HospitalInspections.org

Based on policy review, medical record review, hospital data review and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

1. The hospital failed to ensure a timely medical screening examination was provided that was within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 6 sampled patients (Patient #7 and Patient #8).

~cross refer to Tag A2406

2. The hospital transferred a patient to another hospital when the transferring hospital had capacity and capability to manage the patient for 1 of 2 transferred patients (Patient #4).

~cross refer to Tag A2409

Based on policy and procedure review, medical record review, Emergency Medical Services (EMS) report, and staff and physician interviews, the hospital staff failed to ensure a appropriate medical screening examination was provided within the capability of the hospital's Dedicated Emergency Department (DED) including ancillary services routinely available to the emergency department to determine whether or not an emergency medical condition existed for 2 of 6 sampled patients (Patient #8 and Patient #7).

The findings included:

Review of the Hospital policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Policy" with an effective date of 11/17/2020 revealed "... to provide all services required by EMTALA ... 1. To determine whether an emergency medical condition exists by providing a Medical Screening Examination by a physician or other Qualified Medical Person to any individual ... to determine if the individual has an Emergency Medical Condition, ... 2. If it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of (Initials of Hospital), or to arrange for transfer of the individual to another medical facility in accordance with the procedures ... A. Medical Screening Examination ... 2. An individual who presents anywhere on Medical Center Property ...and seeks treatment for a potential Emergency Medical Condition is immediately transported ... for a Medical Screening Examination and necessary stabilizing treatment ... 4. the Medical Screening Examination is an ongoing process. The patient's medical record reflects continued monitoring according to the patient's needs and continues until it is determined whether or not the individual has an Emergency Medical Condition and, if he or she does, until he or she is stabilized or appropriately transferred. ..."

1. Review on 11/17/2021 of the Stokes County EMS Report dated 08/20/2021 at 1617 revealed " ... Dispatched to private residence in reference to a behavioral problem ...59 year old female was found standing outside, Pts family informed she has been drinking and is having a psy (psychiatric) issue. Pt has previous Hx (history) of same. Pt informed she hasn't been eating or taking her meds because she thinks someone has been messing with them. Pt was placed on the monitor, Vitals were obtained ...Pt complained of nausea during transport but denied any other complaints. IV (intravenous) was established. Zofran was given for nausea ... Pt was transported ... Pt was taken via wheelchair to triage, report was given to Registered Nurse (RN), signatures obtained ... EMD Complaint: Psychiatric Problem/Abnormal Behavior/Suicide Attempt ... Patient Transferred: 1705 ... Condition of Patient at Destination: unchanged."

Review of a closed DED medial record on 11/17/2021 for Patient #8 revealed a 59- year-old female that presented to Hospital A's DED (dedicated emergency department) on 08/20/2021 at 1705 via EMS (emergency medical services) with a chief complaint of "Psych Eval." Review of vital signs documented at 1712 revealed a temperature (Temp) 98.1 degrees Fahrenheit; pulse 82; respirations (Resp) 18; blood pressure (BP) 157/83; and oxygen saturation (SpO2) 94%. Review of the Triage Note at 1713 revealed "Pt (patient) arrived via ems (emergency transport) with complaints of taking her medications on an empty stomach and now is nauseated and vomiting. Per EMS pt stated that she thought people were trying to poison her. Pt denies SI/HI (suicidal ideation/homicidal ideation)." Review revealed at 1715 Patient #8 was assigned an ESI acuity of 4 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of Physician Assistant (PA) #1's medical screening examination dated 08/20/2021 at 1930 revealed "Patient placed in First Look pathway, seen and evaluated for chief complaint of poor oral intake ... Patient states she does not feel like she can pass out but will not elaborate. Patient denies SI/HI (suicidal ideation/homicidal ideation) ... ROS (review of systems): + (positive): nausea, emesis (vomiting), decreased appetite ...Exam: Alert and oriented, NAD (no acute distress), tolerating secretions without difficulty, respirations, are unlabored." Review of the CBC (complete blood count) and Differential Resulted at 2021 revealed an "Abnormal Result ... RBC (red blood cell): 4.05 [Ref (reference) Range: 4.10-5.10] ..." Review of the Comprehensive Metabolic Panel Resulted at 2048 revealed an "Abnormal Result ... Sodium: 134 [Ref Range: 135-146] ... BUN (blood urea nitrogen): 7 [Ref Range: 8-24] ... Glucose: 103 [Ref Range: 70-99]; Creatinine: 0.48 [Ref Range: 0.50-1.50] ..." Review of vital signs documented at 2131 revealed a Temp (temperature) 97.5 degrees Fahrenheit; pulse 72; Resp (respirations) 17; BP (blood pressure) 154/77; and SpO2 (oxygen saturation) 97%.." Review of the Medication Administration Record (MAR) revealed Patient #8 received Zofran (medication to treat nausea) 4 mg (milligrams) disintegrating (dissolving) tablet on 08/21/2021 at 0018. Review of the ED Provider note at 0402 revealed " ... Chief Complaint: Patient presents with *Psychiatric Evaluation ... with PMHx (past medical history) significant for anxiety, hypertension (high blood pressure), depression, schizoaffective disorder (mental health disorder) who presents to (Facility A's name) Emergency Department with nausea, vomiting and poor p.o. intake. Patient endorses mild nausea and decreased p.o. intake over the past few days. She has not had any fever or chills. Her symptoms are worse when she takes her medications on an empty stomach. She feels dehydrated ...The patient denies any SI, HI, or AVH (auditory visual hallucinations) ... Review of Systems: Gastrointestinal: Positive for nausea and vomiting. Negative for abdominal pain and diarrhea; ... Neurological: Positive for light-headedness. Negative for headaches; Psychiatric/Behavioral: Negative ... Mental Status: She is alert and oriented to person, place, and time ...MDM (medical decision making): ... ambulatory in the emergency department and tolerating p.o. intake ... was rehydrated with a 1 L (liter) LR (lactated ringers) bolus ... was administered Zofran for nausea ... patient was cleared for discharge ...Prior to discharge, the patient began to state that she could not walk and could not move her legs. She states that she has a history of transverse myelitis (inflammation of both sides of one section of the spinal cord and interrupts the messages the spinal cord nerves send throughout the body and can cause pain, muscle weakness or paralysis) and MS (Multiple sclerosis - disease where the immune systems eats away at the protective covering of the nerves in the body resulting in damage and disruption of communication between the brain and the body). The patient has a significant behavioral health history ... the patient saw neurology regarding some the (sic) symptoms in 2015. Per the neurology note, ' ...patient does NOT have MS ... patient does appear to have a history of transverse myelitis in 2007 ... appears to be a clinically isolated syndrome fat (sic) did not progress into an active demyelinating disease (damage to the protective covering that surrounds the nerves in the brain)... does have 2 small white matter lesions on her brain, but this is in a location that it would be atypical for demyelinating disease does not appear to have changed or progressed.' The patient has no neck or back pain. She has no fecal or urinary incontinence. She is ambulatory with a steady gait. I suspect likely malingering (falsification or profound exaggeration of illness to gain external benefits) due to secondary gain at this time as the patient refused to leave the emergency department when informed of discharge ... 1. Nausea and vomiting, intractability (hard to control) of vomiting not specified, unspecified vomiting type ... ED Disposition: Discharge ... home/self care." Review of the MAR revealed Patient #8 received a bolus of 1,000 mL (milliliters) of Lactate Ringers at 0508. Review of vital signs documented at 0510 revealed a Temp 98 degrees Fahrenheit; pulse 65; BP 158/77; and SpO2 of 95%. Review of the ED Notes at 0510 revealed "Patient appears to be shaky MD aware." Review of vital signs documented at 0545 revealed a SpO2 pulse 71; BP 153/81; and SpO2 of 94%. Review of the ED Timeline revealed at 0555 the AVS (after visit summary) was printed. Review of the MAR revealed Patient #8 received Zofran 4 mg intravenous injection. Review of the ED Notes at 0620 revealed "Patient said she's still feeling unwell like passing out. MD aware." Review of the Adult Assessment performed by a RN at 0622 revealed " ... Gastrointestinal (WDL [within desired limits]): Exception to WDL; GI Symptoms: Vomiting; Nausea; Psychosocial (WDL): Exceptions to WDL; Patient Behaviors: Appropriate for situation; Anxious."Review of the Orthostatic VS (vital signs) Lying at 0653 revealed "Patient Position: Lying; Pulse: 70; BP: 148/71." Review of the Orthostatic VS Standing at 0654 revealed "Patient Position: Standing; Pulse: 71; BP: 171/88." Review of the ED Timeline at 0707 revealed "Departure Condition: Stable; Mobility at Departure: Wheelchair; ... Departure Mode: By self; Time Patient Departed ED: 0708." Review for the ED Notes at 0708 revealed "AVS (after visit summary) given to the patient. Patient is refusing to leave. MD went to speak to her by the bedside. Security were called to assist, social worker informed for transportation." Review of the Nursing/Ancillary Note dated 08/21/2021 at 0709 revealed " ... Discharge Transport: Bus ... This writer received a call from (Nurses name), RN requesting a cab for patient as patient was refusing to discharge and reports that she does not want to take a bus because she is drowsy ... met with patient in the ED lobby and she reports ... that she cannot see or walk. She reports that she needs a wheelchair. Patient reports that she does not have keys to get into her house and that they are at her brother's house and she does not have his phone number. She reports that she has a son in (City Name) that does not drive. This writer asked if she could call the son and perhaps he can call the brother for a ride and she reports that her son will not answer his phone ... spoke with (Provider Name) ...This writer reported what patient has said and she reports patient is able to walk and can be responsible in finding her ride or way home ... This writer met with patient in ED lobby and spoke to patient again. Patient told this writer that someone has been breaking into her house and taking medications from her and she reports she has spoken to the cops about it but they did not take the medications. This writer spoke to patient about follow-up mental health services and provided information for Daymark and Monarch. Patient is refusing to leave and at this time security approached ... Patient again asked this writer to 'call someone' for her and when the writer asked who she would like to call the patient reports she does not know. Patient continues to say that she cannot walk and needs a wheelchair and assistance and this writer informed her that the provider has cleared her for discharge and reports that she is ambulatory. This writer provided patient with a bus pass and security stepped in to work with patient at that point. Case Closed."

Review revealed Patient #8 was discharged on 08/21/2021 at 0709. Review of the Care Coordination Update note dated 08/21/2021 at 1702 revealed " ... A police officer reported ... that patient's mother had called reporting that she could not find her daughter. Officer asked ... if we had any idea where patient was headed when they left the ED. This writer reported to the officer that the last time she made contact with patient was in the ED lobby and a bus pass was provided to her ... had spoke to her (Patient #8) about Daymark services and how they accept walk-in patients seeking mental health and substance abuse treatment ...officer ...had made contact with patient's son ...this writer informed office (sic) that the patient had mentioned she has a brother in (City Name). The officer reports he may go check Daymark to see if patient is there and be thorough before filing a missing person report."

Telephone interview on 11/17/2021 at 1426 with Medical Doctor (MD) #2 revealed he remembered Patient #8. Interview revealed Patient #8 "initially came into the ED for Neuro (neurology) concerns and subsequent nausea and vomiting from taking medication on an empty stomach." Interview revealed there were no focal deficits which ruled out "could not walk". Interview revealed MD #2 put the "old Neuro note in the system" into his note. Interview revealed there "was concern about walking and MS episode and we focused on that aspect." Interview revealed Patient #8 "made a few bizarre statements" but there was "no concern at that time." Interview revealed Patient #8 was experiencing delusions at the time but not enough for acute hospitalization. Interview revealed Patient #8 was screened for SI, HI, and acute psychosis and did not go any further into Patient #8's bizarre behaviors. Interview revealed MD #2 did not document his psychological exam because of the reason Patient #8 presented for. Interview revealed MD #2 states he performed a psychological exam and thinks his evaluation documentation could have been better as he did not document the psychological exam. Interview revealed MD #2 did not order a psych (psychiatry) consult as Patient #8 was admitted in 07/2021 with the psych team and was given resources in the community. Interview revealed Patient #8 "was willing to discharge." Interview revealed "Daymark was recommended because of (Patient #8's) history of schizophrenia." Interview revealed hospital security was contacted to assist as Patient #8 was refusing to leave. Interview revealed MD #2 had addressed concern from a neurological standpoint and Patient #8 was discharged.

Telephone interview on 11/17/2021 at 1455 with Registered Nurse (RN)#3 revealed he did not remember Patient #8. Interview revealed when a patient is brought in by EMS, report is given by the EMS staff to the ED nurse. Interview revealed when a patient refuses to leave RN #3 would talk with the patient to find out why and what is going on that they are refusing to leave. Interview reveals RN #3 relays that information to the provider and documents it in the medical record. Interview reveals RN #3 would explain to the patient that the MD had discharged them and if the patient still refuses to leave, RN #3 would contact security to get involved and assist with the patient refusing to leave.

Telephone interview on 11/17/2021 at 1534 with Physician Assistant (PA) #4 revealed he was the "First Look Provider" on 08/20/2021. Interview revealed PA #4 did not remember Patient #8. Interview revealed PA #4 does "not take report from EMS, the nurse does." Interview revealed PA #4 assesses the patient and starts the orders for the patient in First Look. Interview revealed PA #4 was unable to say if he saw the nurse's note or chief complaint for Patient #8.

Interview on 11/17/2021 at 1549 with MD #5 revealed the "nursing chief complaint is categorical variable, they pick from a drop-down box." Interview revealed "reasons to get psych involved" are if "harm to self, harm to others or cannot care themselves." Interview revealed there are people out there that have psych problems that are not contributory to reason they came into the DED based off their MSE. Interview revealed the impression from the physician team, Patient #8 came in for "nausea and vomiting" from taking her medication on an empty stomach. Interview revealed there is a "difference from psych disease vs (verses) psych emergency." Interview revealed psych disease can "utilize community resources vs hospital." Interview revealed "there are circumstances when a patient can have psych emergency that is not related to SI or HI. Patient can be delusional and still be safe for discharge also." Interview revealed there are "limited resources" in the ED to get patients set up for follow up outpatient care regardless of the pathology. Interview revealed there is a social worker assigned to the ED to assist/arrange patient needs. Interview revealed the social worker based on their "clinical judgement would make and provide resources in community" to patients. Interview revealed "the clinical judgement is based off the patient's behavior at the time."

Telephone interview on 11/18/2021 at 1133 with MD #6 revealed she supervised Patient #8's ED visit on 08/20/2021. Interview revealed Patient #8 presented with a chief complaint of "nausea and vomiting and decreased intake." Interview revealed Patient #8 was evaluated for those complaints. Interview revealed MD #6 was not sure she was aware that Patient #8 came in via ambulance with a complaint of psychiatric evaluation. Interview revealed the triage nurse would have gotten report from EMS and entered the chief complaint in the medical record. Interview revealed MD #2 "asked if any SI, HI, or auditory visual hallucinations." Interview revealed Patient #8 was having delusions at the time she was being seen. Interview revealed Patient #8 was "odd" acting. Interview revealed an example was "at one point she rolled over" said she "needed to sleep" and when asked how else we could help, she replied she "needed someone to cook and clean for her." Interview revealed Patient #8 was "fairly cooperative until discharge." Interview revealed when Patient #8 was being discharged, Patient #8 said she could not be discharged because she could not walk, and she had transverse myelitis and/or MS. Interview revealed that MD #2 had reported he had seen Patient #8 ambulate to the bathroom and back with a steady gait. Interview revealed "all patients get a psychiatric evaluation performed by a nurse." Interview revealed "sometimes a patient with psychiatric evaluations as chief complaint will tell they are being seen for a psychiatric issue and sometimes they will not." Interview revealed MD #6 looks at if the patient is "imminently in danger" such as "active suicidal with plan, active homicidal with a plan, hallucinations with command voice telling to kill self or others, or inability to care for self." Interview revealed patients can have mental illness that does not constitute a medical emergency.

Telephone interview on 11/18/2021 at 1439 with RN #7 revealed she did not remember Patient #8.

Review of a closed DED medical record on 11/22/2021 for Patient #8 revealed a 59- year-old female that presented to Hospital B's DED on 08/30/2021 at 1621 (8 days 9 hours and 12 minutes after Facility A's ED visit) via EMS (emergency medical services) with a chief complaint of "AMS (altered mental status)." Review of the ED Timeline revealed Patient #8 was discharged out of the hospital DED system on 09/01/2021 at 1017.

2. Review of a closed DED medial record on 11/23/2021 for Patient #7 revealed a 30-year-old male that presented to Hospital A's DED on 08/04/2021 at 0316 (visit #1) with a chief complaint of "Psychiatric Evaluation". Review of the ED Timeline revealed at 0318 "Arrival Complaint: medication refill" and then at 0323 after Triage started revealed "Chief Complaints Updated: Psychiatric Evaluation." Review of Vital Signs at 0324 revealed "Temp: 99.5 degrees Fahrenheit; Pulse: 134; Resp: 24; BP: 149/101; SpO2: 100%; Pain Scale: 8-eight (severe); Pain Type: Acute pain; Pain Descriptors: Aching; Pain Location: Back ..." Review of the ED Triage note at 0325 revealed "Pt to ER (emergency room) for refill of gabapentin, lithium, Seroquel, and visteral. (sic) Pt denies SI/HI. Out of meds for a few weeks. Denies drug use tonight. Tachycardic in triage a 135. Review revealed at 0339 Patient #7 was assigned an ESI acuity of 3 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of the ED Timeline revealed at 0330, Patient Roomed in ED was set to "To room Results Pending." Review revealed at 0718 ED Disposition set to Left Without Being Seen.

Review of a closed DED medical record on 11/23/2021 for Patient #7 revealed a 30-year-old male that presented on 08/06/2021 at 1639 (visit #2) with a chief complaint of "Level 1 Pedestrian Struck." Review revealed at 1647 Patient #7 was assigned an ESI acuity of 1. Review of the vital signs at 1700 revealed "Pulse: 89; Resp: 13; BP: 159/130." Review of the Trauma Level/Details/Pre-Hospital (sic) at 1723 revealed " ... Mode of Arrival: EMS; ... Describe Details: Jump off a bridge and hit by a pick up truck ..." Review of the Trauma Consult note dated 08/06/2021 at 1727 revealed "Patient presented s/p (status post) jump off a bridge and struck by motor vehicle ...Plans to admit to the TICU (trauma intensive care unit) for close monitoring and continued management." Review of the ED Timeline revealed Patient #7 was admitted to the inpatient unit from the ED at 1936. Review of the Discharge Summary dated 08/17/2021 at 1720 revealed "Acute Surgery Discharge: Deceased; ... Hospital Course: Patient is a 30-year-old male who presented after jumping off a bridge and being struck by motor vehicle ... Patient continued to undergo extensive work-up from the appropriate medical teams including multiple orthopedic surgeries and a bolt placed by neurosurgery. After an extended period of time with aggressive medical and surgical management the patient was noted to not be progressing. Hospital course was further complicated by MRSA (methicillin-resistant Staphylococcus aureus - tough bacteria infection hard to treat due to common medications do not work to treat) pneumonia treated with appropriate antibiotics, the need for pressors (medication used to raise the blood pressure), and elevated ICPs (increased intracranial pressure-pressure around the brain). After numerous extensive conversations between the family and the treatment team as well as supportive staff including supportive care nursing and palliative, the family decided to transition the patient to comfort care. Pt was compassionately extubated. . ." Review revealed Patient #7 expired on 08/17/2021 at 1709.

Interview on 11/17/2021 at 1549 with MD #5 revealed the "nursing chief complaint is categorical variable, they pick from a drop-down box." Interview revealed "patient came in needing medications refilled." Interview revealed patients with "Acute SI/HI go in the hallway as the result pending area (area in the ED behind triage) is staffed 12-14 hours a during the day and most likely not open at 0300 when the patient presented." Interview revealed it was a terrible tragedy. Interview revealed "based off documentation it was ok to put the patient in the waiting room." Interview revealed DED patients get "tracker" badges. Interview revealed this tracker badge is a "neat little gadget" that allows staff to know the patient's location while in the DED. Interview revealed MD #5 could not confirm if every patient that presented to the DED received a tracker.

The patient did not receive an appropriate medical screening exam during DED visit #1. There was no discussion regarding the risks of leaving, or an assessment of the patient's capacity to leave without treatment.

Based on policy and procedure review, medical record review, hospital data review and staff and physician interviews, the hospital transferred a patient to another hospital when the transferring hospital had capacity and capability to manage the patient for 1 of 2 transferred patients, (Patient #4).

The findings included:


Review of the Hospital policy titled "EMTALA (Emergency Medical Treatment and Labor Act) Policy" with an effective date of 11/17/2020 revealed "... to provide all services required by EMTALA ... 2. If it is determined that the individual has an Emergency Medical Condition, to provide the individual with such further medical examination and treatment as required to stabilize the Emergency Medical Condition, within the capability of (Initials of Hospital), or to arrange for transfer of the individual to another medical facility in accordance with the procedures ... B ... 1. When a physician or Qualified Medical Person determines as a result of a Medical Screening Examination that the individual does not have an Emergency Medical Condition, the individual may be transferred to another medical facility (if in need of further care) or discharge ..."

Review of a closed DED medial record on 11/23/2021 for Patient #4 revealed a 68-year-old male that presented to Hospital A's DED on 07/01/2021 at 0758 with a chief complaint of "right leg pain." Review of the Vital Signs at 0806 revealed "Temp: 99.5 degrees Fahrenheit; Pulse: 79; Resp: 16; BP: 144/63; SpO2: 100%; ... Pain Assessment: Numerical (0-10) Pain Scale; Pain Score: 10-Ten (severe)." Review of the ED Triage note at 0806 revealed "Endorses right leg pain x 2 days without injury. Reports the pain began on the medial aspect of his foot and now extends all the way up his leg to his knee." Review revealed at 0808 Patient #4 was assigned an ESI acuity of 3 (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). Review of the XR (x-ray) Ankle Right ... resulted at 0918 revealed "Impression: 1. No acute fracture or malalignment. 2. Soft tissue swelling of the ankle. 3. Vascular calcifications." Review of the XR Knee Rt (right) 3 Views ... resulted at 0920 revealed "1. No acute fracture or malalignment. 2. Total knee arthroplasty without complication. 3. Small joint effusion with intra-articular debris. 4. Vascular calcifications." Review of the Adult Assessment performed by a RN at 0941 revealed " ... Musculoskeletal (WDL): (right foot pain with radiation into right lower leg without known injury. PMS [pulse, motor, and sensory] intact distally.)" Review of the Vital Signs at 0950 revealed "SpO2 Pulse: 81; BP: 136/60; SpO2: 94%." Review of the MAR revealed Patient #4 was administered prednisone 60 mg (milligram) tablet (steroid medication) at 1042 and Norco 5-325 mg tablet (pain medication) at 1129. Review of the Hematology Consult note dated 07/01/2021 at 1141 revealed "Chief Complaint/Reason for Consult: hemophilia A (bleeding disorder), swollen joint ... Diagnosis: Moderate factor VIII deficiency; Discussion: Atraumatic onset of progressive swelling and hemophilia a patient. Historically his baseline factor VIII is approximately 20 to 30%. Factor VIII level today in emergency room is 38. We would favor replacement of factor for approximately 3 days to be cautious given that this is an atypical location for gout flare and his symptoms have been progressive to now struggle with weightbearing. The national recommendations for joint hemarthroses in the setting of hemophilia is to maintain factor VIII levels between 40 and 60% for 2 to 3 days. Based off his baseline factor today we would recommend Advate ~ 1300 units daily starting today and ending on Sunday (sic). This is expected to raise his percent factor to between 60 and 70%. Patient can use his home supply of Advate. Plan: --Hematology has placed a one-time order for administration of 1300 units of Advate. This can be of patient's home supply. -Please leave PIV (peripheral intravenous line) access at time of discharge so that patient can continue to administer Advate at home. -We recommend redosing every 24 hours 1300 units of Advate with last does given on Sunday (sic), 7/4/2021 - Pain control per emergency room provider. - We will arrange follow-up in the next 1 to 2 weeks to assess symptoms." Review of the Hematology Consult note attestation signed on 07/02/2021 at 0948 revealed " ...Right ankle swelling and pain which is concerning for hemarthrosis. There is bruising around the medial ankle and developing on the dorsal aspect of the right foot at the base of the 2nd-4th digits. He received a single dose of factor VIII replacement and already feels this is better. We have recommended that he continue with daily home FVIII infusions at approximately 1300 units IV (intravenous) through the weekend. We will arrange additional factor delivery to keep on hand ..." Review of the Vital Signs at 1219 revealed "Temp: 97.6 degrees Fahrenheit; Pulse: 79; Resp: 16; BP: 103/70; SpO2: 94%;" Review of the POCT Glucose Resulted at 1226 revealed an "Abnormal Result ... Glucose ... 124 [Ref (reference) Range: 70-99]." Review of the Pain Assessment at 1236 revealed Pain Assessment: Numerical (0-10) Pain Scale; Pain Score: 5-Five (moderate)." Review of the Factor VIII Assay Resulted at 1350 revealed an "Abnormal Result ... Factor VIII Assay 38% [Ref Range: 50-200]." Review of the Vital Signs at 1402 revealed "SpO2 Pulse: 86; BP: 112/50; SpO2: 91%." Review of the ED Notes at 1424 revealed "O2 sat (oxygen saturation) 84-89% on RA (room air). (Provider name) to bedside. Pt placed on 2L O2 via NC (nasal cannula). O2 sat 94% at this time." Review of the MAR (medical administration record) revealed at 1459 Advate 1,300 Units from Patient #4's home supply was administered intravenously. Review of the Vital Signs at 1600 revealed "SpO2 Pulse: 75; BP: 117/52; SpO2: 97%." Review of the Pain Assessment at 1617 revealed Pain Assessment: Numerical (0-10) Pain Scale; Pain Score: 3-Three (mild)." Review of the Vital Signs at 0806 revealed "SpO2 Pulse: 75; BP: 134/72; SpO2: 96%." Review of the Vital Signs at 1800 revealed "SpO2 Pulse: 78; SpO2: 92%; O2 Device: None (Room air)." Review of the ED Note at 1809 revealed "Noted O2 sat to be 88 on RA while pt is awake. Placed pt on 2L NC at this time saturation rose to 94-97%. (Provider name) notified." Review of the Pain Assessment at 1814 revealed "Pain Assessment: Numerical (0-10) Pain Scale; Pain Score: 3-Three (mild)." Review of the Vital Signs at 1856 revealed SpO2 Pulse Rate: 83; SpO2: 99%; O2 Device: Nasal Cannula; O2 Flow Rate (L/min): 2 L/min." Review of Physician Orders revealed an order placed at 1915 for "ED Consult to Internal Medicine." Review revealed there was no consult note from Internal Medicine at Facility A. Review of the ED Timeline revealed ED Decision to Transfer was documented at 2103. Review of the Nursing/Ancillary Note dated 07/01/2021 at 1931 revealed " ...received a call from (Provider Name) requesting assistance in acquiring home oxygen for patient ... reported patient had previously used oxygen at home and was taken off of it and they believe he needs it again ...met with patient at bedside ... talk about possible home oxygen services. Patient reports that he received oxygen through 02 clinic at VA Salisbury ... writer called VA Salisbury ... the O2 clinic was closed ... writer received a call from after-hours supervisor ... he reports patient must go through the VA clinic to establish a new order of Home Oxygen and cannot be done straight through them ... writer met with (Provider Name) and updated her. At this time, she reports that patient is planning to transfer to Facility C to continue care ..." Review of the MAR revealed Norco 5-325 mg tablet was administered to Patient #4 at 2116. Review of the EMTALA Transfer Form at 2249 revealed "Patient Condition: Stabilized; Reason for Transfer: Bed Utilization; ... Accepting Provider Date: 07/01/2021; Accepting Provider Time: 2020 ..." Review of the Vital Signs at 2300 revealed "SpO2 Pulse Rate: 80; BP: 92/83; SpO2: 96%." Review of the ED Timeline revealed ED Disposition set to Transfer to Another Facility was documented on 07/02/2021 at 0018. Review revealed the AVS was printed at 0020. Review of the EMTALA Transport RN Doc revealed " ... Temp: 96.3 degrees Fahrenheit; Pulse: 70; Resp: 18; BP: 109/62; SpO2: 94%; O2 Flow Rate (L/min): 2 L/min." Review of the ED Timeline revealed Patient #4 discharged out of Facility A's DED on 07/02/2021 at 0043.

Interview on 11/17/2021 at 1549 with MD #5 revealed the patient was stable and could go to another location for continued care. Interview revealed the hospital could provide the needed services however they "didn't want to back log the ED with patients waiting for admission." Interview revealed the hospital staff contacts the regional operation center located in this facility. . Interview revealed the provider discussed the transfer to another facility and the patient and/or family agreed with the transfer. Interview revealed the patient did not request the transfer.

The hospital had the capacity to manage the patient. The hospital staff could have arranged the oxygen supplementation at their facility.