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Based on staff and other interviews and record reviews, the hospital failed to comply with the requirements of §489.24 by:

Failure to provide an appropriate transfer when Patient 1 arrived at Hospital B's emergency room without prior notification from Hospital A's emergency department. (Refer to A 2409).

Based on staff interview and record review, Hospital A's Emergency Department (ED) physicians failed to request a transfer for treatment from Hospital B's ED physician for one (Patient 18) of twenty-one patients. This failure resulted in Patient 18 arriving at Hospital B's ED without a physician's prior knowledge and acceptance of Patient 18. This failure also had the potential that Hospital B's ED would not have the available space and qualified personnel to treat Patient 18.

Findings:

Review of Hospital A's ED triage (process of sorting patients according to severity of EMC--emergency medical condition) record, dated 8/9/16, showed Patient 18 was in her 50's and came to the ED via ambulance, at 11:32 a.m., with a chief complaint of abdominal pain. The documented pain level was 10 on a (1-10) scale with 10 as the maximum pain. The priority (severity level of the EMC on a 1-5 range with "1" being the most severe) assessed by the triage nurse was "3."

ED Physician 1's medical screening exam, dated 8/9/16 at 12:33 p.m., showed that Patient 18 had diagnoses to include diabetes, COPD (chronic obstructive lung disease which makes it hard to breathe), fibromyalgia (widespread muscle pain and tenderness) and a pacemaker. Patient 18 also had vomiting of yellow fluid. The physical exam showed the abdomen was soft, positive for diffuse (widespread) tenderness, no guarding (resisting anyone touching the abdomen) and no rebound tenderness (pain when pressure on the abdomen is released indicative of a severe infection).

The physicians' orders, dated 8/19/16 at 12:24 p.m., included pain medication, chest X-ray, CT (computerized tomography is a type of x-ray which creates cross-sectional images or slices of the body part imaged and provides more information than plain X-rays do) of the abdomen and pelvis, IV (intravenous means into the vein) fluids and antibiotics, respiratory treatments, and lab work.

ED Physician 1 wrote, under the topic of, "Medical Decision Making," dated 8/9/16, that Patient 18's CTs were consistent with moderate enteritis (inflammation of the small intestines usually associated with diarrhea) was treated with IV antibiotics. The EKG (electrocardiogram shows the electrical activity of the heart on paper) was abnormal and changed from the EKG in 6/16. Physician 1 documented: "I think that the patient should be admitted for COPD exacerbation [worsening], abnormal EKG, and indeterminately elevated troponin [proteins in blood indicative of heart damage.]"

Physician 1 also wrote, another physician, Physician 2, saw Patient 18 in the ED, and was deciding whether to discharge the patient from the ED or transfer the patient. ED Physician 1 wrote Physician 2 decided to transfer the patient to the Medical Group Urgent Care under the care of Physician 3 at the Urgent Care, and Physician 2 "...signed the stability transfer paperwork..." ED Physician 1 noted Patient 18's disposition was to transfer to a Short-Term Hospital.

Physician 2 documented his findings related to Patient 18, on 8/9/16 at 4:30 p.m. Under the heading of "Assessment and Plan," Physician 2 wrote Patient 18 reported feeling better. "The plan is for patient to be transferred to Urgent Care for continuing of IV fluid, Zofran [medication which combats nausea and vomiting], and pain medication...Mild elevation of troponin. The patient has chronic elevation of troponin, had recent [cardiac] stress test negative. The patient denies any chest pain, palpitation, or shortness of breath." There was no documentation, on 8/9/16 at 4:30 p.m., by Physician 2, that he discussed the transfer with Physician 3 at the Urgent Care Center.

Physician 2 wrote an addendum, dated 8/12/16 at 6:21 p.m., to note the case was discussed with Physician 3, who accepted Patient 18 for overnight observation, IV fluid and pain control in the Urgent Care. Documentation indicated Patient 1 was agreeable to be transferred to Urgent Care.

On 12/27/16, review of Hospital A's "Transfer Consent" showed Patient 1's signature. The "ED Transfer Form," showed the receiving facility was Hospital B ED and not the urgent care. The prompt on the transfer form for, "Receiving Physician," had "ER" [emergency room] listed without a physician's name. The transferring physician was listed as Physician 4. There was no documentation that any of Hospital A's Physicians: 1, 2, and 4 or the urgent care Physician (3) made contact with the ED physician at Hospital B. The prompts on the transfer form, "Receiving Facility Representative," and "Report given to," had a first name (Staff 1) listed without a title. Registered Nurse (RN 1) signed the Hospital A "ED Transfer Form." At 6:52 p.m., RN 1 wrote in the nurses notes the ambulance company was at bedside for transport and per Staff 1 of the Medical Group, advised Patient 18 be transported to Hospital B, and report to Hospital B was complete. Disposition in the ED record showed that, upon transfer, Patient 1 had a pain level "3," and stable vital signs. Also report was made to Staff 1 at the Medical Group urgent care, and Patient 18 departed ED Hospital A for Hospital B at 7:20 p.m.

On 12/27/16 at 2:30 p.m., during a phone interview, Hospital A Physician 2, said he belonged to the Medical Group of 1000 physicians who owned the Urgent Care Center, which was also a 24 hour-staffed observation unit. Physician 2 said, in his professional judgement, Patient 18 did not require additional emergency care and did not require an admission. Physician 2 said ED Physician 1 agreed with his assessment. Physician 2 said he then discussed Patient 18 with Physician 3, who accepted Patient 18 at the urgent care for 24 hour observation. Physician 2 said: "I left [Hospital A ED] and got a surprise call that the patient went to ____ [Hospital B ED]...There was a miscommunication at the urgent care center and other than that I don't know."

On 12/27/16 at 3:30 p.m., during an interview, RN 1 said she was the assigned nurse to Patient 18 on 8/9/16. RN 1 said Staff 1 from the urgent care called and said that Patient 18 was to be transferred to Hospital B ED. RN 1 said she thought Staff 1 was a nurse. Staff 1 told RN 1 the doctors figured out Patient 18 was in Hospital B's region so the ambulance was on the way to transfer Patient 18 to Hospital B. Staff 1 told RN 1 she didn't have to give report to the receiving hospital. RN 1 said, "When insurance is involved it's usually doctor to doctor [report]." RN 1 did not inform either ED Physician 1 or 2 about the transfer of Patient 18 to Hospital B ED instead of the Medical Group Urgent Care. RN 1 did not endorse a report to Hospital B ED, because Staff 1 said it wasn't necessary.

On 12/27/16 at 4 p.m., during a phone interview, Hospital A ED Physician 1 said she could not recall Patient 18 or the incident, of 8/9/16, without reading the record upon her return on 1/5/16. ED Physician 1 checked her calendar and said her shift ended, at 6 p.m. on 8/9/16, prior to Patient 18's transfer.

On 12/28/16 at 10:23 a.m., during a phone interview, Staff 1 identified herself as a medical receptionist. Staff 1 said she could not recall the incident of Patient 18. Staff 1 said she would not make the decision to transfer the patient without notifying Hospital B. Staff 1 said her job was to gather information and the charge nurse and doctor were responsible to notify the receiving hospital of the transfer. The Director of the urgent care said there were no nurses with the same first name as Staff 1.

On 12/28/16 at 11:30 a.m., Physician 5, the Medical Groups' Lead Hospitalist (doctor who delivers in-patient care in the hospital,) said Physician 3 was unavailable for an interview. Physician 5 knew about the incident and said Physician 3 accepted Patient 18 for urgent care from Hospital A. Afterwards Physician 3 researched Patient 18's medical record. Since Patient 18's primary care physician worked at Hospital B, Physician 3 made the decision to send Patient 18 to Hospital B. Physician 3 told Staff 1 to make the arrangements. Physician 5 said in a "perfect world" Physician 3 would have notified Physician 2 and the ED physician at Hospital B. Physician 5 said that is the usual course of communication but in this case the communication between physicians did not occur.

On 12/28/16, review of Hospital B's ED record, dated 8/9/16, showed Patient 18 arrived, on 8/9/16 at 7:48 p.m. A triage assessment, at 8:09 p.m., showed a chief complaint of "abdominal pain since 4 a.m.," with a pain intensity of "8," and an acuity level of "3." At 8:37 p.m., ED Physician 6 at Hospital B wrote that Physician 4 at Hospital A ED "...is very apologetic the patient was sent here. He will contact the UCC [urgent care] clinic and arrange transport from here to there instead now..." At 8:57 p.m., ED Hospital B Physician 6 wrote that Physician 7 from the urgent care called and, "He states that the patient needs a reevaluation to see if she requires their care [at hospital B] before he will accept her [at the urgent care.]" Also ED Physician 6 contacted Hospital A and the nurse (not named) did not know how Patient 18 ended up in the care of Hospital B. At 11:23 p.m. on 8/9/16, Patient 18 was admitted to Hospital B. The "Final Report" from Hospital B, dated 8/12/16 at 6 p.m., showed Patient 18 was discharged home in stable condition from Hospital B.

On 12/28/16 review of the ED policy and procedure, entitled "Patient Transfers," dated 7/2013, had the following directions: "A representative of the receiving facility must have confirmed that...the receiving facility has available space and qualified personnel to treat the individual...The nurse will document the time, date and name of the person they verify this information with from the receiving facility on the nurses note...When the individual has an emergency medical condition the receiving physician must agree to accept and treat the individual. The name of the receiving physician will be documented on the transfer record."

Hospital A's administrative policy and procedure, entitled "Transfer of Patient to Outside Facilities (Interfacility)," dated 10/14/15, had the following: "...For all transfers, a receiving physician must be identified and his/her agreement to accept the patient must be obtained...A transfer will not be processed without acceptance by the receiving facility."