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Based on the review of the Fire Rescue report, letter to Fire Captain, hospital license, written statement, and policies and procedures and interviews by physicians and staff, the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's Emergency Department to determine whether or not an emergency medical condition existed for an individual sampled patient (SP #1) of 21 sampled patients who presented to the hospital ' s emergency department with complaints of second degree burns. Refer to findings in Tag A-2406.

Based on the review of the Fire Rescue Report, policies and procedures and interviews, the hospital failed to ensure that 1 of 5 Sampled Patients (SP#1) was provided medical treatment that was within the capacity of the hospital to minimize the risks to the individual ' s health. The facility also failed to ensure that their Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure was followed related to transferring and unstable patient (SP#1) to another acute care hospital for treatment. Refer to findings in Tag A-2409.

Based on the review of the Fire Rescue report, Pre-arrival log, Emergency Department Log, policies and procedures and interview the facility failed to ensure the Emergency Department Log/control register maintained accurate information on each individual who comes to the emergency department seeking assistance and whether he or she refused treatment, was refused treatment, or whether he or she was transferred, admitted and treated, stabilized and transferred, or discharged for 1 of 21 Sampled Patients (SP#1).

The Findings:

Review of Fire Rescue report (dated 7/14/2016) showed Patient: Sampled Patient (SP #1), Complaint: Burns/ Explosion, a 42 year old male, who was rescued on 7/14/2016 for injury: with primary impression as burn. Brief narrative showed that the patient poured lighter fluid on a BBQ and it flashed when lit. Patient sustained 2nd degree burns to lower legs, right forearm, and right hand.

Record review of the Emergency Department (ED) log for the month of July, 2016 in particular on July 14, 2016 showed no evidence that SP#1 was presented and registered in the ED.

Record review showed that the only record related to the July 14th burn case was the Pre- arrival registration log which showed BRAVO-C, Unknown arrived 7/14/2016 at 17:42; Mode of Injury (MOI) - Burn; disposition 07/14/2016 transfer to Hospital #2. There was no name, time of transfer, the date of birth and age was incorrect, and no medical screening was done, but according to the Trauma Medical Director/Trauma Surgeon he did a quick assessment to make sure the patient was stable for transfer. There was no evidence of any clinical records of a medical screening related to SP#1.


Interview with the Emergency Department (ED) Nursing Director on 7/28/16 around 1:30 PM revealed, that SP#1 was not on the main ED log, but listed on the pre-arrival log for ground and air rescue. The ED log should have been updated with correct information, but the incident happened so fast and that the patient was brought in then transferred immediately to hospital #2. There was no opportunity for the ED staff to get the correct patient information.


Review of the policy, " Patient Transfers between the JHS Hospital and Another Hospital " dated: 02/2013 stated at IV. A. 4. All emergency treatment areas are to maintain a record listing each individual who request emergency care and services or on whose behalf such services are requested, for a period of five years. Requested information shall also be included in the patient ' s permanent medical record, if a permanent medical record is created. The record shall indicate, at a minimum: patient's name, age, and sex, date, time and means of patient arrival, nature of complaint, and disposition: patient was transferred, admitted, treated, or stabilized and transferred; and time of departure.

Based on the review of the Fire Rescue report, letter to Fire Captain, hospital license, written statement, and policies and procedures and interviews by physicians and staff, the facility failed to provide an appropriate medical screening examination that was within the capability of the hospital's Emergency Department to determine whether or not an emergency medical condition existed for an individual sampled patient (SP #1) of 21 sampled patients who presented to the hospital ' s emergency department with complaints of second degrees burns.


The findings:

Review of the Fire Rescue report (incident # 6154018), Patient (sampled patient) SP #1), Complaint: 7A3- Burns/ Explosion, showed this is a 42-year-old male, who was rescued on 07/14/2016 for injury: yes; primary impression burn. Brief narrative showed that the patient poured lighter fluid on a BBQ and it flashed when lit. Patient sustained 2nd degree burns to lower legs, right forearm, right hand, approximately 12% (percent) BSA (Body Surface Area). The patient was given 10 mg (milligram) of Morphine sulfate (pain medication) intravenously with little pain relief to burned areas. Transfer date: 2016 -07-14 at 17:47:04 PM. " Jackson Memorial Hospital (Hospital #1) was contacted as the closest trauma center prior to arriving at the LZ (loading zone). Once ARS (Air Rescue Squad) received the pt (patient) from R6. Hospital #1 was contacted once again with more detailed patient information regarding the burn injuries. Hospital #1 received the report and acknowledged the ETA (estimate time of arrival). Upon arrival in the ER the trauma [named] physician advised that hospital #1 was not equipped to handle burns and could we transfer the pt to hospital #2 for burn treatment. Pt was loaded back into ARS for transfer to hospital #2, pt transferred without any incident or change. "

Record review of letter sent by the Captain of the Fire Rescue dated 7/29/2016 at 9:10 AM, subject: Trauma Alert ... Burn patient, 7/14/2016 showed and it read: a trauma alert was declared with hospital #2 as the destination, as they were the closest burn center.
Air Rescue's lieutenant later changed the destination to facility #1. His rationale was that facility #1 was the closest trauma center, irrespective of its burn capabilities dictates that burn patients meeting trauma alert criteria shall be transported to the closest burn center.


Review of the hospital ' s current license effective 07/01/2016 to 6/30/2017 and the current license effective 07/25/2016 to 06/30/2017 showed that " burns " as one of the dedicated emergency department emergency services.


Record review showed that the only record related to the July 14th burn case was the Pre- arrival registration log which showed BRAVO-C, Unknown arrived 7/14/2016 at 17:42; Mode of Injury (MOI) - Burn; disposition 07/14/2016 transfer to Hospital #2 (another acute care hospital). There was no patient name, time of transfer, the date of birth and age was incorrect, and no medical screening was done, but according to the Trauma Medical Director/Trauma Surgeon he did a quick assessment to make sure the patient was stable for transfer.

Phone interview with the Trauma Medical Director/Trauma Surgeon on 7/28/2016 at 11:39 AM revealed that on that day 07/14/16, we received a Trauma/ Burn alert being transported by Air Rescue to our center. We are not a Burn Center and in light of this I tried to redirect the Helicopter Team to bring the patient to the nearest Burn Center Level I Trauma Center (Hospital #2). Unfortunately, the Air Rescue team had already landed so as they presented, I redirected the team after I assured the patient was stable for them to just continue on to Hospital #2 without admitting him to our unit which I felt would be best care for the patient, with the least delay, and ethically the right thing to do. I did not refuse the patient. Since we are new as a Level II Trauma center, there was a lot of confusion about our ability to handle this type of patient. It was unclear to some rescue that we have our limitations as a Level II Trauma Center. Interview in person with the Trauma Surgeon, on August 3, 2016 around 2:30 PM revealed, " when he got the call about the burn (SP #1) Trauma Alert on 7/14/16 he promptly went to the ED and was about to call the Air Rescue and request to divert the patient to the nearest Trauma Burn Center (Hospital #2), but Air Rescue was already in the process of landing. As soon as he saw the patient in the ED's hallway he made a quick assessment of the patient's condition and made sure SP#1 was stable enough to be immediately airlifted again and transferred to the closest Trauma Burn Center without delay. " The Trauma surgeon added that my reasoning was that the patient needed to be rapidly cared for in the facility that was most prepared and capable to treat the severity of the patient's condition. In this case, the patient needed to go to the nearest burn center. There was no need to delay the transfer for another hour when SP #1 can be airlifted and treated immediately thus preventing any deterioration of the condition. The important thing was that the patient was safe. There were really opportunities for improvement learned from this incident. I personally spoke with the Director of (name of) Trauma Center (Hospital #3) at JMH (Jackson Memorial Hospital) main campus and discussed this case. The Trauma Surgeon further stated in part, " Looking back, we should have documented everything we did. " The interviews with the Trauma Medical Director/Trauma Surgeon validated that there was no documented evidence of any clinical records of a medical screening examination being performed by a qualified medical personnel related to SP#1 on 7/14/2016.


Review of a written statement from the Trauma Medical Director/Trauma surgeon dated 7/28/2016 -subject: July redirect to burn Center showed in part, Follow-up statement dated 7/28/2016-1:59 PM subject follow-up on July 14th burn case reads, " I then called our Burn Center at Hospital #3 to inform them of my decision. The recommendations for future patients of this Red Criteria and circumstances is to simply accept, admit the patient and then go through the process of transferring them to our Burn Center if needed since hospital #3 is on the most experienced Burn Center... I also called and followed up with the pre-hospital team leader to discuss future recommendations on the care of Burn patients as to those who meet Burn Trauma criteria and those who do not meet so we are all on the same page. "


Interview conducted with the ED Nursing Director and Associate Director of Quality/Compliance Officer on 7/28/2016 at 10:10 AM confirmed that Hospital #1 has been designated as a Level II Trauma designation. The big difference with Level I Trauma Center was that Level II Trauma -do not have the capability for patients requiring Organized Burn Care or Pediatric ICU (Intensive Care Unit). The Rescue or ambulance are redirected to the closest Level I Trauma Facility (Hospital #2) if still in route.



The Trauma (Registered Nurse) who was working on July 14, 2016 was interviewed on 7/28/2016 between 2:15 PM to 2:40 PM. The Trauma (Registered Nurse) RN#1 stated, in general, the nurse gets the radio report from the radio dispatcher, from the company called MED-COM. According to him no complete information was given; only pre-alert is given stating that ARS is on the way. He did not receive the call. However, according to him he remembered a report was received that day. Estimated Time of Arrival (ETA) was 2 minutes. But they are already there. He does not recall who received the call.

Interview conducted on 07/28/2016 between 2:15 PM to 2:40 PM with Trauma RN#2, it was reported she did not receive the call but she recalled she went to the helipad while other Team members prepared the Trauma room. She also said that the patient was brought down to the ED and didn't make it to the Trauma room. Trauma RN#2 stated further that the Trauma Medical Director/ Trauma Surgeon saw the patient (SP#1) in the hallway enroute to the Trauma room, made a quick assessment of the patient, determined the patient required a Trauma Level I services, and requested Air Rescue to transfer the patient to Hospital #2.


Review of the policy, " Patient Transfers between the JHS Hospital and Another Hospital " dated: 02/2013 state at IV. A. When an individual comes to a JHS Hospital* and a request is made, in any form or manner, by the individual or on the individual ' s behalf for examination or treatment for a suspected emergency medical condition or active labor, the authorized hospital staff, as described in the Medical Staff Bylaws, shall immediately initiate an appropriate medical screening examination to determine whether or not an emergency medical condition or active labor exists. Under H. *note that for patients who came to the hospital seeking medical care for a suspected emergency condition, the emergency care for a suspected emergency condition, the emergency screening examination must be completed prior to making such a determination.

Based on the review of the Fire Rescue Report, policies and procedures and interviews, the hospital failed to ensure that 1 of 5 Sampled Patients (SP#1) was provided medical treatment that was within the capacity of the hospital to minimize the risks to the individual ' s health. The facility also failed to ensure that their Emergency Medical Treatment and Labor Act (EMTALA) policy and procedure was followed related to transferring an unstable patient (SP#1) to another acute care hospital for treatment.

The Findings:



Review of the policy, " Patient Transfers between the JHS Hospital and Another Hospital " date: 02/2013 state at IV. C. 4. General Procedure: for transfer from JHS to another Hospital: The conditions and information as outlined in the Transfer Form (C-210W) must be adhered to in order to transfer a patient to another hospital as outlined in section IV: C.1-IV.C.3 above. Specifically, the sections of the transfer form are: " a. Physician Counseling of the Patient...For all patients, the physician is to document that he/she explained the risks and benefits of transfer to this patient, b. Informed Patient Consent: Written consent for transfer muse be obtained from the patient or person who is legally responsible for the patient ...The consent procedure will include a description of the medical risks and benefits of transfer by the physician, with documentation to be included in the medical record that these have been discussed with the patient if patient ' s legal representative ... c. Reason for transfer that the patient will be transferred is to be indicated. d. Physician Statement Regarding Authorization for Transfer Authorization: The physician ' s statement shall reflect the current status of the patient, following a screening evaluation and indicate whether or not the patient is stable for transfer and whether or not the transfer is authorized. For patients to be transferred with an active emergency medical condition, the PHT attending physician must sign 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 hospital outweigh the increased risks to the individual ' s medical condition from effecting the transfer. The sending physician ' s signature in the Statement Regarding Authorization for Transfer may serve as the physician ' s order for transfer of a patient from JMH to a receiving hospital.; e. preparation for transfer and communication of pertinent medical information: ...(4) For patients originating for transfer from the Emergency Service s area: the transfer Center will assist and confirm arrangements and consent of personnel at the receiving hospital and review the Transfer Form (C-210 W) to make sure it is complete ...F. Transfer Documentation: ... (2) The sending JHS physician shall discuss the transfer with the accepting physician at the receiving hospital. An agreement must be reached that the patient is stable for transfer. The name of the accepting physician will be listed on the transfer form ... (3) When the patient is leaving from the Emergency Services Area, the Transfer Center (or corresponding departments ...) shall verify and document that the receiving hospital and physician have accepted the patient and that a bed is available ... (5) The JHS nurse shall communicate the patients current medical status to the receiving ...hospital. (6) The JHS Hospital Secretary will make copies of the patient ' s medical record and obtain copies of x-rays and lab results. The copy of the medical records will be sent with the patient ... "

Review of Fire Rescue report (incident # 6154018), Patient (sampled patient) (SP #1), Complaint: 7A3- Burns/ Explosion, showed this is a 42-year-old male, who was rescued on 07/14/2016 for injury: yes; primary impression burn. Brief narrative showed that the patient poured lighter fluid on a BBQ and it flashed when lit. Patient sustained 2nd degree burns to lower legs, right forearm, right hand, approximately 12% (percent) BSA. Transfer date: 2016 -07-14 at 17:47:04 PM. The hospital #1 was contacted as the closest trauma center prior to arriving at the LZ (loading zone). Once ARS received the pt (patient) from R6. Hospital #1 was contacted once again with more detailed patient information regarding the burn injuries. Hospital #1 received the report and acknowledged the ETA (estimate time of arrival). Upon arrival in the ER the trauma [named] physician advised that hospital #1 was not equipped to handle burns and could we transfer the pt to hospital #2 for burn treatment. Pt was loaded back into ARS for transfer to hospital #2, pt transferred without any incident or change. There was no evidence of any clinical records from Hospital #1 that a medical screening examination was performed on 7/14/2016 for SP#1.




Phone interview with the Trauma Medical Director/ Trauma Surgeon on 7/28/2016 at 11:39 AM revealed that on that day 07/14/16, we received a Trauma/ Burn alert being transported by Air Rescue to our center. We are not a Burn Center and in light of this I tried to redirect the Helicopter Team to bring the patient to the nearest Burn Center Level I Trauma Center (Hospital#2). Unfortunately, the Air Rescue team has already landed so as they presented, I redirected the team after I assured the patient was stable for them to just continue on to Hospital #2 without admitting him to our unit which I felt would be best care for the patient, with least delay, and ethically the right thing to do. I did not refuse the patient. Since we are new as a Level II Trauma center, there was a lot of confusion about our ability to handle this type of patient. It was unclear to some rescue that we have our limitations as a Level II Trauma Center.

Interview conducted on 07/28/2016 between 2:15 PM to 2:40 PM with Trauma RN#2 stated she did not receive the call but she recalled she went to the helipad while other Team members prepared the Trauma room. She also said that the patient was brought down to the ED and didn't make it to the Trauma room. Trauma RN#2 stated further that the Trauma Medical Director/ Trauma Surgeon saw the patient (SP#1) in the hallway in route to the Trauma room, made a quick assessment of the patient, determined that patient required a Trauma Level I services, and requested Air Rescue to transfer patient #SP1 to Hospital #2.



Interview in person with the Trauma Surgeon, on August 3, 2016 around 2:30 PM revealed that "when he got the call about the burn (SP #1) Trauma Alert on 7/14/16 he promptly went to the ED and was about to call the Air Rescue and request to divert the patient to the nearest Trauma Burn Center (Hospital #2) but Air Rescue was already in the process of landing. As soon as he saw the patient in the ED ' s hallway he made a quick assessment of the patient ' s condition and made sure the patient was stable enough to be immediately airlifted again and transferred to the closest Trauma burn center without delay. " There was no need to delay the transfer for another hour when SP#1 can be airlifted and treated immediately thus preventing any deterioration of the condition. The Trauma Surgeon further stated in part, " Looking back we should have communicated to the receiving facility about the transfer. "

The facility failed to ensure that there policy and procedure was followed as evidenced by there was no documented evidence of a written transfer certification that was signed by the ED physician, based upon the reasonable risks and benefits to the patient, and based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another acute care hospital outweighed the increased risks to the individual ' s medical condition from effecting the transfer. There was no documented evidence that the ED nurse had communicated with the receiving hospital regarding the medical status of SP #1 on 7/14/2016. There was also no documented evidence that the physician discussed SP#1 ' s care to an accepting physician and to obtain acceptance of the patient on 7/14/2016. As this resulted in an inappropriate transfer for SP#1.