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Based on record review and interview the facility's On-Call Physician failed to come to the Emergency Room (ER) when called by the ER physician to come and treat patients # 1& 2 with medical emergency conditions.

The facility's on- call physician also failed to comply with the facility's trauma policy which required an On-Call Physician to personally go to the ER when called for a trauma one (1) activation , or called by the ER Physician.

Findings:

Patient # 1
Review of Emergency Room (ER) records for Patient # 1 revealed the following information:
On November 16 ,2008 the 19 year old patient arrived at the ER via Emergency Medical Services (EMS) at 02:23 with history of motor vehicle accident. The patient was triaged at 2:43 am and was assigned Acuity Level-3 (Urgent).
He was alert oriented and awake and gave history of loss of consciousness. Examination revealed the patient had injuries to left and right ear lower lobes and laceration to his face and head. He complained of pain to his right ear, head and shoulder at a level of 8/10. There was no surface injury to the chest. All other areas were within normal limits. Blood pressure was 188/107, purse 76, respiration 18 and temperature 98.7.
Further review revealed documentation that intravenous line was started, blood was drawn for analysis. CT of head and Cervical Spine were done, also X- Ray of face shoulder and chest.
The medical screen examination was conducted by ER Physician # 55, at 02:46. The physician documented that the patient was his own historian and said he was driving a four wheeler unrestrained, and had a roll over accident. He had lost consciousness and was complaining of right shoulder pain and headache.
The examination notes revealed almost complete avulsion (severed) of the right ear. Small inferior pole ridicule attached. The ear was hanging off the skull but the capillary refill was good. The cartilage was torn off and the skull was mangled.
At 3:05 am the patient was given morphine and phenergan for nausea and pain. Diphtheria and Tetanus vaccine was also administered.
Review of treatment records revealed documentation timed at 4:29 am there was documentation that the laceration was repaired; it was complex and extra sutures. The area was dressed with a large Kerlix and covered with 4x4. There were notes that the patient tolerated the procedure well.
Review of vital signs documented on 11/16/08 at 4:49 am revealed they as follows: Blood pressure 172/82, pulse 76, respiration 18, and temperature 100.1 The patient was given intravenous morphine at 3:05 am for pain and was started on IV Ancef (antibiotics).
Patient # 1's condition improved and he was admitted to the floor. He left the ER at 6:00 am.
There was a progress notes written on ER record signed by Physician # 55 which gave information that he called Physician # 52 to come to the ER and repair the patient's ear, because he was not comfortable doing the repair.
According to the note Physician # 52 refused to come in, and asked him (Staff # 55) to do a basic closure which he did.
There was no documentation that Administrative personnel were informed of the Physician's refusal to come in and see the patient.
Review of Unit admission records revealed Patient # 1 arrived on the unit on 11/16/08 at 06:00 am with diagnosis of head injury, right ear (near) avulsion.
His assessment notes documented the patient's systems were all within normal limits. He had no complaints.
Review of nursing notes dated 11/16/08 at 10:57 am documented the following information:
Spoke with Physician # 52, undressed ear wound ,cleaned with sterile water, described wound to Dr. # 52, order to "dc pt home" ,follow up tomorrow am in his office, phone number given and to take "meds" as ordered.
Review of physician ' s orders revealed a verbal order from Dr. #52 to discharge the patient, was written by Nurse # 54. The order was e-signed by Dr. #52 on 11/16/08 at 4:46 pm.
The Nurse gave the patient discharge instructions on 11/16/08 at 10:42am.
Further review of the clinical record revealed a history and physical that was completed on 11/16/08, dictated by Physician # 52 at 1:52 pm and was transcribed at 2:28pm. There was documentation that a physical examination was conducted while the patient was in a hospital bed.
There was documentation on the clinical record that the patient was given discharge instructions at 10:42 am by Staff # 54, Registered Nurse.

During an interview on 8/13/10 at 10 am at the facility with staff # 54 Registered Nurse, she stated she remembered the patient very well. She recounted that she did care for the patient and had discussed his condition with Dr. # 52. According to staff # 54, she took a verbal discharge order for the patient from Dr # 52 and she subsequently discharged the patient with the instructions for him to follow up with the physician in his office. Staff # 52 stated the patient left prior to the end of her shift, which ended at 7 pm. She also stated she did not see the physician come in and see the patient during her shift (7am-7pm). Registered Nurse # 54 stated it was not customary for a patient to be discharged without being seen by a physician, however in this case the patient was not seen as far as she could recall.
During a telephone interview on 8/13/10 at 2pm with Dr. # 52 he stated Dr. # 55 called him to the ER to suture a lacerated ear. According to Dr. # 52 he told Dr. # 55 that an ER Physician should be capable of suturing a lacerated ear. Dr. # 55 said he was not comfortable suturing such a laceration and so he (Dr. # 52) instructed him on what to do. According to Dr. # 52 he did not go to the ER because a lacerated ear was not an emergency situation. There was no threat to loss of life or limb and the patient was not bleeding.
Dr. # 52 stated he could not recall whether or not he saw the Patient # 1. The patient wanted to leave the hospital that ' s why he was discharged. The Doctor further stated he was on his way to the Unit and might have seen the patient in the hall -way.
Dr. # 52 further stated he did see the patient in his office and there was no problem with the ear.
Physician # 52 sent a document from his office dated 11/19/08 which documented Patient # 1 was examined in his office and that his sutures were intact, no evidence of infection, no bleeding or opened wounds. There was no hematoma and that he would see the patient back in his office in a week.
There was also a picture of an ear with Patient # 1's name dated 12/15/08 there was no other information with the picture.

During an interview on 8/13/10 at 11:35 am with Dr. # 53 Emergency Room Medical Director, he stated he had a discussion after the fact, with Dr. # 52 who told him he (Dr. # 52) did not think the patient had an emergency condition and that was his reason for not coming to the hospital.

Patient # 2
Review of Emergency Medical Service (EMS) Report dated 5/8/08 revealed the following information:
EMS went to the home of Patient # 2 on 5/8/08 at 9:29 am and found her lying in bed. She was alert and oriented to person, time and place. The patient had history of having abdominal pain, vomiting, nausea and passing dark colored stools for the past four days and up to the present time.
The EMS Staff examination at that time revealed her skin was cool and clammy, pulse 154 respiration 26 with systolic blood pressure of 70 the staffs were unable to obtain a diastolic pressure, oxygen was administered. She was transported to the Emergency Room.
Review of Emergency Room (ER) Report revealed:
Patient # 2 arrived at the emergency room on 5/8/08 at 10:02am she was triaged right away and was assigned an Acuity Level -2 (Emergent). At the time of triage she was in no apparent distress, skin warm, staffs were unable to assess a blood pressure.
There was documentation that the ER Physician (#55) completed a medical screen examination on 5/8/08 and he documented the patient had dyspnea, and gastric bleeding since 4 days ago.
EMS was unable to get IV, however the patient was given oxygen. She gave history of heavy alcohol consumption, tobacco and cocaine use. She had history of Gastric Bypass.
The patient also complained of abdominal and chest pain.
On examination her abdomen was distended, tender, with no bowel sounds. She was having diarrhea with bloody stool. Decreased air movement in the lungs, dyspnea and was using her accessory muscles. Patient # 2 was diagnosed with perforated bowel and respiratory arrest. Further review of nursing assessment notes revealed the following information:
At 10:20 am Patient # 2 had unstable vital signs her pulse was 160, respiration 36, temperature 93.5, Oxygen saturation 91% on an oxygen mask. At 11:06 the patient ' s condition deteriorated, Staff was unable to obtain a blood pressure.
The Acuity status was changed to Level-1 (Critical). Between the hours of 11:06 and 12:51 pm Patient # 2 remain unstable. She was intubated to assist with her respirations. Staffs were never able to obtain a blood pressure. A central line and nasogastric tube were placed. X-rays were taken and blood collected for complete blood work up. The patient was transfused with blood and blood products and multiple drugs were administered including Dopamine.
There was documentation that the ED physician discussed the case with Dr. #56 at 11:00am and Dr. #50 (Trauma Surgeon on call) at 11: 10 am on 5/8/08. There was no documentation regarding the discussion with the two physicians. There was no documentation that either of the physicians saw the patient.
Further review of the clinical record revealed Patient # 2 was admitted to the Intensive Care Unit (ICU) in critical condition on 5/8/08 at 5:57pm, with diagnoses of bowel perforation and Metabolic Acidosis.
Review of ICU record for Patient # 2, revealed documentation that the patient had purposeful movements, and was able to follow simple commands. Skin Cool, Clammy, mottled, dusky, unable to palpate pulse. Monitor with heart rate of 156. There was documentation that the patient's condition remained unstable. The patient coded and expired at 7:05 pm on 5/8/08.
Review of ICU Nursing notes revealed documentation that the Attending Physician in ICU spoke to Dr. # 50 at 1945 hours and informed him of situation-code Blue. The surgeon stated surgery was not indicated because the patient had no blood pressure.

During an interview on 8/11/10 at 11:45 am with Dr. # 53, Medical Director of the Emergency Room , he stated , following the death of Patient # 2 a peer review of the case was done for quality improvement purposes. According to the Medical Director (Dr. # 53) the review found that Patient # 2 came to the ER in a very unstable condition. She was critically ill. The ER physician (Dr. # 55) consulted with the on-call surgeon (Dr. # 50) in a timely manner and discussed the case with him, however based on the fact that he told the surgeon that the patient was very unstable and chances were she would not make it, and that he would call back with an update the on- call physician did not come in.
The Medical Director stated the physicians did not follow protocol which was that once a trauma one (1) was activated the on call physician must come to the hospital in person or if he was asked to come in he must come in, and if the Surgeon did not come in then the ER physician should have reported to his Superior.
The Medical Director further stated a peer review was done for Patient # 2 because she expired within 24 hours of admission. At the review Dr. # 50 explained that he did not come in because the ER physician said there was no need for him at that time and that the patient might not make it.
During a telephone interview on 8/13/10 at 1:45pm with Dr. # 50 (On-call Surgeon)
The Doctor stated if he were asked to come in he would have come in and assisted the physician. The physician stated he was given the impression that the patient would not make it because she had coded. According to Dr. # 50 he was told he would be informed if he was needed. He further stated he was never called so he assumed the patient had died. Later (about an hour) he went to the ICU and was told the patient was admitted to ICU and had expired shortly afterward. Dr. # 50 stated three months later he was called to a peer review for questioning about the patient. Fortunately he had made some notes when he was called by Dr. # 55 on 5/8/08 ,just in case the situation " came back to haunt him ' he did not make any notation in the patient ' s record because the patient had expired and he never saw her. According to Dr.#50 ,he would never refuse to come see a patient, but the ED physician told him there was not much he could do because the patient was very unstable.
Review of the facility Peer Review document revealed a peer review of the care and death of Patient # 2 was conducted in August 2008.

Review of the facility's Trauma Team Activation # TRA-000002 dated 7/2/2010 revealed:

The purpose of the policy is to identify the criteria to be used in determining the level of trauma team response and the process for notifying the team.
The policy documented in part the following information:

Level 1 response is for most severe injuries. The criteria indicating high risk or life threatening injuries:
1) Confirmed blood pressure less than 90 at any time in adults and age specific hypotension in children.
The response team is as follows:
Trauma Surgeon (will be in EC upon arrival or within 30 minutes, after notification).

Review of Trauma Surgical Services Agreement effective April 2009 until March 31, 2011 page seven (7) section 1.2 documented the following information:

Physicians will respond in a timely manner (Physicians present at bedside within thirty (30) minutes of Trauma Activation) and as requested by the Hospital Emergency Center physician. If the physician is unable to respond in a timely manner, Physician is responsible to for providing back up coverage.

Based on record review, and interview, the facility failed to ensure that On-Call physicians came to the hospital to provide stabilizing treatment for patients with an emergency medical condition;
The facility's on-call physician further failed to come to the hospital and examine a patient who was admitted for further stabilizing treatment .Citing two(2) patients identified in a complaint.

Findings:

Patient # 1
Review of Emergency Room (ER) records for Patient # 1 revealed the following information:
On November 16 , 2008 the 19 year old patient arrived at the ER via Emergency Medical Services (EMS) at 02:23 with history of motor vehicle accident. The patient was triaged at 2:43 am and was assigned Acuity Level-3 (Urgent).
He was alert oriented and awake and gave history of loss of consciousness. Examination revealed the patient had injuries to left and right ear lower lobes and laceration to his face and head. He complained of pain to his right ear, head and shoulder at a level of 8/10. There was no surface injury to the chest. All other areas were within normal limits. Blood pressure was 188/107, purse 76, respiration 18 and temperature 98.7.
Further review revealed documentation that intravenous line was started, blood was drawn for analysis. CT of head and Cervical Spine were done, also X- Ray of face shoulder and chest.
The medical screen examination was conducted by ER Physician # 55, at 02:46. The physician documented that the patient was his own historian and said he was driving a four wheeler unrestrained, and had a roll over accident. He had lost consciousness and was complaining of right shoulder pain and headache.
The examination notes revealed almost complete avulsion (severed) of the right ear. Small inferior pole ridicule attached. The ear was hanging off the skull but the capillary refill was good. The cartilage was torn off and the skull was mangled.
At 3:05 am the patient was given morphine and phenergan for nausea and pain. Diphtheria and Tetanus vaccine was also administered.
Review of treatment records revealed documentation timed at 4:29 am there was documentation that the laceration was repaired; it was complex and extra sutures. The area was dressed with a large Kerlix and covered with 4x4. There were notes that the patient tolerated the procedure well.
Review of vital signs documented on 11/16/08 at 4:49 am revealed they as follows: Blood pressure 172/82, pulse 76, respiration 18, and temperature 100.1 The patient was given intravenous morphine at 3:05 am for pain and was started on IV Ancef (antibiotics).
Patient # 1's condition improved and he was admitted to the floor. He left the ER at 6:00 am.
There was a progress notes written on ER record signed by Physician # 55 which gave information that he called Physician # 52 to come to the ER and repair the patient's ear, because he was not comfortable doing the repair.
According to the note Physician # 52 refused to come in, and asked him (Staff # 55) to do a basic closure which he did.
There was no documentation that Administrative personnel were informed of the Physician's refusal to come in and see the patient.
Review of Unit admission records revealed Patient # 1 arrived on the unit on 11/16/08 at 06:00 am with diagnosis of head injury, right ear (near) avulsion.
His assessment notes documented the patient's systems were all within normal limits. He had no complaints.
Review of nursing notes dated 11/16/08 at 10:57 am documented the following information:
Spoke with Physician # 52, undressed ear wound ,cleaned with sterile water, described wound to Dr. # 52, order to "dc pt home" ,follow up tomorrow am in his office, phone number given and to take "meds" as ordered.
Review of physician ' s orders revealed a verbal order from Dr. #52 to discharge the patient, was written by Nurse # 54. The order was e-signed by Dr. #52 on 11/16/08 at 4:46 pm.
The Nurse gave the patient discharge instructions on 11/16/08 at 10:42am.
Further review of the clinical record revealed a history and physical that was completed on 11/16/08, dictated by Physician # 52 at 1:52 pm and was transcribed at 2:28pm. There was documentation that a physical examination was conducted while the patient was in a hospital bed.
There was documentation on the clinical record that the patient was given discharge instructions at 10:42 am by Staff # 54, Registered Nurse.

During an interview on 8/13/10 at 10 am at the facility with staff # 54 Registered Nurse, she stated she remembered the patient very well. She recounted that she did care for the patient and had discussed his condition with Dr. # 52. According to staff # 54, she took a verbal discharge order for the patient from Dr # 52 and she subsequently discharged the patient with the instructions for him to follow up with the physician in his office. Staff # 52 stated the patient left prior to the end of her shift, which ended at 7 pm. She also stated she did not see the physician come in and see the patient during her shift (7am-7pm). Registered Nurse # 54 stated it was not customary for a patient to be discharged without being seen by a physician, however in this case the patient was not seen as far as she could recall.
During a telephone interview on 8/13/10 at 2pm with Dr. # 52 he stated Dr. # 55 called him to the ER to suture a lacerated ear. According to Dr. # 52 he told Dr. # 55 that an ER Physician should be capable of suturing a lacerated ear. Dr. # 55 said he was not comfortable suturing such a laceration and so he (Dr. # 52) instructed him on what to do. According to Dr. # 52 he did not go to the ER because a lacerated ear was not an emergency situation. There was no threat to loss of life or limb and the patient was not bleeding.
Dr. # 52 stated he could not recall whether or not he saw the Patient # 1. The patient wanted to leave the hospital that ' s why he was discharged. The Doctor further stated he was on his way to the Unit and might have seen the patient in the hall -way.
Dr. # 52 further stated he did see the patient in his office and there was no problem with the ear.
Physician # 52 sent a document from his office dated 11/19/08 which documented Patient # 1 was examined in his office and that his sutures were intact, no evidence of infection, no bleeding or opened wounds. There was no hematoma and that he would see the patient back in his office in a week.
There was also a picture of an ear with Patient # 1's name dated 12/15/08 there was no other information with the picture.
During an interview on 8/13/10 at 11:35 am with Dr. # 53 Emergency Room Medical Director, he stated he had a discussion after the fact, with Dr. # 52 who told him he (Dr. # 52) did not think the patient had an emergency condition and that was his reason for not coming to the hospital.

Patient # 2
Review of Emergency Medical Service (EMS) Report dated 5/8/08 revealed the following information:
EMS went to the home of Patient # 2 on 5/8/08 at 9:29 am and found her lying in bed. She was alert and oriented to person, time and place. The patient had history of having abdominal pain, vomiting, nausea and passing dark colored stools for the past four days and up to the present time.
The EMS Staff examination at that time revealed her skin was cool and clammy, pulse 154 respiration 26 with systolic blood pressure of 70 the staffs were unable to obtain a diastolic pressure, oxygen was administered. She was transported to the Emergency Room.
Review of Emergency Room (ER) Report revealed:
Patient # 2 arrived at the emergency room on 5/8/08 at 10:02am she was triaged right away and was assigned an Acuity Level -2 (Emergent). At the time of triage she was in no apparent distress, skin warm, staffs were unable to assess a blood pressure.
There was documentation that the ER Physician (#55) completed a medical screen examination on 5/8/08 and he documented the patient had dyspnea, and gastric bleeding since 4 days ago.
EMS was unable to get IV, however the patient was given oxygen. She gave history of heavy alcohol consumption, tobacco and cocaine use. She had history of Gastric Bypass.
The patient also complained of abdominal and chest pain.
On examination her abdomen was distended, tender, with no bowel sounds. She was having diarrhea with bloody stool. Decreased air movement in the lungs, dyspnea and was using her accessory muscles. Patient # 2 was diagnosed with perforated bowel and respiratory arrest. Further review of nursing assessment notes revealed the following information:
At 10:20 am Patient # 2 had unstable vital signs her pulse was 160, respiration 36, temperature 93.5, Oxygen saturation 91% on an oxygen mask. At 11:06 the patient ' s condition deteriorated, Staff was unable to obtain a blood pressure.
The Acuity status was changed to Level-1 (Critical). Between the hours of 11:06 and 12:51 pm Patient # 2 remain unstable. She was intubated to assist with her respirations. Staffs were never able to obtain a blood pressure. A central line and nasogastric tube were placed. X-rays were taken and blood collected for complete blood work up. The patient was transfused with blood and blood products and multiple drugs were administered including Dopamine.
There was documentation that the ED physician discussed the case with Dr. #56 at 11:00am and Dr. #50 (Trauma Surgeon on call) at 11: 10 am on 5/8/08. There was no documentation regarding the discussion with the two physicians. There was no documentation that either of the physicians saw the patient.
Further review of the clinical record revealed Patient # 2 was admitted to the Intensive Care Unit (ICU) in critical condition on 5/8/08 at 5:57pm, with diagnoses of bowel perforation and Metabolic Acidosis.
Review of ICU record for Patient # 2, revealed documentation that the patient had purposeful movements, and was able to follow simple commands. Skin Cool, Clammy, mottled, dusky, unable to palpate pulse. Monitor with heart rate of 156. There was documentation that the patient's condition remained unstable. The patient coded and expired at 7:05 pm on 5/8/08.
Review of ICU Nursing notes revealed documentation that the Attending Physician in ICU spoke to Dr. # 50 at 1945 hours and informed him of situation-code Blue. The surgeon stated surgery was not indicated because the patient had no blood pressure.

During an interview on 8/11/10 at 11:45 am with Dr. # 53, Medical Director of the Emergency Room , he stated , following the death of Patient # 2 a peer review of the case was done for quality improvement purposes. According to the Medical Director (Dr. # 53) the review found that Patient # 2 came to the ER in a very unstable condition. She was critically ill. The ER physician (Dr. # 55) consulted with the on-call surgeon (Dr. # 50) in a timely manner and discussed the case with him, however based on the fact that he told the surgeon that the patient was very unstable and chances were she would not make it, and that he would call back with an update the on- call physician did not come in.
The Medical Director stated the physicians did not follow protocol which was that once a trauma one (1) was activated the on call physician must come to the hospital in person or if he was asked to come in he must come in, and if the Surgeon did not come in then the ER physician should have reported to his Superior.
The Medical Director further stated a peer review was done for Patient # 2 because she expired within 24 hours of admission. At the review Dr. # 50 explained that he did not come in because the ER physician said there was no need for him at that time and that the patient might not make it.
During a telephone interview on 8/13/10 at 1:45pm with Dr. # 50 (On-call Surgeon)
The Doctor stated if he were asked to come in he would have come in and assisted the physician. The physician stated he was given the impression that the patient would not make it because she had coded. According to Dr. # 50 he was told he would be informed if he was needed. He further stated he was never called so he assumed the patient had died. Later (about an hour) he went to the ICU and was told the patient was admitted to ICU and had expired shortly afterward. Dr. # 50 stated three months later he was called to a peer review for questioning about the patient. Fortunately he had made some notes when he was called by Dr. # 55 on 5/8/08 ,just in case the situation " came back to haunt him ' he did not make any notation in the patient ' s record because the patient had expired and he never saw her. According to Dr.#50 ,he would never refuse to come see a patient, but the ED physician told him there was not much he could do because the patient was very unstable.
Review of the facility Peer Review document revealed a peer review of the care and death of Patient # 2 was conducted in August 2008.

Review of the facility's Trauma Team Activation # TRA-000002 dated 7/2/2010 revealed:

The purpose of the policy is to identify the criteria to be used in determining the level of trauma team response and the process for notifying the team.
The policy documented in part the following information:

Level 1 response is for most severe injuries. The criteria indicating high risk or life threatening injuries:
1) Confirmed blood pressure less than 90 at any time in adults and age specific hypotension in children.
The response team is as follows:
Trauma Surgeon (will be in EC upon arrival or within 30 minutes, after notification).

Review of Trauma Surgical Services Agreement effective April 2009 until March 31, 2011 page seven (7) section 1.2 documented the following information:

Physicians will respond in a timely manner (Physicians present at bedside within thirty (30) minutes of Trauma Activation) and as requested by the Hospital Emergency Center physician. If the physician is unable to respond in a timely manner, Physician is responsible to for providing back up coverage.

Based on record review and interview the facility failed to document the reason for transfer and the risk and or benefits for Patients # 3, 4 & 5 who went to the Emergency Room for treatment and were transferred to other facilities.

The facility further failed to comply with their transfer policy dated 7/21/10 which require documentation of reason, risk and or benefit of a transfer. Citing 3 of 5 randomly selected transfer patients.

Findings:

Patient # 3
Review of Emergency Room (E R) record for Patient # 3 revealed the Nine months old infant arrived at the ER on 5/28/10 with history of abscess on right buttocks since two days ago. Fever of 100.2, runny nose, skin rash, and had vomited once that day.
The baby was evaluated had a medical screen examination which included blood and urine analysis. The baby was treated with oral Tylenol and clindamycin antibiotic injection.
The physician documented the clinical impression was " Abscess on the buttocks " .
There was documentation that the baby needed follow up and was transferred for higher level of care and insurance to "Hospital B". There was no further documentation of the risk and or benefit of the transfer to the patient.
Patient # 4
Review of ER record for Patient # 4 revealed the four ( 4 ) year old was taken to the ER on 6/14/10 with chief complaint of abdominal pain, nausea, and vomiting. He had a temperature of 99.2, pulse 115 and respiration of 30. There was documentation that the child vomited four times while in the ER. He was triaged assessed, and had a medical screen examination which included blood, urine, and stool analysis.
The patient had an abdominal X-ray, and ultrasound examination also a chest X-ray was done.
There was documentation that he was treated with Morphine for pain, Ondansetron for nausea and intravenous normal saline.
The Clinical Impression was abdominal pain and Hydronephrosis. There was documentation that the patient was transferred to "Hospital B" for higher level of care /out of system transfer. There was no documentation of risk or benefits of the transfer.
During an interview on 8/13/10 at 11:30 an with the Quality Improvement Director Staff # 57 he stated the facility provided Children's services.
Patient # 5
Review of ER record for Patient # 5 revealed the 38 year old revealed was taken to the ER on 5/20/10 with chief complaint of snake bite on right hand, third digit.
He had a temperature of 98.0, pulse 100 and respiration of 20. He was triaged assessed, and had a medical screen examination which included blood for analysis. There was documentation that he was treated with Antivenin, Morphine for pain, and Ondansetron for nausea and intravenous antibiotics. Lead only EKG was done. The Clinical Impression was snake bite.
There was documentation that the patient was transferred to "Hospital C" for higher level of care. There was no documentation of risk or benefits of the transfer.

Review of Transfer policy ADM- 00075 - dated 7/21/10 revealed the following information:

" When a patient has an Emergency Medical condition that has not been stabilized, the patient may be transferred if:

(B) The transferring physician completes a certification statement, which includes a summary of the risks and benefits that, based on the information available at the time of, the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risk to the patient, and in the case of labor, to the unborn child.
Other qualified medical personnel may complete the certification statement on behalf of the physician after consultation with the physician if the physician is not present in the emergency room at the time of the transfer. The physician shall countersign as soon as possible if it is completed initially by Hospital personnel " .