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Based on review of medical records, Bylaws of the Medical Staff and Rules and Regulations, Professional Services Agreement Emergency Department, ambulance trip report, ED physician's schedule, physicians' on-call schedules, current Medical Staff Roster, policies and procedures, and staff interviews, it was determined that the facility failed to provide treatment within its capacity that minimize the risk to the individual's health for one (1) individual (patient #2) out of twenty (20) sampled patients with services that the facility was capable of providing prior to transferring the patient to another acute care facility.

Cross refer to A-2409, as it relates to failure to provide an appropriate transfer for patient #2.

Based on review of medical records, Bylaws of the Medical Staff and Rules and Regulations, Professional Services Agreement Emergency Department, ambulance trip report, ED physician's schedule, physicians' on-call schedules, current Medical Staff Roster, policies and procedures, and staff interviews, it was determined that the facility failed to provide treatment within its capacity that minimize the risk to the individual's health for one (1) individual (patient #2) out of twenty (20) sampled patients with services that the facility was capable of providing prior to transferring the patient to another acute care facility.

Findings were:

Review of the patient's medical record #2 revealed the patient presented to the ED on 01/20/18 at 2:48 p.m. Documentation revealed the patient signed the consent for treatment and that he/she received patient rights information on 01/20/18 at 2:49 p.m. The triage (assessment by a nurse to determine the priority in which patients will be seen based on their presenting complaints and symptoms) nurse (#5) noted that the patient was triaged at 2:55 p.m. as a level three (3) priority. The triage nurse noted that the patient's chief complaint was abscess/cellulitis (infection/inflammation of the skin and/or muscle). The nurse noted that the patient presented to the triage desk and reported that he/she (patient) had an abscess below a Jackson Pratt (JP - closed suction device used to collect fluid from a surgical site) in the back. The nurse noted that the patient had purulent (pus) drainage running down his/her (patient) back, leg, and onto the floor.

Physician notes indicated Physician's Assistant (PA #1) examined the patient at 3:11 p.m. The PA noted that the patient had a history of diabetes (high blood sugar) and that the patient reported that the right back abscess started one (1) week (01/13/18) prior to arrival in the ED. The PA noted that the abscess was on the right lower back, was constantly mildly achy, nothing increased or relieved the symptoms. The PA further noted that the patient was in no apparent distress, was alert and oriented to person, place, and time, that all other systems were negative, and that the patient had no known allergies. The PA noted that upon examination, the patient had no back tenderness, normal movement, and had a draining abscess on the right lower back area.

At 5:46 p.m., the patient's vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation) was 97.8, 86, 18, 135/81, and 100%. In addition, the nurse noted that the patient denied pain. At 5:46 p.m., nurses' notes revealed the patient reported having two (2) JP drains in his/her (patient) back and that a boil had developed at the site yesterday (01/19/18). In addition, nurses' notes revealed that the patient had copious (large amount) of thick tan drainage from the site. The nurse noted that the patient had a history of heart disease, high blood pressure, Guillain -barre (immune system attacks the nervous system causing numbness, tingling, and can lead to paralysis) more than five (5) years ago, diabetes, and sacral (tailbone area) wound debridement (removal of dead tissue).

At 6:24 p.m., physician #3 discussed the patient's case with the on-coming physician #2, regarding the patient's need to return to the facility that originally placed the two (2) JP drains.

Nurses' notes indicated that an intravenous line (IV) was inserted at 6:53 p.m.

Physician orders, medication administration documentation, nurses notes, lab results, and x-ray results revealed the following:
--Complete Blood Cell Count with Automated Differential, results revealed the white blood cells (signify infection) were within normal limits, hemoglobin (blood cells that carry oxygen to the body) was 7.7 (reference was 11.0-15.0), hematocrit (percentage of red blood cells) was 24.1 (reference was 32-44.7).
--Comprehensive Metabolic Panel (electrolytes and minerals), results revealed the sodium was 129 (reference was 133-148), creatinine (indicates kidney function) was 1.45 (reference was .60-1.20), glomerular filtration rate (measures the kidney function and level of kidney damage) was 38 (reference 30-59 indicates moderate decrease in kidney function).

--C-Reactive Protein High Sensitivity (blood test to determine inflammation in the body), the result was 18.636 (reference was less than 1.000).
--Hemoglobin A1C (average blood sugar level over a three (3) month period), the result was 7.1 (reference was 3.0-6.0).
--Blood cultures time two (2), results were negative for growth after five (5) days.
--Lactic Acid Venous (measures how the body breaks down carbohydrates into water and carbon dioxide), result was 1.0 (reference was 0.5-1.9).
--Rocephin (antibiotic) 1,000 milligrams (mg) intramuscular injection was administered at 5:55 p.m.
--Computerized tomography (CT) scan (specialized x-ray) of the abdomen and pelvis without contrast, results indicated the patient had an intramuscular abscess formation involving the right psoas muscle (long muscle that is located on both sides of the lower back, the muscle runs from beside the spinal cord down below the hip bone ) and right kidney stones. In addition, the CT scan revealed the right tube leading from the kidney to the bladder was obstructed leading to moderate hydronephrosis (kidney fails to drain properly), right adrenal nodule (a gland located on top of the kidney) that likely represented an adrenal adenoma (benign tumor), and gallbladder stones.
--Xylocaine 1% (numbing agent) 2.1 milliliter (ml) and a second dose of 2.0 ml to be administered as needed was administered at 5:55 p.m.
--Normal saline 1,000 ml to be administered at 500 ml/hour intravenously was administered at 6:55 p.m.
--Type and screen blood type, retype ABO (blood type)/Rh (blood factor), this test determines ABO/Rh antigen(immune response), results revealed the patient had O positive blood type and that the antibodies were negative.
--Consult physician (#4) Urology Surgeon
--Occult blood no results found.
--Urinalysis no results found.
--Culture wound, results revealed a moderate growth of normal skin bacteria.
--Transfer out of the facility.

At 6:24 p.m., the physician (#2) noted that the diagnosis and transfer were discussed with the patient.

At 7:42 p.m., nurses' notes indicated that the nurse called the receiving facility's transfer center and spoke with a representative who informed the nurse that all nurses at the receiving facility were busy and someone would call back to receive report. At 7:52 p.m., nurses' notes indicated that report was given to a staff member at the receiving facility.

At 7:59 p.m., physician #2 noted that the patient had a right lower back abscess. The physician noted that the patient's history was significant for a right psoas abscess that was drained at an acute care hospital in another city in December 2017. The physician noted that there was an open area on the right lower back that was draining large amounts of pus. The physician noted that the CT scan showed right-sided intramuscular abscess over the psoas muscle that could be potentially connected to the draining area on the right lower back. In addition, the physician noted that the CT scan revealed the patient had right kidney stones and a moderate amount of hydronephrosis. In addition, the physician noted that the CT scan revealed the patient had gallbladder stones. The physician noted that the facility had no previous laboratory for comparison. The physician noted that the patient required admission and surgical intervention and that he/she had requested that the patient be transferred to the facility that had initially placed the JP drains but that the patient refused to go to that facility. The physician noted that he/she spoke with the accepting physician at the receiving facility and that the patient was accepted in transfer.

At 8:13 p.m., physician #2 noted that the discharge diagnosis was: elevated serum creatinine, right psoas abscess, microcytic anemia, renal insufficiency, right lower back fistula, gallstones, kidney stones, hydronephrosis, and morbid obesity. Physician #2 further noted that the patient's condition was serious.

The transfer form revealed that the name of the accepting facility and doctor, which portions of the medical record were sent to the receiving facility, evidence that the patient was transferred by ambulance with Emergency Medical Service personnel and Advanced Cardiac Life Support protocol. This form noted that the risks of transfer included deterioration of condition and/or death and that the benefit of the transfer was for specialized care. Patient #2 signed the form on 01/20/18 at 9:21 p.m.

At 9:00 p.m., nurses' notes indicated that the patient's vital signs were: pulse 81, respirations 15, blood pressure 133/79, and oxygen saturation 98%, and pain level was four (4) on a scale of one (1) to 10 (10) with one (1) being mild pain and 10 (ten) being severe pain. . At 9:04 p.m., nurses' notes indicated that the patient was accepted by the receiving facility at 7:44 p.m.

The ambulance trip report dated 01/20/18 revealed patient #2 left the facility by ambulance at 9:49 p.m. The trip report revealed the patient had chronic renal failure/dialysis. Documentation revealed the patient's vital signs and condition remained unchanged during transport. The report revealed the patient arrived at the receiving facility at 10:15 p.m.

Review of the facility's Bylaws of the Medical Staff, approved by the Board of Trustees on 06/27/12, Rules and Regulations, section V. Emergency Room, F. Patients presenting to the facility will have a Medical Screening Exam consistent with EMTALA (Emergency Medical Treatment and Labor Act) regulations performed by a Physician, Registered Nurse, Nurse Practitioner, or Physician Assistant credentialed by the Medical Staff. Section V. F. was approved by the Board of Trustees on 10/28/15.

Review of the facility's Professional Services Agreement Emergency Department, effective 01/31/14, revealed the contractors agreed to comply with the professional standards established by the Joint Commission and specialty societies of which the Physicians are members, including any accrediting boards, with all applicable federal and state regulatory agencies, the then current Bylaws, Policies and Procedures of the Hospital, and the then standards of medical practice.

Review of the ED physician's schedule revealed that on 01/20/18 PA #1 was scheduled from 9:00 a.m. to 9:00 p.m., physician #3 was scheduled from 6:30 a.m. to 4:30 p.m., and physician #2 was scheduled from 8:30 a.m. to 6:30 p.m.

Review of the physicians' on-call schedules for 01/20/18 from 7:00 a.m. to 01/21/18 7:00 a.m., revealed the facility had an on-call general surgeon, an on-call urology surgeon (physician #4), and an on-call Interventional Radiologist (IR physician #10 - specialty that uses image guidance to perform procedures).

Review of the facility's current Medical Staff Roster revealed the following Medical Staff Membership: PA #1 was an Advanced Dependent Practitioner, ED Physicians #2 and #3 were both Active, Urology Surgeon #4 was Active Affiliate, Internal Medicine physician #6 was Active, Interventional Radiologists #9 was Active and #10 Active Provisional and ED Physician #12 was the ED Medical Director and was an Active Consulting.

Review of facility policies included the following:
1. Emergency Department Triage, no policy number, effective 10/10/17, revealed a rapid triage assessment will occur in the main ED waiting area. With room unavailability, secondary triage may occur in the triage area. Utilization of a medical triage (Emergency Severity Index -ESI) and a behavioral health triage (BH ESI) is incorporated.
Triage Patient Categories: (Medical)
--ESI Level I: Conditions that may result in loss of life or limb if not treated immediately. Identified examples would include the following: cardiac arrest, severe overdose, serious multi-system trauma, apnea, or pulselessness.
--ESI Level II: Conditions that have potential for major life or limb threat, patients in high-risk situations, patients with acute confusion, lethargy, or disorientation. Patients with danger zone vital signs that will require multiple resources are considered. Identified examples would include the following: Active chest pain, suspicious for coronary syndrome, signs and symptoms of stroke, suicidal/homicidal ideations/gestures, and immuno-compromised patients with fever, and children under 24 months with fever should be considered.
--ESI Level III: Conditions that require two or more resources to reach a disposition. Identified examples would include: laceration with controlled bleeding, non-cardiac chest pain, contusions, chronic hypertension, vaginal discharge, abdominal pain, vomiting/diarrhea without dehydration, or stable psychiatric patients.
--ESI Level IV: Conditions that need evaluation and treatment, but are predicted, to only require one resource. Identified examples would include: rash, abrasion, chronic arthritis, chronic headache, cold symptoms, and sprains.
--ESI Level V: Conditions that require routine/follow-up, no resources required. Identified examples: stable vital signs, wound, rechecks, suture removals, prescription refill.

2. Emergency Medical Screening, Treatment, and Transfer, no policy number, effective 01/16/18, revealed the facility defined the following:
I. "Emergency Medical Condition" means: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
a. Placing the health of the individual (or, with respect to a pregnant woman, the health of a woman or her unborn child) in serious jeopardy;
b. Serious impairment to any bodily function; or,
c. Serious dysfunction of any bodily organ or part.
II. With respect to a pregnant woman who is having contractions:
a. That there is inadequate time to affect a safe transfer to another hospital before delivery; or,
b. That the transfer may pose a threat to the health or safety of the woman or the unborn child.
III. Medical Screening Exam means examination by a physician, physician assistant, or nurse practitioner, to include diagnostic studies, interventions or treatment needed to confirm or rule out an emergency medical condition.
IV. The term "stabilization" means, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer or discharge of the individual from a facility or, in the case of a pregnant woman having contractions, when the woman has delivered (including the placenta).
V. The term "transfer" means the movement (including the discharge) of an individual outside a hospital's facilities at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include such a movement of an individual who (A) has been declared dead, or (B) leaves the facility without the permission of any such person.
--Treatment of Patients in the ED
When patients in the ED require the services of a specialist for further care, the ED physician will call the appropriate specialist for assistance as determined by the "on call" roster of physicians, or contact the patient's own physician, if known.
--Transfer of Patients from the ED to another Facility
1. Patients will be transferred to another facility if they require more definitive or specialized treatment that is not available at the hospital. When the patient has had stabilization to the best capabilities of the hospital, the patient may be transferred to receiving facility. The private physician will be contacted and will accept the patient prior to transfer.
a. Patients are to be stabilized before the patient leaves the hospital unless a delay in transfer will compromise the patient's condition (i.e., severe head trauma).
b. The physician in attendance will provide a signed statement in the medical record attesting that the medical benefits of the transfer outweigh the risks to the individual. (Transfer Record)
2. The patient and/or his family will be fully informed by the attending physician of the need for the transfer, the hospital's obligation to treat, and the risk of the transfer. The patient and/or family will sign a written consent for the transfer.
3. The ED physician or specialist in attendance will appropriately refer the patient to a physician at the receiving facility.
a. The physician at the hospital will call the physician specialist needed and give a full and detailed report of the patient's condition and reason for requesting the transfer.
b. The physician will wait for confirmation of acceptance by the receiving physician and hospital before the patient leaves.
c. The primary nurse will give the receiving primary nurse a detailed report.
4. When the patient is transferred to another facility, a copy of all records will be sent with the patient,(or promptly faxed) to include the ED record, all consultation notes from physicians, nurse's notes, lab reports, electrocardiograms (heart rate and rhythm), x-rays, and transfer form.
5. The patient will be transferred to the receiving facility by the ambulance or other service based on need. (Helicopter).
6. The patient may make a request for transfer as outlined in the Transfer Record.

During a telephone interview with ED physician #2 on 01/30/18 at 10:00 a.m. in the Conference Room, the physician confirmed that he/she remembered the patient. The physician explained that he/she must have forgotten to write a note regarding the conversation he/she had with the Urology Surgeon (#4). The physician said that the Urology Surgeon informed him/her (ED physician #2) that the Urology Surgeon had only seen the patient (#2) once and that the Urology Surgeon was waiting on the patient's medical records from the facility that had placed the patient's two (2) JP drains. The ED physician stated that he/she did not ask the Urology Surgeon to come in to see the patient because the patient had an abscess in the psoas muscle and it was not a urology issue. The ED physician went on to explain that he/she initially wanted to send the patient to the facility that had inserted the two (2) JP drains, but that the patient did not want to be transferred to that facility. The ED physician said that the patient (#2) had an abscess draining through his/her back, it was not a urology issue, the patient needed a surgeon and an IR to drain the abscess. The physician was asked if the facility had on-call surgeons and IR and the physician (#2) replied: "I guess so". The ED physician explained that this was a very complicated patient and he/she didn't want to get "our surgeons" involved in a complicated case.

During a telephone interview with Urology Surgeon #4 on 01/30/18 at 10:15 a.m. in the Conference Room, the physician confirmed that he/she was barely familiar with the patient (#2). The physician explained that he/she received a telephone call from the ED physician (#2) on 01/20/18 which was during the weekend. The physician explained that previously, he/she received a call from a Nurse Practitioner (NP) asking if he/she could take the patient. The physician went on to explain that the NP reported that the patient had two (2) JP drains placed by another facility and that the NP could not find a physician to take the patient. The physician said that the patient showed up at my office, I had no records, the patient had two (2) drains in his/her back but I didn't know where the drains went. The physician explained that he/she ordered a CT scan to be performed at this facility but the patient wanted the CT scan done in her hometown. The physician said that the patient did not have the CT scan done as ordered. The physician said that on 01/20/18 the patient presented to the ED and informed the staff that he/she (patient #2) was my patient. The Urology Surgeon said that he/she received a call from ED physician (#2), I told ED physician (#2) that I didn't know what was going on with this patient because I still had not received any of the patient's medical records and that I didn't know where the drains went. The Urology Surgeon explained that he/she was informed by the ED physician (#2) that the drains were placed in the psoas muscle and that he/she (ED physician #2) thought the patient should go back to the facility that placed the drains. The Urology Surgeon stated that since the drains were not in the kidney the patient did not need a urologist. Physician #4 stated that this was all he/she knew from the information provided and that he/she was dealing with the patient (#2) blindly because he/she never saw an x-ray or CT report.

During an interview with IR physician #9 on 01/30/18 at 10:30 a.m. in the Conference Room, the physician confirmed that he/she was not the physician who read the patient's CT scan and was also not the IR on call 01/20/18. The IR physician reviewed MR and explained psoas abscess (fluid collection in a muscle in the back) caused by any infectious organism usually occurs in patients that are bedridden for a long time, or patients with kidney or neighboring organs infections, or recent spinal surgery, or immunocompromised patients. When questioned as to whether the abscess could be drained at the facility the physician explained it depended on whether the abscess was in a straight line or how deep the abscess was. The physician explained that the procedure would be done under image guidance, ultrasound, CT or fluoroscopy. The physician confirmed that the procedure would be performed by an IR physician. The IR physician said that if it is a superficial infection the abscess tracks around and comes to the surface and can be drained using needle drainage by a surgeon. However, deep tissue infection needs image guidance drainage by an IR physician. The IR went on to explain that the facility performs on an average two (2) or three (3) psoas drainage procedures a month if drainable based on the findings. The IR physician reviewed the patient's (#2) CT films and confirmed that the patient had kidney stones, 2 (two) drains, and the fluid is going through the process of evolution probably pus. When questioned as to whether the patient's psoas abscess could have been handled at the facility, the IR physician confirmed that it could have been handled in-house. As this resulted in an inappropriate transfer of patient #2 on 1/20/2018.