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Based on interview and record, the facility failed to perform a medical screening exam (MSE, the initial exam performed when a patient presents to a dedicated emergency department and requests care) for one (1) of 21 sampled patients (Patient 1). Patient 1, who had a possible battery acid splash to the eyes, was brought to the emergency department (ED) via ambulance without having a MSE before being transferred to a different facility (Facility 2).

This deficient practice delayed Patient 1's treatment and had the potential for blindness caused by the possible battery acid splash.

Findings:

On 2/11/2020, the facility was entered, and an entrance conference was conducted with the Director of Performance Improvement (DPI) and the Director of Cardiac Services (DCS). Complaint CA00673705 was identified as an Emergency Medical Treatment and Labor Act (EMTALA, a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay) complaint. The documents to initiate the investigation were requested and the DPI stated that he was aware of the incident and had expected an investigation would be conducted.

Immediately following the entrance conference, the emergency department was toured with the DPI, the DCS, and the emergency room medical director (ERMD 1).

The ERMD 1 stated all patients are triaged (assigned urgency) and assessed (MSE), and stabilized by an ER physician prior to transfer to a different facility.

On 2/11/2020, at 2:30 PM, during an interview with the DPI and concurrent record review of Patient 1's medical record, the DPI stated that there is no documented evidence Patient 1 was triaged. The DPI stated, for Patient 1, the ER doctor should have followed protocol by doing a complete MSE, stabilizing the patient, and have completed a doctor-to-doctor report prior to transfer to Facility 2 but did not.

On 2/12/2020, at 7:30 AM, ERMD 2 stated that Patient 1 was received by ambulance with a possible splash of battery acid to the eyes. ERMD 2 stated that when Patient 1 arrived, the patient complained of severe pain and could not open their eyes. ERMD 2 was concerned that Patient 1 could have corrosive damage to their eyes but was not evaluated or treated because they do not offer ophthalmology (doctor who specializes in eye). ERMD 2 confirmed he did not do a complete MSE. ERMD 2 stated treatment was delayed because a MSE was not performed.

A record review of the medical staff meeting minutes, dated 1/21/2020, indicated Patient 1 was sent to Facility 2 without the proper transfer protocol. The paramedics reported that they were directed by the ED physician to place Patient 1 back in their ambulance and take her to a "higher level of care."

A review of the facility policy, EMTALA Guidelines, dated 4/27/2017, indicated that all patients presenting to the facility will receive a MSE by a physician with documentation on the medical record.

A review of the policy, Transfer of Patient to Outside Facility, dated 7/25/2018, indicated that the facility will follow EMTALA protocols for appropriate patient medical screening examination, treatment, stabilization and safe transfer to another facility. The policy indicated that for all transfers, a receiving physician must be identified and his/her agreement to accept the patient must be obtained.

Based on interview and record, the facility failed to provide stabilizing treatment (to provide medical treatment of the condition as may be necessary to assure that no decline of the condition is likely to result from or occur during the transfer) for one (1) of 21 sampled patients (Patient 1). Patient 1, who had possible battery acid splash to the eyes, was brought to the emergency department (ED) via ambulance without first having their condition stabilized (having the eyes cleansed) before being transferred to a different facility (Facility 2).

This deficient practice delayed Patient 1's treatment and had the potential for blindness caused by the possible battery acid splash.

Findings:

On 2/11/2020, the facility was entered, and an entrance conference was conducted with the Director of Performance Improvement (DPI) and the Director of Cardiac Services (DCS). The complaint # CA00673705 was identified as an Emergency Medical Treatment and Active Labor Act (EMTALA) complaint. The documents to initiate the investigation were requested and the DPI stated that he was aware of the incident and had expected an investigation would be conducted.

Immediately following the entrance conference, the ED was toured with the DPI, the DCS and the Emergency Room Medical Director (ERMD 1).

The ERMD 1 stated all patients are triaged (assigned urgency) and assessed by completing a medical screening exam (MSE, the initial exam performed when a patient presents to a dedicated emergency department and requests care) and stabilized by an ER physician prior to transfer to a different facility.

On 2/11/2020, at 2:30 PM, during an interview and concurrent record review, the DPI stated that there is no documented evidence Patient 1 was triaged. The DPI stated, for Patient 1, the ER doctor should have followed protocol by doing a complete MSE, stabilizing the patient, and have completed a doctor-to-doctor report prior to transfer to Facility 2 but did not.

On 2/12/2020, at 7:30 AM, ERMD 2 stated that Patient 1 was received by ambulance with a possible splash of battery acid to the eyes. ERMD 2 stated that when Patient 1 arrived, the patient complained of severe pain and could not open their eyes. ERMD 2 was concerned that Patient 1 could have corrosive damage to their eyes but was not evaluated or treated because they do not offer ophthalmology (doctor who specializes in eye). ERMD 2 admitted Patient 1 could have been stabilized by washing the eyes but did not; washing the eyes could prevent further corrosive damage. ERMD 2 stated that the facility's lack of ophthalmology is not a reason to have not assessed or washed Patient 1's eyes.

A review of the policy, Transfer of Patient to Outside Facility, dated 7/25/2018, indicated that the facility will follow EMTALA protocols for appropriate patient medical screening examination, treatment, stabilization and safe transfer to another facility. The policy indicated that for all transfers, a receiving physician must be identified and his/her agreement to accept the patient must be obtained.

36206

Based on interview and record review, the facility failed to ensure an appropriate transfer for one (1) of 21 sampled patients (Patient 1) by, first:

1. triaging (assigning urgency) and stabilizing (to provide medical treatment of the condition as may be necessary to assure that no decline of the condition is likely to result from or occur during the transfer) the patient;
2. ensuring the patient was notified of the risks of being transferred to a different facility (Facility 2);
3. ensuring the receiving facility (Facility 2) had qualified personnel to treat the patient;
4. ensuring the physician notified the receiving physician at Facility 2; and,
5. ensuring the medical record was provided to Facility 2.

Patient 1, who had possible battery acid splash to the eyes, was brought to the emergency department (ED) via ambulance without being triaged (assign urgency), fully assessed with a medical screening exam (MSE, the initial exam performed when a patient presents to a dedicated emergency department and requests care), and having their condition stabilized (having the eyes cleansed) before being transferred to another facility (Facility 2).

This deficient practice delayed Patient 1's treatment and had the potential for blindness caused by the possible battery acid splash.

Findings:

A review of Patient 1's history of present illness note, dated 1/5/2020 and timed at 3:27 AM, indicated Patient 1 was brought to the ED by paramedics because Patient 1 had a battery plugged into a charger when it exploded in her face and she got battery acid in her eyes. Patient 1 stated she had severe eye pain and cannot open her eyes due to mild swelling. The physician did not believe the patient could be served well in this hospital and needed an ophthalmologist (eye doctor) for proper assessment and treatment. The physician called and spoke to Facility 2's base command, who stated if the paramedics were willing that they could take patient to Facility 2's emergency room. Full assessment not performed and proper eye exam not possible. Patient 1 was transferred to a short-term hospital.

On 2/11/2020, at beginning at 11:26 AM, during the tour of the emergency department (ED) and a concurrent interview with the emergency room medical director (ERMD 1), ERMD 1 stated, for a facility-to-facility transfer of patients, the patient must be stabilized prior to transfer. The receiving physician must accept the patient through physician to physician communication. In addition, a transfer form would be completed by the physician indicating the reason for the transfer and signed by the patient. ERMD 1 stated medical records would also be sent to the receiving hospital.

On 2/11/2020, at 2:19 PM, during an interview with the Director of Performance Improvement (DPI) and concurrent record review of Patient 1's Medical Record, the DPI stated Patient 1 arrived at the ED on 1/5/2020 by ambulance after a battery connected to a charger exploded in Patient 1's face. The DPI stated Patient 1 was not triaged. According to the records, Patient 1 was transferred to Facility 2 because their ER did not provide services for the eye. The DPI stated there was no documented evidence Emergency Room Doctor 2 (ERMD 2) communicated with the receiving physician at Facility 2, documented the reasons for transfer, copied the medical record for Facility 2, signed an acknowledgement of transfer, and explained the risk and benefits of transfer to Patient 1.

On 2/12/2020, at 7:19 AM, during an interview with ERMD 2, ERMD 2 stated that the ER was notified that Patient 1 was being brought to the ER with a possible corrosive (damage or destroy) eye injury from a battery explosion to the face. ERMD 2 that when Patient 1 arrived, he tried to evaluate Patient 1 by opening her eyes. ERMD 2 suspected corrosive damage because Patient 1 was not able to open her eyes. ERMD 2 instructed the paramedics to take Patient 1 to the other facility (Facility 2) if they were willing. ERMD 2 stated he did not communicate with the receiving physician at Facility 2. ERMD 2 stated Patient 1 was transferred to Facility 2 without triaging, assessment (MSE), and stabilization.

On 2/12/2020, at 7:30 AM, ERMD 2 stated there was no verification that Facility 2 had ophthalmology (diagnosis and treatment of eye disorders) care available. ERMD 2 admitted Patient 1 could have been stabilized by washing the eyes but did not; washing the eyes could prevent further corrosive damage. ERMD 2 stated that the facility's lack of ophthalmology is not a reason to have not assessed or washed Patient 1's eyes.

On 2/11/2020, at 2:30 PM, during an interview with the DPI and concurrent record review of Patient 1's medical record, the DPI confirmed there was no admission documentation, no insurance documentation, and no consent to treat. The DPI also confirmed the facility's ED Transfer Form, Transfer Consent Form, and Patient's Rights Acknowledgement form was not completed prior to transfer to Facility 2.

A review of the policy and procedure, Transfer of Patient to Outside Facility (Interfacility), dated 4/12/2017, indicated this policy establishes the following protocols for appropriate patient medical screening examination, treatment, stabilization and safe transfer to another facility.

The procedure includes:
1. The physician will indicate the patient's destination, and in consultation with the patient's nurse, determine the level of transportation service required.
2. The physician is responsible for informing the patient and /or patient representative agent of the transfer/transport plan, including risks and benefits.
3. For all transfers, a receiving physician must be identified and his/her agreement to accept the patient must be obtained.
4. A transfer will not be processed without acceptance by the receiving facility or without insurance company approval.

In addition, patients transferred or transported to another acute care facility, to an extended care facility, or to another service provider will have a copy of their medical record sent with them.

A review of Patient 1's medical record from Facility 2 indicated that Patient 1 arrived to the ED department at Facility 2 on 1/5/2020 and seen by a physician at 4:07 AM. Upon arrival, Morgan lenses (plastic lenses inserted into the that allow cleansing of the eye) were inserted into Patient 1's eyes. The physician flushed Patient 1's eyes with 1 liter of lactated ringers solution (solution that may help the body neutralize acid). Patient 1 was discharged home with follow-up with her primary care provider (PCP).