generally, if it's an adult, and the patient said someone slipped them something, yes, we do [tests for substances/alcohol]." When asked if it could have been possible that the patient in question could have been drugged by the perpetrator, EMP10 stated, "Yeah, I suppose."

4. Review of MR2 revealed that the patient presented to the Warren General ED in February 6, 2016, for an alleged sexual assault. On August 31, 2016, at approximately 9:08 AM, when asked what type of care was provided to this patient, EMP10 reviewed the medical record and stated, "This one, it appears they did the assault interview, ... very thorough. ... This assessment, wasn't on the other one (MR1). ... Sexual interview ..." When asked if the patient's examination would have been internal and/or external, EMP10 stated that there was no SANE nurse called for this patient. When asked if there was a SANE nurse available at the time the patient presented, EMP10 stated, "We could have. If there was a SANE nurse working, they would do it, but we don't [didn't] have a SANE nurse on-call." EMP10 confirmed that full examination [internal] was offered and lab testing was done for the patient. EMP10 further confirmed that the facility does have a supply of rape kits stating, "... Yes. They're kept in a locked cabinet." When asked if there was a policy or internal memo explaining how the ED was to function without a SANE nurse, EMP10 stated, "I don't know of revisions."

5. Between 10:07 AM and 10:30 AM on August 31, 2016, a telephone interview was conducted with EMP1. When asked about [his/her] recollection of the primary case [MR1], EMP1 stated, "I remember it pretty well. We don't see many [age of the patient-pediatric] come through that get assaulted that often." EMP1 confirmed that Warren no longer has SANE nurses. When asked what portion of the examination is done by the ED physician versus the SANE nurse, EMP1 stated, "During my training, before SANE nurses were out, you could do your own sexual assault exam from beginning to end. You take care of them just the same way SANE nurses do. ... If there wasn't a SANE nurse available, I could do the examination from beginning to end. ... That is before [SANE nurses]." EMP1 added, "SANE nurses now do a much better job. ... It's kind of a higher level of care, if you will. ... SANE nurses have a higher level of knowledge at [specimen] collection. ... They dot all the I's and cross all the T's better. ... I don't do sexual assault exams anymore. ... I think that that's a feeling amongst most ER physicians at this time, that if there is a sexual assault, you want to try to get your patient to a SANE nurse, because you have a better chance at catching a perp if a SANE nurse does it [internal and external examination]. ... SANE nurses, I think that is the direction that most ER professional head to, if they're available." When asked if there would still be some ED physicians that will do the sexual assault examinations, EMP1 stated, "I think most of my colleagues feel the same way that I just expressed. I can't imagine any of my colleagues do them [sexual assault examinations] any more." When explained that the external examination only was noted on MR1, EMP1 confirmed that the internal examination is left for the SANE nurse to complete. EMP1 added, "Especially at [Tertiary Hospital] ... most SANE nurses know how to use a Culpo scope. ... [Tertiary Hospital] has ... a pediatrician or pediatric gynecologist that do pediatric sexual assaults in their office, ... They have a practice dedicated to the pediatric sexual assault victims." EMP1 stated, "I made sure [MR1] wasn't significantly injured. ... vital signs, that kind of thing. ... If you were going to do the complete [exam], that's what you would do [laboratory testing]. ... If you're going to send them to the SANE nurse, that's what they would do [laboratory testing]. ... In the ED, the SANE nurse has a protocol/policy that they follow. There is an order on the [Health System for Tertiary Hospital] system that would include all of that stuff. I'm not sure who exactly signs for that eventually." Regarding the primary case patient, EMP1 stated, "I'm not sure that we did anything with [him/her]. We may have gotten a urine. ... I think [he/she] had to pee, so we got a urinalysis. ..." When asked what information, regarding the patient's care at Warren, was conveyed to [Tertiary Hospital], EMP1 stated, "My evaluation, ... I explained to the nurse that I did a brief external exam. ... I don't think we sent a copy of the lab work, because I don't think that we had it back." EMP1 added, "We took as good of care of that patient as we could. ... I'm confused as to why this has turned into an EMTALA investigation."

Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to provide further examination and stabilizing treatment within the capabilities of the hospital's Emergency Department (ED) for one of two patients presenting for alleged sexual assault (MR1).

Findings include:

Review, at approximately 1:12 PM on August 30, 2016, of the "Warren General Hospital Medical Staff Rules and Regulations & Allied Health Professional Rules and Regulations," updated March 27, 2015, revealed, "... I. Medical Staff Policies ... C. Transfer Orders. 3. To Other Healthcare Facility. ... No patient who presents with an emergency medical condition (including a woman in labor) shall be transferred who has not received ... appropriate stabilization."

Review, at approximately 1:23 PM on August 30, 2016, of Policy #101.18, EMTALA Compliance Plan, effective December 2, 2009, revealed, "... Warren General Hospital shall comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) and all other federal and state laws governing the treatment of persons with emergency medical conditions. ... If the individual has an emergency medical condition, the hospital with either (i) provide any necessary stabilizing treatment, or (ii) transfer the individual to another facility, or (iii) admit the patient for inpatient or observation services. ... The medical record must reflect continued monitoring, according to the individual's needs, until it is determined whether or not the individual has an emergency medical condition, and, if the individual has an emergency medical condition, until the individual is stabilized or appropriately transferred.

Review, at approximately 1:50 PM on August 30, 2016, of Policy #1207-d-R, Sexual Assault, revised December 9, 2005, revealed, "Policy: To provide victims of sexual assault with prompt, comprehensive, and professional treatment while respecting their need for privacy. Procedure: As soon after arrival as possible, a victim of sexual assault should be placed in a private examination room. The screening nurse should take a brief history to the events of the assault. History should be limited to a very brief description of the events surrounding the assault including date, time and location of assault. Medical history per screening policy #1202-R should be obtained. Patients should be screened for any injuries needing emergency treatment. ... Any individual who identifies herself/himself as a victim of sexual assault that occurred within the previous 120 hours should be asked if she/he wishes to be seen by a Sexual Assault Nurse Examiner (SANE). If the patient refuses, the ECC physician will see that patient. Patients identified with need for emergency treatment for injuries received as a result of a sexual assault will be evaluated by the ECC physician, initially. The SANE nurse will perform a detailed history and forensic exam with the intent of collecting evidence under the auspices of the ECC physician, and will document all findings thoroughly. ... A careful assessment will be done with particular attention to the events prior to and during the assault, the time of assault, the clothing worn, and any bathing since the event. ... Specimens will be collected in conjunction with the guidelines of the Tri-Tech Sexual Assault Evidence Kit, or a suitable alternative. After the examination is complete, all specimens are appropriately labeled, and the chain of evidence is transferred to the investigating officer. Initial testing will include serum pregnancy test for any female of childbearing age. Urine drug screen and Rohypnol testing may be done when appropriate. The Pennsylvania Department of Health or the primary care physician should do testing for sexually transmitted diseases, including HIV, on follow-up within 2 weeks. Preventative medical care will be provided through the offering of the following medication(s): Ceftriaxone 125-250 mg IM in a single dose Metronidazole 2 gm orally BID x 7 days Doxycycline 100 mg orally BID x 7 days Azithromycin 1 gm PO in a single dose Cipro 500 mg PO in a single dose Plan B one tablet PO STAT and repeat in 12 hours, if pregnancy test is negative HIV prophylaxis at discretion of the SANE/ECC physician ..."

1. Review of MR1 revealed that the patient presented to the Warren General Hospital ED on July 23, 2016, at 2:21 AM for an alleged sexual assault. Review of the record revealed no documentation of a SANE assessment or internal examination of the patient. The record further revealed no initial testing and preventative medical care as per facility policy.

2. Review of the physician documentation revealed, "EMERGENCY COURSE Urinalysis was obtained as [MR1] had to urinate here in the ER. I discussed the case with the [Tertiary Hospital] Nurse OTH4 and it was agreed the patient would be sent to [Tertiary Hospital] for evaluation by the SANE nurse on call tonight. ..." The documentation was electronically signed by EMP1 on July 23, 2016 at 3:38 AM.

3. Between 8:50 AM and 9:30 AM on August 31, 2016, an interview was conducted with EMP10. Upon identifying MR1 and asking about [his/her] recollection of the case, EMP10 stated, "Vaguely. I knew there was one [pediatric sexual assault case], but I don't believe I was here." EMP10 went on to stated, "[EMP1] discussed the case with a [Tertiary Hospital] nurse. ... It was agreed that the patient would be sent to [Tertiary Hospital] to be seen by the SANE nurse on-call. ..." Upon reviewing the medical record, EMP10 stated, "This patient, looks like [he/she] had a UA [urinalysis] and a culture." When asked if there would typically have been testing for positivity of drugs and/or alcohol in the patient's system, EMP10 stated, "Generally, if it's an adult, and the patient said someone slipped them something, yes, we do [tests for substances/alcohol]." When asked if it could have been possible that the patient in question could have been drugged by the perpetrator, EMP10 stated, "Yeah, I suppose." When asked if [he/she] could identify where any antibiotics and/or prophylactics were ordered for the patient, EMP10 stated, "No, none of those were ordered." EMP10 confirmed that those medications were available.

4. Review of MR2 revealed that the patient presented to the Warren General ED on February 6, 2016, for an alleged sexual assault. On August 31, 2016, at approximately 9:08 AM, when asked what type of care was provided to this patient, EMP10 reviewed the medical record and stated, "... Ok, discussion with prophylaxis against pregnancy and STI. ... check tetanus status, and if not within last five years, please update. ... They did the Hepatitis B and C and serum pregnancy test, and an HIV baseline." EMP10 confirmed that lab testing was done and preventative care was arranged for the patient. When asked if there was a policy or internal memo explaining how the ED was to function without a SANE nurse, EMP10 stated, "I don't know of revisions."

5. Between 10:07 AM and 10:30 AM on August 31, 2016, a telephone interview was conducted with EMP1. When asked about [his/her] recollection of the primary case [MR1], EMP1 stated, "I remember it pretty well. We don't see many [age of the patient-pediatric] come through that get assaulted that often." EMP1 confirmed that Warren no longer has SANE nurses. EMP1 stated, "I made sure [MR1] wasn't significantly injured. ... vital signs, that kind of thing. ... If you were going to do the complete [exam], that's what you would do [laboratory testing]. ... If you're going to send them to the SANE nurse, that's what they would do [laboratory testing]. ... In the ED, the SANE nurse has a protocol/policy that they follow. There is an order on the [Health System for Tertiary Hospital] system that would include all of that stuff. I'm not sure who exactly signs for that eventually." When asked if the protocol/policy being referred to would be inclusive of antibiotics and/or prophylaxis, EMP1 stated, "Yeah, there's an entire order set that they collect and somebody signs off, it's either the ED medical director or the physician on duty." Regarding the primary case patient, EMP1 stated, "I'm not sure that we did anything with [him/her]. We may have gotten a urine. ... I think [he/she] had to pee, so we got a urinalysis." When asked what information, regarding the patient's care at Warren, was conveyed to [Tertiary Hospital], EMP1 stated, "My evaluation, ... I explained to the nurse that I did a brief external exam. ... I don't think we sent a copy of the lab work, because I don't think that we had it back." EMP1 added, "We took as good of care of that patient as we could. ... I'm confused as to why this has turned into an EMTALA investigation."

Based on review of facility documentation and medical records (MR), as well as employee interviews (EMP), it was determined that the facility failed to follow its policy for appropriate transfer, for physician to physician discussion between the sending and accepting facility, accepting physician, consent to transfer, documentation that the benefits outweighed the risks for the patient transfer, and provision of medical record information related to the patient's emergency condition for one of one patients transferred following presentation for alleged sexual assault (MR1).

Findings include:

Review, at approximately 1:12 PM on August 30, 2016, of the "Warren General Hospital Medical Staff Rules and Regulations & Allied Health Professional Rules and Regulations," updated March 27, 2015, revealed, "... I. Medical Staff Policies ... C. Transfer Orders. 3. To Other Healthcare Facility. Patients are transferred to another health care facility only on the written order of a physician. No patient should be transferred if Warren General Hospital has the facilities and personnel to provide all necessary treatment, except at the patient's request. It is the policy of this Hospital to comply with all applicable state and federal laws and regulations regulating patient transfer. No patient who presents with an emergency medical condition (including a woman in labor) shall be transferred who has not received a medical screening examination and appropriate stabilization. The physician ordering the transfer shall make arrangements with an accepting physician at a facility appropriate to the medical needs of the patient. The mode of transport chosen shall be based on the patient's medical need. The receiving institution will be furnished copies of an appropriate medical summary and other pertinent records. The informed consent of the competent patient or his representative shall be obtained where possible. ... 6. Patient Transfer: Transportation Arrangements. Social Service, Nursing Manager/Supervisor, or designee shall arrange transportation based upon the orders of the transferring physician. The responsible physician should specify whether the patient requires personnel and equipment with Advanced Life Support capability. The selection of the helicopter, ambulance, or wheel chair service shall be based upon availability, with regard to patient preference. ... D. Discharge Orders. ... 3. Discharge Summary All inpatient, surgical, outpatient observation, and emergency department records must contain a discharge summary. The discharge summary discusses the outcome of the hospitalization, the disposition of the patient, and provisions for follow-up care. ..."

Review, at approximately 1:23 PM on August 30, 2016, of Policy #101.18, EMTALA Compliance Plan, effective December 2, 2009, revealed, "... Warren General Hospital shall comply with the Emergency Medical Treatment and Active Labor Act (EMTALA) and all other federal and state laws governing the treatment of persons with emergency medical conditions. ... If the individual has an emergency medical condition, the hospital with either (i) provide any necessary stabilizing treatment, or (ii) transfer the individual to another facility, or (iii) admit the patient for inpatient or observation services. ... The medical record must reflect continued monitoring, according to the individual's needs, until it is determined whether or not the individual has an emergency medical condition, and, if the individual has an emergency medical condition, until the individual is stabilized or appropriately transferred. ... Transfer to another facility An individual may be transferred to another facility that has available space, qualified personnel, and has agreed to accept the transfer of the individual. Medical records pertinent to the individual's emergency medical condition will be sent to the receiving facility at the time of transfer, or as soon as possible following the transfer. Transfer will occur upon the following conditions: 1. Transfer is requested by the individual or the physician. ... b. A physician must certify, in writing, 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 facility outweigh the increased risks to the individual. The certification must summarize the risks and benefits upon which the physician's certification is made. ... 3. The receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept the transfer and provide appropriate medical care. 4. Warren General Hospital sends to the receiving facility all medical records available at the time of transfer that are related to the emergency medical condition. Pertinent records that are not available at the time of transfer (e.g. test results) shall be sent as soon as practicable after the transfer. 5. The transfer is effectuated by qualified personnel and the transportation equipment, as required, including the use of necessary and medically appropriate life support measures during transfer. Physician On-Call Responsibilities ... The hospital will transfer the patient to another facility in the event (i) a particular specialty is unavailable and the services required are beyond the scope of the hospital's capabilities, or (ii) the physician on-call is unavailable, due to circumstances beyond his/her control, and the hospital is unable to arrange for appropriate medical services. ..."

Review, at approximately 1:05 PM on August 30, 2016, of Policy #1501-e-R, Transfer of Patient to Another Health Care Facility, revised November 28, 2005, revealed, " Purpose: Establish guidelines based on EMTALA standards to insure that adequate care is given to each patient; if unable to continue with care, offer specialty care or higher level of care, patient is to be transferred to an appropriate facility. Policy: ... The decision to transfer a patient from the ECC to another health care facility is the responsibility of the physician If the physician determines, through the Hospital policy, that the patient should be transferred to another facility for further care or a higher level of care, EMTALA standards must be followed: The patient must: Have no life threatening condition ... Not require immediate need for surgery Be medically stable or medical benefits of transfer must outweigh the risks Agree to the transfer Acceptance to the receiving facility must be made physician to physician with documentation of the receiving facility's physician's name. Patient shall be informed of the reason for transfer: HMO request Continued care not offered at this Hospital Higher level of care Specialty care The ECC physician is responsible for the following: Stabilizing the patient Determining necessity of transfer Completing the Physician Transfer Certification portion of the "Consent for Patient Transfer" form Discussing transfer necessity and options with the patient and/or the significant other/family members Contacts the physician at the receiving facility. The physician at the receiving facility must accept the patient being transferred. Giving orders for use during transport The RN is responsible for: Advising the nursing supervisor of the transport Completing the "Consent for Patient Transfer" form Arranges for copies of all ECC records, lab results, x-rays to accompany the patient ... Assuring that the receiving facility has appropriate space and qualified personnel for the treatment of the individual and has agreed to accept the transfer of the individual Contacting the receiving hospital unit and giving verbal or written report prior to the patient's arrival at the receiving facility Copy of medical records, labs and x-rays will accompany the patient. Documentation shall include, but is not limited to: Report given to transport team Condition of patient prior to transport Vital signs prior to transport ..."

1. Review of MR1 revealed that the patient presented to the Warren General Hospital ED on July 23, 2016, at 2:21 AM for an alleged sexual assault. Review of the physician documentation for MR1 revealed, "... I discussed the case with the [Tertiary Hospital] Nurse OTH4 and it was agreed the patient would be sent to [Tertiary Hospital] for evaluation by the SANE nurse on call tonight. ... Education/Counseling provided: Patient, family Provided Edu/Counseling on: Diagnosis, Treatment, Prognosis, need for follow up ... Primary Impression: Reported sexual assault. Transferred to Go to [Tertiary Hospital] and be evaluated by the SANE nurse on-call. Condition: Stable." The documentation was electronically signed by EMP1 on July 23, 2016 at 3:38 AM.

2. Review of nursing documentation authored by EMP3, on July 23, 2016, at 3:34 AM revealed, "Reviewed discharge instructions with patient has had opportunity to read and ask questions about discharge instructions. expressed understanding of discharge instructions. PT TRANSPORTED BY PRIVATE CAR TO [Tertiary Hospital]."

3. Review of MR1 revealed no documentation of physician to physician discussion between EMP1 and a physician at the receiving facility. The review of MR1 further revealed no accepting physician, consent to transfer, documentation that the benefits outweighed the risks for the patient to go to [Tertiary Hospital] for further evaluation or that medical records related to the emergency condition were sent to the receiving facility.

4. On August 30, 2016, at approximately 12:10 PM, EMP4 confirmed that there was no transfer documentation for MR1 due to the patient being "discharged." On August 30, 2016, at approximately 12:12 PM, in response to specific discharge instructions that were provided to the patient (MR1), EMP4 stated, "This is what the patient received." The document titled "Patient Visit Information," revealed, "You were seen today for: reported sexual assault. Staff your caregivers today were: [EMP1] ... Patient Instructions Reviewed Sexual Assault ... Please contact the following to make an appointment for follow-up care: [PCP name and address and contact information]. Review of the instructions revealed, "Sexual Assault ... Treatment focuses on taking a careful history and physical exam, first aid of any injuries, blood tests, possible emergency birth control, and mental health counseling. Follow-up with your regular doctor (or recommended specialist) is required. Home Care *Rest as needed *Take over-the-counter and prescription medications as directed by the doctor. *follow-up as directed for further evaluation, testing, and mental health counseling. ... Follow up with family medical doctor if worse or return to ER as needed." Further review of the instructions revealed no documentation directing the patient to [Tertiary Hospital] for further evaluation or by the SANE nurse or physician.

5. Between 8:50 AM and 9:30 AM on August 31, 2016, an interview was conducted with EMP10 regarding MR1. When asked what the patient's instructions were following discharge, EMP10 stated, "Go to [Tertiary Hospital] to be evaluated by the SANE nurse on call." When asked to clarify if the patient was to present to the ED at [Tertiary Hospital], EMP10 stated, "It says [Tertiary Hospital], I would imagine that it was the emergency room." When asked if the patient was discharged or transferred, EMP10 stated that the patient was transported by private car. EMP10 added, "Generally, when they go by private car, it's not considered a transfer, it's considered a discharge and a readmission." When asked what information from the Warren ED medical record went with the patient, EMP10 stated, "This just shows discharge instructions went with the patient." When asked if there was a physician-to-physician report between the Warren ED physician and a physician at [Tertiary Hospital], regarding the patient, EMP10 stated, "It [medical record documentation] says [he/she] spoke with the SANE nurse at [Tertiary Hospital]. ... [Normally] the physician always speaks with them (physician) ... [EMP10 reiterating documentation in the medical record] 'I discussed the patient with the [Tertiary Hospital] nurse, OTH4 ... and the patient will be seen by the [Tertiary Hospital] SANE nurse on-call.' When again asked if the patient's medical record was sent to [Tertiary Hospital], EMP10 stated, "Not that I can tell from this (MR1)." When asked if there is any type of technological link between the receiving facility physicians and Warren General that enable [Tertiary Hospital] physicians to view the Warren General Hospital medical records, EMP10 stated, "We generally send paper."

6. Between 10:07 AM and 10:30 AM on August 31, 2016, a telephone interview was conducted with EMP1. When asked about [his/her] recollection of the primary case [MR1], EMP1 stated, "I remember it pretty well. We don't see many [age of the patient-pediatric] come through that get assaulted that often." EMP1 confirmed that Warren no longer has SANE nurses. When asked what portion of the examination is done by the ED physician versus the SANE nurse, EMP1 stated, "SANE nurses now do a much better job. ... It's kind of a higher level of care, if you will. ... SANE nurses have a higher level of knowledge at [specimen] collection. ... They dot all the I's and cross all the T's better. ..." When asked if the patient was discharged or transferred to a higher level of care, EMP1 stated, "I called the SANE nurse on duty at [Tertiary Hospital], well the charge nurse on duty that night, was the SANE nurse on duty. ... I asked [him/her] if we should do some specimen collection tonight, or was it something that the pediatric gynecologist could do the following day. ... The recommendation was that [he/she] go to [Tertiary Hospital] that night. The patient was discharged, and arrangements were made for the patient to have a SANE exam that night, in the next couple of hours. ... I can't answer that [transfer versus discharge] any better than that." When asked what information, regarding the patient's care at Warren, was conveyed to [Tertiary Hospital], EMP1 stated, "My evaluation, ... I explained to the nurse that I did a brief external exam. ... I don't think we sent a copy of the lab work, because I don't think that we had it back." EMP1 added, "We took as good of care of that patient as we could. ... I'm confused as to why this has turned into an EMTALA investigation."