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Based on observation, interview, and record review the facility failed to meet the emergency needs of Patient #5 in accordance with acceptable standards resulting in the inappropriate discharge/transfer of Patient #5. The deficient practices identified were determined to pose a risk to the health and safety of Patient #5 and may have the potential of placing all patients at risk.


Findings:
Patient #5 received a diagnosis of a spinal abscess, sepsis, and leukocytosis on 01/12/2023 at 0035 by the treating physician, Staff #17. Patient #5 received an initial Sepsis Risk Score of 3.2 at 2101 on 01/11/2023 which rose to a high of 5.24 at 0240 on 01/12/2023, less than one hour prior to her leaving the Emergency Department [a score greater than 7 indicates a high risk for sepsis]. Patient #5 was considered a critical care patient by the treating physician, Staff #17, and placed on cardiac monitoring at 2204 on 01/11/2023 and had lab testing and imaging accordingly. Patient #5 did receive treatments that included IV fluids, Morphine [for pain], Zofran [for nausea], Cefepime [a broad-spectrum antibiotic prescribed empirically to septic patients prior to the pathogen being known], and Vancomycin [a more powerful broad-spectrum antibiotic that is effective in treating resistant organisms and is reserved for serious drug-resistant infections].


The treating physician, Staff #17, spoke with Patient #5's surgeon from the initial surgery on 12/05/2023, Staff #22 at Hospital B [from surgery on 12/05/2022] at 0153 on 01/12/2023, who suggested the covering physician from Hospital B may perform the needed surgery. One minute later a transfer process was initiated by the treating physician, Staff #17.
There was a note entered by the treating ED physician, Staff #17, at 0300 on 01/12/2023 that stated, "I discussed with hospitalist [Staff #23 for Hospital B]. He [Staff #23] states that he cannot accept the patient without the backup of Neurosurgery to evaluate the patient. We have tried reaching out to the on-call service several times including multiple conversations between nursing and their on-call service. I ultimately discussed with the patient [Patient #5] about options. She [Patient #5] will leave against medical advice and drive straight to Hospital B for evaluation since this is where she [Patient #5] obtained her surgery [Hospital B]. She [Patient #5] will be sent with her [Patient #5's] imaging as well as report for their viewing." Patient #5 left within 25 minutes of this note at 0325 on 01/12/2023.


Patient #5 left this facility [Hospital A] at 0325 on 01/12/2023 and arrived at the Emergency Department of Hospital B at 0409 on 01/12/2023 and was transferred from the Emergency Department to the surgical unit with a diagnosis of 'status post lumbar fusion of L2-S1; Failure of hardware S1; and Epidural abscess L1-S1'. Within an hour of Patient #5's arrival at 0508. Patient #5 had the first of 3 surgical procedures to alleviate her emergency medical condition and spent 18 days in that hospital for treatment of the emergency medical condition.


Policy Review of the facility's Patient Transfer (EMTALA) showed that the policy stated, in part, "Stabilize - means, with respect to an Emergency Medical Condition, to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the Transfer of the individual from a facility ..."

The facility failed to provide stabilizing treatment in accordance with their policy, which posed a risk to the health and safety of Patient #5 and may have the potential of placing all patients at risk.

In an interview on the morning of March 21, 2023, Staff #16, the Medical Director of the Emergency Department, was asked what constituted an emergent condition regarding abscesses or fluid pockets.


Staff #16 replied that there were many factors to consider, such as size, location, and type of abscess. Staff #16 further stated that all abscesses would need drainage, so they should not delay this care. Staff #16 stated that in abscesses, there is not good blood flow to a "pocket of pus." Staff #16 further clarified that a doctor had to ask him/herself if it was a true abscess or a pocket of fluid when dealing with a postoperative patient. Staff #16 stated that if the pocket of fluid was just a pocket of fluid, it would be sterile and should not be touched, but it is really hard to answer the question as there are so many factors to consider.


Additionally, Staff #16 was asked how a physician might know if a pocket of fluid was an abscess or just a pocket of fluid.


Staff #16 replied that testing should reveal an infection, such as blood tests, inflammatory markers, MRIs, and CT scans should help define the difference as well as the patient's symptoms.


Additionally, Staff #16 was asked what might cause the physicians to not treat a patient at this facility and transfer them to another ED.


Staff #16 replied that it could be related to being at capacity, for continued continuity of care, like in cases of a postoperative patient whose surgeon was not affiliated with this facility, or the need for specialty care, such as pediatric cases, that cannot be provided at this facility.


Additionally, Staff #16 was asked how the ED physicians determined if a patient should be transferred by ambulance versus private vehicle when a transfer needed to take place.


Staff #16 replied that it was rare to send a patient by private vehicle and it was not usually recommended. Staff #16 further stated that there were occasions when a patient requested to take a private vehicle instead of an ambulance for a variety of reasons, such as expense, a child being afraid to ride without his/her parents, or other personal reasons.


Additionally, Staff #16 was asked when an infection might not be treated at this facility, and/or a patient would be sent to another medical facility for treatment.


Staff #16 stated that "If you are sick enough to require transfer to another facility, you should go by ambulance, and transfer by private vehicle is not recommended." Staff #16 also stated that care can be continued while in an ambulance and cannot be in a private vehicle. Staff #16 further stated that in cases of sepsis, they would always be recommended to go by ambulance.


In an interview on the morning of March 21, 2023, Staff #15, an Emergency Department physician, was asked what constituted an emergent condition regarding abscesses or fluid pockets.


Staff #15 replied that if the patient were ill-appearing and needed antibiotics or surgery it would be an emergent condition and the patient would need admission or transfer if the facility was unable to admit the patient to this facility.


Additionally, Staff #15 was asked what might cause the physicians to not treat a patient at this facility and transfer them to another ED.


Staff #15 replied that if the patient needed a specialist that was not associated with this facility or had a recent surgery the patient would need to go to the treating facility for continuity of care and that type of patient would be transferred to another or the formerly treating facility's ED.


Additionally, Staff #15 was asked when an infection might not be treated at this facility and/or a patient would be sent to another medical facility for treatment and how was it decided by the ED physician if the patient should go by ambulance versus private vehicle.


Staff #15 replied that most patients are transferred by ambulance so the patient could continue receiving care while en route to the receiving facility. Staff #15 further replied that patients are discouraged from transferring by private vehicle by providing the risks of doing so (such as having an automobile accident, becoming more ill while traveling, or a more emergent condition appearing while traveling). Staff #15 stated that patients often refuse an ambulance for a variety of reasons. Staff #15 stated that often, in the cases of children being transferred, the parents do not wish for further anxiety of their children and want to transfer them by private vehicle. Staff #15 further stated that all unstable patients would be sent via ambulance for further stabilization. There was no documentation provided that Patient #5 was offered a transfer by ambulance.