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Based on document review, policy review, medical record review and interview, the hospital failed to ensure a complete and on-going medical screening exam was performed and failed to provide stabilizing treatment and/or transfer for 2 of 6 (Patients #2 and #11) sampled patients who presented to the Emergency Department (ED) seeking medical treatment for burns.

The findings included:

1. Patient #2 was an 81-year-old female who presented to Hospital #1's ED on 7/4/2024 after the patient became dizzy and suffered a syncope episode while cooking jam on the stove in the kitchen. The hot jam spilled on Patient #2 causing burn injuries. Patient #2 had a medical screening exam (MSE) initiated which included a physical exam. The ED Physician documented Patient #2 had primarily first degree burns with only 1 percent (%) total body surface area being second degree burn. The ED Physician note documented first degree burns to the patient's arms, anterior chest and left lateral chest, and a small number of second-degree burns. Patient #2 reported she had been experiencing the syncope episodes for about a year, had sought treatment, but no cause had been determined. There were no laboratory tests or radiological imaging completed to determine the cause(s) of the syncope episode which led to the burns. Patient #2 was discharged home on 7/4/2024 with instructions to apply over the counter aloe vera to her burns and provided a prescription for oral pain medication. There was no documentation the ED Physician contacted a burn center to discuss the case, or provided photos of the burns to a burn center in order to determine if Patient #2 required a higher level of care to treat her burn injuries.

2. Patient #11 was a 79-year-old male who presented to Hospital #1's ED on 2/26/2024 after a welding spark caught his shirt on fire. Patient #11 received a MSE which documented Second degree burns to the upper back, arm and shoulder area covering 9% of the patient's total body surface. Patient #11 was discharged home on 2/26/2024 with prescriptions for oral pain medication and topical burn cream. There was no documentation the ED Physician contacted a burn center to discuss the case, or provided photos of the burns to burn center to determine if Patient #11 required a higher level of care to treat his injuries.

Cross Refer to C-2406 and C-2407.

Based on document review, policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment for an emergency medical condition were provided an appropriate medical screening examination (MSE) for 2 of 6 (Patients #2 and #11) sampled patients suffering burn injuries.

The findings included:

1. Review of the hospital's Medical Staff Rules and Regulations approved by the Board of Director's on 12/10/2023 revealed, "... Emergency Services...In accordance with EMTALA [Emergency Medical Treatment and Labor Act], individuals presenting to the Emergency Department will receive a Medical Screening Exam (MSE) within the capabilities of the Hospital, conducted by a Qualified Medical Person (QMP), as well as treatment and stabilization, as determined necessary by the QMP. In all cases, a Qualified Medical Person will be defined as a physician..."

2. Review of the hospital's "EMTALA definitions and Terminology" policy reviewed on 4/23/2024, revealed, "PURPOSE: To ensure consistent use of terminology related to the Emergency Medical Treatment Act (EMTALA) within [named Hospital system]... POLICY: The Hospitals will demonstrate compliance with requirements under EMTALA... PROCEDURE:... EMTALA Definitions:...Emergency Medical Condition...For all individuals- A medical condition manifesting itself by acute signs and symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in either: 1. placing the health of the individual...in serious jeopardy; 2. Serious impairment to bodily functions; or 3. serious dysfunction of any bodily organ or part...EMTALA means the Emergency Medical Treatment Labor Act...which requires hospitals to provide medical screening, treatment and transfer of individuals with Emergency Medical Conditions...Medical Screening Examination means and examination conducted by a QMP of a sufficient nature to determine whether or not an Emergency Medical Condition exists. The examination is non-discriminatory and consistent for all patients with the same symptoms...A Medical Screening Examination includes ancillary services routinely available to the ED, including tests, procedures, and the services of on-call physicians....Qualified Medical Person or QMP means those professionals who have been identified by the Hospital's governing body as qualified to administer a Medical Screening Examination..."

Review of the hospital's "EMTALA- Medical Screening Examinations" policy reviewed on 6/21/2022 revealed, "PURPOSE: To ensure compliance with the Emergency Medical Treatment and Labor Act (EMTALA) requirement to conduct Medical Screening Examinations on individuals that present to a [named Hospital system] Emergency Department (ED) and request emergency services. POLICY: All individuals presenting to a Hospital ED or other hospital property requesting examination or treatment are entitled to receive an appropriate MSE performed by qualified individuals to determine whether or not an Emergency Medical Condition exists...PROCEDURE: Any individual presenting to the ED or other Hospital property and requesting emergency care will receive an MSE within the capabilities of the Hospital's ED to determine whether or not and Emergency Medical Condition exists. These capabilities include the utilization of ancillary services, diagnostic methods and specialist physicians routinely available to the Hospital and the ED...Qualified Medical Persons: Qualified Medical Persons (QMPs) will conduct MSEs in the ED...The MSE will determine, within reasonable medical probability, whether a person presenting to the Hospital requesting an examination or treatment is suffering from an Emergency Medical Condition. The MSE will be performed in accordance with standard protocols established by the ED...as appropriate and approved by the Medical Staff..."

3. Review of the ED medical record for Patient #2 dated 7/4/2024 revealed an 81 year old female who presented to Hospital #1's ED at 10:53 AM via private vehicle with complaints of burns to the arm. A nursing triage assessment was initiated at 11:00 AM and revealed, "Patient arrived to ED with her daughter. Patient reports she was canning jelly and became hot and dizzy. Patient was alone at home when this happened and reports when she woke up she had burns on her arms, chest and abdomen." Patient #2's pain assessment revealed primary pain to the upper arm, lower arm, chest and abdomen with a burning sensation, and defined as severe pain, with grimacing noted. The patient reported movement made the pain worse.

A MSE was initiated by ED Physician #1 on 7/4/2024 at 11:00 AM. ED Physician #1 documented, "The patient presents with burn. The onset was just prior to arrival. Agent hot liquid (Hot Jelly off the stove). The character of symptoms is pain and redness. The degree of symptoms is moderate...the location where the incident occurred was at home. Additional history: Pt [patient] was carrying jelly off the stove and she passed out. Pt reportedly has these 'spells' (syncopal episodes) when she gets hot and has been evaluated for this before, 'but they can never find anything wrong'..." The physical examination by ED Physician #1 revealed, "...Skin: Burn(s): Arms, anterior chest and left lateral chest, 1st degree [First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters] 15% [percentage of total body with 1st degree burn] partial (2nd degree) [second degree burns affects the first and second layers of skin, blisters may develop and pain can be severe] 1% (small amount of 2nd degree/blistering over inner aspects of arms)..." ED Physician #1 documented Patient #2 had "Burn of upper arm, first degree, burn of abdominal wall, first degree, burn of upper arm, second degree..."

On 7/4/2024 at 11:30 AM (2 minutes after Patient #2 had received Fentanyl for pain relief), ED Physician #1 documented Patient #2 was improved and stable for discharge home with medication prescriptions sent to her pharmacy. ED Physician #1 documented, "...Patient was given the following educational materials: Advised patient to dress her burns with Aloe Gel and take pain medication PRN [as needed]. Cautioned to watch for signs of infection. She voiced a good understanding of this plan. Follow up with: Primary Care Physician...."

There was no documentation ED Physician #1 performed a further assessment of Patient #2 and no documentation of radiological imaging or laboratory testing to determine the cause of Patient #2 dizziness, and/or syncopal episode that was reported just prior to the fall and multiple burns. There was no documentation ED Physician #1 had contacted a burn center for consultation on how to treat the burns or if the burns required a higher level of care.

The following day on 7/5/2024, Patient #2 contacted Emergency Services (EMS). Review of the EMS Patient Care Record for Patient #2 dated 7/5/2024 revealed dispatch was notified at 6:32 AM (20 hours after Patient #2 was discharged from Hospital #1) and arrived at the home of Patient #2 on 7/5/2024 at 6:57 AM. EMS documented, "Received call from [named dispatch] to respond to unknown age female feeling faint and hot. Responded immediately and found this patient [Patient #2] lying on couch. Daughter met us outside giving patient update. Patient was burnt yesterday w/ [with] second degree burns while cooking. She now c/o [complains of] being hot and dizzy and nauseated...skin pale slightly clammy...2nd degree burn blisters and present at arm pits, on or near palm, chest and upper abdomen, she was seen yesterday in [named Hospital #1] for burns...Assist X [by] 2 to the cot. Moved to unit [EMS van]...Difficult to find an IV [intravenous- to give patient fluids] site due to burns...Start INT [intermittent needle therapy] in right ankle w [with] 20G [size of needle that was used], flushed well. Administered 4 mg of Zofran [medication used to treat nausea and vomiting] with slight relief. Transport to [named Hospital #2] per patient request. Patient vomits 2-3 times during transport. Arrived at Hospital #2 ED stable..."

Patient #2 care was transitioned to Hospital #2's ED staff at on 7/5/2024 at 8:11 AM.

Review of the laboratory results for Patient #2 at Hospital #2 on 7/5/2024 at 8:41 AM revealed the following: D dimer (a test to check for blood clotting problems), level was elevated at 1.77 (normal range equal to or less than 0.50), Sodium was low at 130 (normal range 137-145),
White Blood Cell count (WBC) was elevated at 14.2 (normal range 4.8-10.8), Neutrophils were elevated at 82.2 (normal 43.0-65.0), Lymphocyte counts were low at 10.3 (normal 20.5-45.5).

The CT with contrast, performed at Hospital #2, resulted on 7/5/2024 at 11:52 AM revealed, "Mild dependent lower lobe ground glass opacification and nodular consolidative opacity in the dependent right lower [ground glass opacity shows up on lung scans if something, such as swelling or fluid, is partially blocking the air spaces in the lungs]. Findings may represent any combination of atelectasis infectious infiltrate or aspiration. follow-up imaging recommended to ensure resolution..."

On 7/5/2024 at 2:04 PM, the ED Physician documented that Hospital #3 (a higher level of care for burns) had accepted Patient #2 as a transfer. The ED Physician documented Patient #2's discharge diagnoses were near syncope, first- and second-degree deep thickness burns, and sepsis secondary to pneumonia, and "...She [Patient #2] triggered SIRS [Systemic inflammatory response syndrome - inflammation that affects the whole body in response to and infectious or non-infectious insult] CT scan concerning for possible pneumonia..."

Patient #2 was admitted to the hospital's burn unit on 7/6/2024 at 3:11 AM.

3. In an interview on 7/22/2024 at 10:30 AM, the Director of Quality at Hospital #1 reported the Hospital #1 was a Critical Access Hospital and did not have an on-call physicians for specialties. She reported all patients requiring a higher level of care were transferred out.

In an interview on 7/23/2024 at 1:08 PM, the Chief Nursing Officer, Clinical Manager of the ED and Director of Quality for Hospital #1 stated there were no specific protocols for patients presenting with burns or thermal injuries at Hospital #1. At 1:10 PM, the Clinical Manager of the ED stated the nursing staff follow the specific physician orders for care of burn patients.

In an interview on 7/23/2024 at 3:35 PM, ED Physician #1 at Hospital #1 verified he had provided care to Patient #2 in the ED on 7/4/2024. When asked if there were specific protocols for treating burn patients, ED Physician #1 stated he always sent third degree burns and significant second degree burns to a higher level of care burn center. ED Physician #1 stated Patient #2 had minimal second-degree burns. ED Physician #1 stated Patient #2 had "a little bit of blistering on her chest area." ED Physician #1 stated the Patient had a majority of first degree burns and no skin sloughing when she presented to Hospital #1. ED Physician #1 stated he had Hospital #3's burn unit telephone number in his phone, and he had the ability to call and send pictures if he had concerns a burn patient needed a higher level of care. ED Physician #1 stated, "If minor burns, I don't call..." ED Physician #1 verified he did not address the syncopal episodes/blacking out, and stated it was because Patient #2 reported it had been happening for some time, and that she had already been worked up with no cause determined.

In a telephone interview on 7/23/2024 at 3:51 PM, the ED Medical Director at Hospital #1 verified there were no specific protocols for patients with burns or thermal injuries. The ED Medical Director stated just like triage the ED physician assessed the burn and depending on the degree of the burn and percentage area of the burn, the physician determined if the patients needed to be referred to a local burn center. The ED Medical Director stated it was based on the physician's assessment of the individual patient and there was no hard and fast rule about when to transfer to a higher level of care. The ED Medical Director stated if the burn was circumferential (where a full thickness burn affects the entire circumference of a digit, extremity, or even the torso), a hand, face or genitalia, they would refer to a burn center.

The hospital did not evaluate syncopal episode, consult or transfer Patient #2 to a burn center for definitive care when she presented to Hospital #1's ED on 7/4/2024 at 10:53 AM seeking care for an emergency medical condition.

4. Review of the ED medical record for Patient #11 dated 2/26/2024 revealed a 79 year old male who presented to Hospital #1's ED at 1:32 PM via private vehicle with complaints of an arm burn. A nursing triage assessment was initiated on 2/26/2024 at 1:40 PM and revealed, "Pt presents to ED with complaints of burn to right arm/shoulder. pt states that he was cutting metal when the sparks caught his shirt on fire. pt states he ran over to water hose and put the fire out, pt took off burned clothing. pt states his injury occurred about 45 mins [minutes] prior to his arrival. pt has burns noted to right shoulder/bicep/axillary area/scapula. pt states his pain is moderate in intensity, aching. pt is alert and oriented, ambulatory, respirations even and unlabored..." The nursing burn assessment revealed Patient #11 with a thermal burn to the shoulder and upper arm with the appearance of dry and leathery (white, black or brown tissue), red and dry, and the length of exposure to fire as unknown.

A MSE of Patient #11 was initiated by ED Physician #2 on 2/26/2024 at 2:10 PM. ED Physician #2 documented, "The patient presents with burn and shirt caught fire from grinder sparks, got clothes off douced in water. The onset was just prior to arrival. The course/duration of symptoms is improving. Agent flame. Location: Right back upper extremity. The character of symptoms is pain and redness. The degree of symptoms is minimal. Risk factors consist of none...The location where the incident occurred was at home..." The physical examination performed by ED Physician #2 revealed, "...Skin: Burn(s) R ue [upper extremity]/back, partial (2nd degree) 9% [percentage of total body with 2nd degree burn], r [right] ant [anterior] arm, shoulder and r upper back..." ED Physician #2 documented Patient #11 had "Burn of multiple sites of upper extremity, right, second degree..."

ED Physician #2 documented Patient #11 was stable and medically cleared for discharge home, with medication prescriptions sent to his pharmacy.

On 2/28/2024 at 7:41 PM, Patient #11 presented to Hospital #3's ED. The triage nursing assessment initiated at 7:45 PM revealed, "Pt with c/o [complaints of] 3rd degree burns to right arm sustained Monday [2/26/2024] was cutting metal and had a spark caught shirt on fire. Pt seen at [named Hospital #1]...Pt seen at [outpatient] wound center today and sent to see burn here..."

Patient #11 was admitted to the Hospital #3's burn unit on 2/29/2024 at 12:02 AM.

5. In a telephone interview on 7/23/2024 at 11:30 AM, Patient #11 verified he was treated and released from Hospital #1's ED on 2/26/2024. When asked if he had to seek further treatment for his burn injuries after discharge from Hospital #1's ED, Patient #11 stated, "Yes, I went to [named Hospital #3] the next day...drove up there and sit in the waiting room..." Patient #11 stated he was admitted to Hospital #3's burn unit after evaluation in Hospital #3's ED. The Patient stated he was in the hospital for 3 weeks. Patient #11 stated he still had limitations in his arm from the burns. Patient #11 did not recall Hospital #1's medical staff recommending he be transferred to Hospital #3 during his 2/26/2024 ED visit.

In a telephone interview on 7/23/2024 at 2:00 PM, ED Physician #2 at Hospital #1 verified he had provided treatment to Patient #11 on 2/26/2024 for a burn. Physician #2 stated he did recall Patient #11. ED Physician #2 stated, "What is the problem exactly?" The surveyor asked the Physician how the determination was made to discharge a patient with burns, versus referral to a higher level of care. ED Physician #2 stated, "He [Patient #11] left AMA [against medical advice]. I wanted to send him to [named Hospital #3 burn unit] but he refused...he left AMA. The surveyor asked ED Physician #2 if the refusal of a higher level of care and leaving AMA was documented. ED Physician #2 stated, "I believe I did..." When the surveyor explained to the ED Physician that there was no documentation of recommendations to transfer Patient #11 to Hospital #3's burn unit, or any documentation about Patient #11 leaving AMA or refusing the transfer, ED Physician #2 stated, "I am not sure, all I am saying is I had a conversation with the patient...you can call him and verify. He refused to go to [named Hospital #3]." There was no documentation of an AMA form in Patient #11's medical record.

In an interview on 7/23/2024 at 2:15 PM, the surveyor asked the Director of Quality at Hospital #1 to review the ED Physician note for Patient #11 dated 2/26/2024 at 2:20 PM. The Director of Quality was specifically asked if Patient #11 refused the higher level of care at a burn center and had left the ED AMA. The Director of Quality verified there was no documentation in the record about referring Patient #11 to a burn unit,or the patient's refusal to follow the physician's medical direction or that Patient #11 had left AMA. The Director of Quality verified Patient #11 was medically cleared and discharged to home.

The hospital did not consult or transfer Patient #11 to a burn center for definitive care when he presented to Hospital #1's ED on 2/26/2024 at 1:32 PM seeking care for an emergency medical condition.

Cross Refer to C2407.

Based on document review, policy review, medical record review and interview, the hospital failed to ensure all patients presenting to the hospital's Emergency Department (ED) seeking medical treatment for an emergency medical condition were stabilized within the capabilities of the hospital or appropriately transferred to a higher level of care for 2 of 6 (Patients #2 and #11) sampled patients suffering from burns injuries.

The findings included:

1. Review of the hospital's Medical Staff Rules and Regulations approved by the Board of Director's on 12/10/2023 revealed, "B. Emergency Services... In accordance with EMTALA [Emergency Medical Treatment and Labor Act], ... Patients with conditions whose definitive care is beyond the capabilities of this Hospital shall be referred to the appropriate facility, when in the judgement of the attending practitioner, the patient condition permits such a transfer. The Hospital's procedures for patient transfers to other facilities shall be followed ensuring compliance with... EMTALA guidelines..."

2. Review of the hospital's "EMTALA definitions and Terminology" policy reviewed on 4/23/2024, revealed, "... Stabilized... means resolution of the Emergency Medical Condition such that the patient's condition is one where no material deterioration is likely, within reasonable medical probability, to occur or result from the transfer/discharge of the patient... Stable for Discharge means that after providing a Medical Screening Examination and stabilizing treatment, the Hospital may discharge a patient if the treating physician, has determined, within reasonable clinical confidence, that the patient has reached the point where his/her continued care (including diagnostic work up and treatment) could be reasonable performed as an outpatient or at a later time as inpatient..."

Review of the hospital's "EMTALA Stabilization and Transfer" policy reviewed on 12/19/2023 revealed, "PURPOSE: To ensure compliance with the Emergency Treatment and Active Labor Act (EMTALA) requirements to stabilize, and in some instances transfer, individuals presenting to [named Hospital system] that are found to have emergency medical conditions. POLICY: Patients found to have an emergency medical condition will be provided with stabilizing treatment within the Hospital's capabilities before being transferred or discharged. Patient transfers will be performed according to procedures and within the guidelines of EMTALA. PROCEDURE: A. Stabilization: A patient is deemed to have been stabilized when the treating physician attending the patient in the Emergency Department (ED) determines within reasonable clinical confidence that the emergency medical condition has resolved... Stabilizing treatment may include: a. evaluation of the patients emergency medical condition by a physician, b. stabilizing treatments within the capabilities of the Hospital's medical staff, ED and ancillary services routinely available in the ED..."

3. Review of the ED medical record for Patient #2 revealed an 81 year old female who presented to Hospital #1's ED on 7/4/2024 at 10:53 AM via private vehicle with complaints of burns.

A nursing triage assessment was initiated on 7/4/2024 at 11:00 AM and revealed Patient #2 arrived to Hospital #1's ED with her daughter. Patient reported she was canning jelly, became hot and dizzy and passed out. Patient #2 was alone at home when this happened and reports when she woke up she had burns on her arms, chest and abdomen. Patient #2's pain assessment revealed primary pain to upper arm, lower arm, chest and abdomen with a burning sensation, and defined as severe pain, with grimacing noted. The patient reported movement made the pain worse.

A MSE was initiated by ED Physician #1 on 7/4/2024 at 11:00 AM. ED Physician #1 documented, "The patient presents with burn. The onset was just prior to arrival. Agent hot liquid (Hot Jelly off the stove). The character of symptoms is pain and redness. The degree of symptoms is moderate... the location where the incident occurred was at home. Additional history: Pt [patient] was carrying jelly off the stove and she passed out. Pt [patient] reportedly has these 'spells' (syncopal episodes) when she gets hot and has been evaluated for this before, 'but they can never find anything wrong'..." The physical examination by the ED Physician revealed, "...Skin: Burn(s): Arms, anterior chest and left lateral chest, 1st degree [First-degree burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters] 15% [percentage of total body with 1st degree burn] partial (2nd degree) [second degree burns affects the first and second layers of skin, blisters may develop and pain can be severe] 1% (small amount of 2nd degree/blistering over inner aspects of arms)..." ED Physician #1 documented Patient #2 had "Burn of upper arm, first degree, burn of abdominal wall, first degree, burn of upper arm, second degree..."

On 7/4/2024 at 11:30 AM (2 minutes after Patient #2 received Fentanyl for pain relief), ED Physician #1 documented Patient #2 was improved and stable for discharge home and medication prescriptions had been sent to the patient's pharmacy. ED Physician #1 documented, "...Patient was given the following educational materials: Advised patient to dress her burns with Aloe Gel and take pain medication PRN [as needed]. Cautioned to watch for signs of infection. She voiced a good understanding of this plan. Follow up with: Primary Care Physician...."

There was no documentation of further stabilization or treatment following the Fentanyl administration. There was no documentation ED Physician #1 performed imaging or laboratory testing and no documentation Patient #2's pain was reassessed prior to discharge. There was no documentation ED Physician #1 at Hospital #1 contacted a burn center for consultation on how to treat the patient's burns and if the burns required a higher level of care.

On 7/5/2024 Patient #2 contacted the Emergency Services (EMS). Review of the EMS Patient Care Record for Patient #2 dated 7/5/2024, revealed EMS dispatch was notified at 6:32 AM (20 hours after discharge from Hospital #1) and arrived at the home of Patient #2 on 7/5/2024 at 6:57 AM. The EMS narrative revealed, "Received call from [named dispatch] to respond to unknown age female feeling faint and hot. Responded immediately and found this patient lying on couch. Daughter met us outside giving patient update. Patient was burnt yesterday w/ [with] second degree burns while cooking. She now c/o [complains of] being hot and dizzy and nauseated... skin pale slightly clammy...2nd degree burn blisters and present at arm pits, on or near palm, chest and upper abdomen, she was seen yesterday in [named Hospital #1] for burns... Assist X [by] 2 to the cot. Moved to unit. ...Difficult to find an IV [intravenous- to give patient fluids] site due to burns... Start INT [intermittent needle therapy] in right ankle w [with] 20G [20 grams of normal saline], flushed well. Administered 4 mg of Zofran [medication used to treat nausea and vomiting] with slight relief. Transport to [named Hospital #2] per patient request. Patient vomits 2-3 times during transport."

Review of Patient #2's ED Medical record from Hospital #2 dated 7/5/2024 at 8:25 AM revealed the triage nurse documented Patient #2 had a syncopal episode while cooking jelly on 7/4/2024 resulting in second degree burns to her bilateral arms, left flank, left breast, bilateral sides of neck, and she was evaluated and released from Hospital #1 on 7/4/2024. Patient #2 reported her pain at 10, on a scale of 1-10 with 10 being the most severe. A nursing note dated 7/5/2024 at 10:30 AM revealed, "This nurse called [named Hospital #1] to obtain ER [Emergency Room] visit from yesterday, per provider order."

The ED Physician at Hospital #2 documented the following on 7/5/2024 at 8:40 AM: "81-year-old female with history of bradycardia with pacemaker... Patient states her syncopal episodes began approximately one year ago. She states they typically associated when she gets hot. She states that a couple weeks ago she was attending a funeral outside, got hot and did pass out...Patient states yesterday she was feeling significantly better and decided to make jamb [jam/jelly]. Patient states she got hot while making the gym [jam] and the next thing she knows she was on the floor. The jam did fall over her and she states she did have to cut off her shirt. She is not sure how long she was down for and she denies any seizure like activity... She does note that typically she gets nauseous prior to the episodes. She did go to an outlying emergency room who evaluated her for her burns. She states that she was told to use Aloe Vera and was given pain medication and tetanus was updated... She states she has had decreased po [by mouth] intake and decreased urination. Patient states that this morning she got up was going to get breakfast. She began feeling hot diaphoretic and near [knew] she was about to pass out, so she went to lay down."

The Physician's physical examination at Hospital #2's ED on 7/5/2024 at 11:52 AM revealed Skin: first and second- degree burns bullae (bullae are large blisters on the skin that are filled with clear fluid) on the right upper extremity, bullae on the abdomen, circumferential burns (burns that go around the body- when the entire circumference of a limb or finger is burned) to fingers 2 on the right side.

Hospital #2 performed laboratory and diagnostic tests. Patient #2's D dimer was elevated at 1.77 (normal range equal to or less than 0.50), Sodium was low at 130 (normal range 137-145), white blood cell count was elevated at 14.2 (normal range 4.8-10.8), Neutrophils were elevated at 82.2 (normal 43.0-65.0), lymphocyte counts were low at 10.3 (normal 20.5-45.5).

The results of the CT (Computerized Tomography - scan that takes cross sections or slices of the structures of the body) with contrast on 7/5/2024 at 11:52 AM revealed, "Mild dependent lower lobe ground glass opacification and nodular consolidative opacity in the dependent right lower [ground glass opacity shows up on lung scans if something, such as swelling or fluid, is partially blocking the air spaces in the lungs]. Findings may represent any combination of atelectasis infectious infiltrate or aspiration. follow-up imaging recommended to ensure resolution..."

On 7/5/2024 at 12:30 PM, Patient #2 was administered pain medication and started on intravenous antibiotic,Vancomycin (antibiotic) for possible pneumonia. The ED Physician documented Hospital #3 had accepted Patient #2 as a transfer. The discharge diagnoses were: Near syncope, first- and second-degree deep thickness burns, sepsis secondary to pneumonia. The ED Physician further documented, "...She triggered SIRS [Systemic inflammatory response syndrome of non-infectious origin without acute organ dysfunction] CT scan concerning for possible pneumonia...The patient will be transported to a higher level of care..."

Patient #2 was transported by air ambulance on 7/5/2024 Hospital #2 to Hospital #3 for further care and treatment of her burn injuries.

Patient #2 presented to Hospital #3's ED on 7/5/2024 at 8:47 PM. The triage nursing assessment initiated at 8:47 PM revealed, "Pt arrived via [named air ambulance]... as level 2 burn alert. Pt had syncopal episode yesterday around 10 am [AM] while cooking jelly. Pt awoke on the ground with burns to BUE [bilateral upper extremities], chest, abdomen, and back..."

At Hospital #3 a MSE was initiated on 7/5/2024 at 9:00 PM and revealed, "presented to the ED via EMS as a level 2 burn alert for concern of thermal burns to approximately 18% BSA [body surface area is the percentage of total area burned on the body]... She went to an outside hospital [Hospital #1] yesterday... discharged home instructed to place aloe vera on her burns. She presented to another hospital [Hospital #2] today... she was transferred here for further evaluation..." The ED Physician's physical exam revealed Neck burns, multiple first and second degree burns to bilateral upper extremities, left neck, torso calculated to be 13 to 14% BSA, with full thickness (also known as third degree burns burns, third-degree burns destroy the epidermis and dermis, may also damage the underlying bones, muscles, and tendons and leave no sensation in the area since the nerve endings are destroyed) to upper extremities although body surface area is minimal.

A Burn Surgery History & Physical note dated 7/6/2024 at 12:27 AM at Hospital #3 revealed Patient #2 was seen on 7/5/2024 in the ED. The Burn Surgery Team documented, "...81-year-old female presenting... after sustaining 12.9% second degree and 1.4% third degree burns (14.3 TBSA) [total body surface area is a tool medical professionals use to assess the severity of burns] by thermal scald from hot jam... She complains of acute onset, mild- moderate, burning pain localized to her burns. The pain is worse with palpation or exposure to the air and better with administration of pain control medications..."

Patient #2 was admitted to Hospital #3's burn unit on 7/6/2024 at 3:11 AM.

At Hospital #3 on 7/8/2024 at 7:33 PM an Autonomics (Autonomics is a branch of neurology that deals with the autonomic nervous system which controls heart rate blood pressure and respirations) consult note dated 7/8/2024 revealed Patient #2 had a clinical picture of vasovagal syncope (causes heart rate and blood pressure to drop suddenly leading to reduced blood flow to the brain, causing the brief loss of consciousness). The physician recommended good hydration, continued pain management for burns, use of an abdominal binder when getting out of bed and drinking water 15 minutes prior to standing.

An operative report dated 7/8/2024 at 3:42 PM revealed, "PROCEDURE... She comes to the OR [Operating Room] today for excision [removal of burned skin while preserving underlying viable tissue] and allograft [skin graft taken from the skin bank (cadaver skin) and placed on a patient's burn to help it heal- not a permanent graft] for full thickness areas...Procedure performed: 1. Excision burn left upper arm 162cm [centimeters] 2 [squared area], right upper arm 426cm2, right forearm 80cm2, abdomen 137cm2, left breast 48cm2 2. Placement cadaveric allograft on left upper arm 162cm2, right upper arm 426cm2, right forearm 80cm 2, abdomen 137cm2, left breast 48cm2. Findings: all excised areas were full thickness aka [also known as] third degree burns..."

An operative report dated 7/19/2024 at 12:50 PM revealed, "...PROCEDURE... The patient has been undergoing daily wound care and has previously had excision and allograft to multiple sites. We are returning today to remove the allograft, excise additionally converted full thickness areas, and autograft [grafts that have been taken from the patient] as able..."

Patient #2 required Occupational Therapy (OT) services related to the burn injuries during hospitalization at Hospital #3. An OT evaluation was conducted on 7/6/2024 at 12:10 PM due to limited range of motion and generalized weakness, limited mobility and limited tolerance related to activities of daily living.

Patient #2 required Physical Therapy (PT) services related to burn injuries during hospitalization at Hospital #3. A PT evaluation was conducted on 7/7/2024 at 12:15 PM due to decreased strength, difficulty ambulating and decreased activity tolerance.

Patient #2 was discharged home on 7/25/2024 with referrals for home health care for skilled nursing services to provide daily wound care to the burn injuries and PT services for continued therapy, and instructions to follow up with the outpatient burn clinic.

In an interview on 7/22/2024 at 10:30 AM, Hospital #1's Director of Quality reported the hospital was a Critical Access Hospital and did not have an on-call physicians for specialties. She reported all patients requiring a higher level of care were transferred out.

In a telephone interview on 7/23/2024 at 10:40 AM, Patient #2's sister stated had undergone 2 skin grafts due to the severity of her burn injuries.

In an interview on 7/23/2024 at 1:08 PM at Hospital #1, the Chief Nursing Officer, Clinical Manager of the ED and Director of Quality stated there were no specific protocols for patients presenting with burns or thermal injuries at Hospital #1. At 1:10 PM, the Clinical Manager of the ED stated the nursing staff follow the specific physician orders for care of burn patients.

In an interview on 7/23/2024 at 3:35 PM, ED Physician #1 at Hospital #1 verified he had provided care to Patient #2 in the ED on 7/4/2024. When asked if there were specific protocols for treating burn patients, ED Physician #1 stated he always sent third degree burns and significant second degree burns to a higher level of care burn center. ED Physician #1 stated Patient #2 had minimal second-degree burns. ED Physician #1 stated Patient #1 had "a little bit of blistering on her chest area." ED Physician #1 stated the Patient had a majority of first degree burns and no skin sloughing when she presented to Hospital #1. ED Physician #1 stated he had Hospital #3's burn unit telephone number in his phone and he had the ability to call and send pictures if he had concerns a burn patient needed a higher level of care. ED Physician #1 stated, "If minor burns, I don't call..." ED Physician #1 verified he did not address the syncopal episodes/blacking out.

In a telephone interview on 7/23/2024 at 3:51 PM, the ED Medical Director at Hospital #1 verified there were no specific protocols for patients with burns or thermal injuries. The ED Medical Director stated, just like triage, the ED physician assessed the burn and depending on the degree of the burn and percentage area of the burn, the provider determined if the patients need to be referred to a local burn center. The ED Medical Director stated it was based on the provider's assessment of the individual patient and there was no hard and fast rule about when to transfer to a higher level of care. The ED Medical Director stated if the burn was circumferential (where a full thickness burn affects the entire circumference of a digit, extremity, or even the torso), a hand, face or genitalia, they would refer to a burn center.

Hospital #1 failed to provide stabilizing treatment to Patient #2's extensive burns to her body and transfer Patient #2 to a higher level of care that provided specialized care for patients who experienced burns. Patient #2 sought continued emergency treatment of her emergency medical condition at Hospital #2 on 7/5/2024.

4. Review of the ED medical record for Patient #11 dated 2/26/2024 revealed a 79 year old male who presented to the Hospital #1's ED at 1:32 PM via private vehicle with complaints of an arm burn. A nursing triage assessment was initiated at 1:40 PM and revealed, "Pt presents to ED with complaints of burn to right arm/shoulder. pt states that he was cutting metal when the sparks caught his shirt on fire. pt states he ran over to water hose and put the fire out, pt took off burned clothing. pt states his injury occurred about 45 mins [minutes] prior to his arrival. pt has burns noted to right shoulder/bicep/axillary area/scapula. pt states his pain is moderate in intensity, aching. pt is alert and oriented, ambulatory, respirations even and unlabored..." The nursing burn assessment revealed a thermal burn to the shoulder and upper arm with the appearance dry and leathery (white, black or brown tissue), Red and dry, with the length of exposure to fire unknown.

A MSE was initiated by ED Physician #2 on 2/26/2024 at 2:10 PM at Hospital #1. ED Physician #2 documented, "The patient presents with burn and shirt caught fire from grinder sparks, got clothes off douced in water. The onset was just prior to arrival. The course/duration of symptoms is improving. Agent flame. Location: Right back upper extremity. The character of symptoms is pain and redness. The degree of symptoms is minimal. Risk factors consist of none... The location where the incident occurred was at home..." The physical examination performed by ED Physician #2 revealed, "...Skin: Burn(s) R ue [upper extremity]/back, partial (2nd degree) 9% [percentage of total body with 2nd degree burn], r [right] ant [anterior] arm, shoulder and r upper back..." ED Physician #2 documented Patient #11 had "Burn of multiple sites of upper extremity, right, second degree..."

ED Physician #2 documented Patient #11 was stable and medically cleared for discharge home, with medication prescriptions sent to his pharmacy.

Patient #11 presented to Hospital #3's ED on 2/28/2024 at 7:41 PM. The triage nursing assessment initiated at 7:45 PM revealed, "Pt with c/o [complaints of] 3rd degree burns to right arm sustained Monday [2/26/2024] was cutting metal and had a spark caught shirt on fire. Pt seen at [named Hospital #1]...Pt seen at [outpatient] wound center today and sent to see burn here..."

A MSE was initiated at Hospital #3 on 2/28/2024 at 7:45 PM. At 8:08 PM, the ED Physician note revealed, "...presented with c/o of burn to right back and rue [right upper extremity]. Pt states he was welding Monday night when his shirt caught fire. He presented to an OSH [outside hospital] and was recommended for him to present here. Pt "felt fine" and f/u [followed up] with wound care clinic today in [named county] where it was recommended that he present to our [Hospital #3] ED..." The ED Physician documented the Patient had full and partial thickness burns to the right back and RUE extended distally to the elbow.

A Burn Surgery consult note, performed in the ED, dated 2/28/2024 at 9:28 PM revealed, "...79 y.o. [year old] male with PMH [past medical history] of CKD [chronic kidney disease] and HTN [hypertension] who presented 2/28/2024 for e/m [evaluation and management] of burn wounds. Mechanism of injury described as welding accident...admitted to the burn unit for management. Assessment revealed 7 % TBSA partial thickness burn wounds to posterior torso and right arm forearm..."

Patient #11 was admitted to the Hospital #3's burn unit on 2/29/2024 at 12:02 AM.

An operative report dated 2/29/2024 at 1:02 PM revealed, "...OPERATION: 1. Tangential excision of burn wound eschar [Tangential excision of burned tissue involves unroofing the burn eschar and debriding the dead tissue layer by layer until encountering healthy bleeding tissue] and preparation of wound bed to right forearm 208cm2, right upper arm 784cm2, right back 315cm2, right shoulder 144cm2. 2. Placement of 2:1 meshed allograft [Skin meshing is frequently used in the coverage of extensive burn injuries and allows coverage of more extensive areas] to right forearm 208cm2, right upper arm 784cm2, right back 316cm2, right shoulder 144cm2... INDICATIONS FOR PROCEDURE:... Patient requires excision and grafting of their full thickness burns for both wound closure and preservation of function..."

An operative report dated 3/6/2024 at 1:40 PM revealed, "PROCEDURE... admitted to [named Hospital #3 burn unit] 1 week ago after sustaining a 6.5 % TBSA 3rd degree burn involving his right upper back, shoulder, axilla [arm pit], upper arm and forearm. He underwent initial burn excision and placement of cadaveric allograft [donated cadaver skin usually cryopreserved and available through tissue banks] on February 29,2024. He returns to the OR today for further debridement and skin grafting."

Patient #11 required OT services related to his burn injuries during his hospitalization at Hospital #3. An OT evaluation was conducted on 2/29/2024 at 8:00 AM due to decreased strength, mobility and activity tolerance related to activities of daily living.

Patient #11 was discharged home on 3/15/2024 with referrals for home health care for skilled nursing services to provide daily wound care to the burn injuries and instructions to follow up with the outpatient burn clinic.

In a telephone interview on 7/23/2024 at 11:30 AM, Patient #11 verified he was treated and released from Hospital #1's ED on 2/26/2024. When asked if he had to seek further treatment for his burn injuries after discharge from Hospital #1's ED, Patient #11 stated, "Yes, I went to [named Hospital #3] the next day... drove up there and sit in the waiting room..." Patient #11 stated he was admitted to Hospital #3's burn unit after evaluation in Hospital #3's ED. The Patient stated he was in the hospital for 3 weeks. Patient #11 stated he still had limitations in his arm from the burns. Patient #11 did not recall Hospital #1's medical staff recommending he be transferred to Hospital #3, during his 2/26/2024 ED visit.

In a telephone interview on 7/23/2024 at 2:00 PM, ED Physician #2 at Hospital #1 verified he had provided treatment to Patient #11 on 2/26/2024 for a burn. Physician #2 stated he did recall Patient #11. ED Physician #2 stated, "What is the problem exactly?" The surveyor asked the Physician how the determination was made to discharge a patient with burns, versus referral to a higher level of care. ED Physician #2 stated, "He [Patient #11] left AMA [against medical advice]. I wanted to send him to [named Hospital #3 burn unit] but he refused...he left AMA. The surveyor asked ED Physician #2 if the refusal of a higher level of care and leaving AMA was documented. ED Physician #2 stated, "I believe I did..." When the surveyor explained to the ED Physician that there was no documentation of recommendations to transfer Patient #11 to Hospital #3's burn unit, or any documentation about Patient #11 leaving AMA or refusing the transfer, ED Physician #2 stated, "I am not sure, all I am saying is I had a conversation with the patient...you can call him and verify. He refused to go to [named Hospital #3]." There was no documentation of an AMA form in Patient #11's medical record.

In an interview on 7/23/2024 at 2:15 PM, the surveyor asked the Director of Quality at Hospital #1 to review the ED Physician note for Patient #11 dated 2/26/2024. Hospital #1's Director of Quality was specifically asked if Patient #11 refused the higher level of care at a burn center, and left AMA. The Director of Quality verified there was no documentation in the record about referring the Patient to a burn unit or his refusal to follow the physician's medical direction or leave AMA. The Director of Quality verified Patient #11 was medically cleared and discharged to home.

Hospital #1 failed to provide stabilizing treatment to Patient #11's extensive burns to his body and transfer to a higher level of care that provided specialized care for patients who experienced burns. Patient #11 sought continued emergency treatment of his emergency medical condition at Hospital #3 on 2/28/2024.