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The CMS Kansas City Regional Office notified the hospital's Vice President of Medical Affairs on 1/26/17 at 4:15 pm of the violations at 42 CFR 489.24(e) and 42 CFR 489.20(l) and that the deficiencies represented an immediate and serious threat (immediate jeopardy) to the health and safety of all patients presenting to the emergency department (ED) seeking treatment for an emergency medical condition. While actively bleeding and in need of emergent surgery, the hospital inappropriately discharged Patient # 9 and directed him to go to another hospital for stabilizing treatment. The hospital failed to appropriately transfer patient # 9 and did not arrange safe transport utilizing qualified medical personnel. Patient # 19 presented to the ED seeking care for an abscess in her throat preventing her from swallowing. The hospital did not arranage an approrpriate transfer or utilize qualified medical personnel for transport when it directed patient # 19 to leave and travel 149 miles to Hospital A for treatment to stabilize an emergency medical condition. Please refer to the following citations for details.


Based on record review, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, staff and provider interviews the facility failed to provide 2 Patients (Patient, 9 and 19) a safe and appropriate transfer. Patient 9 and 19 were transferred by private car without medical personnel. Patient 9 was actively bleeding and in need of emergent surgery. Patient 19 had an abscess in the throat causing difficulty swallowing and in need of specialized medical personnel during transport. The appropriate mode of transport and physician certification that the benefits of transfer outweighed the risks were not obtained for Patients 9 & 19. Medical records to facilitate immediate treatment was not provided to the receiving Emergency Room (ER) for Patient 9. The total sample size was 30.

Findings are:

A. Review of Patient 19's medical record revealed the patient was brought to the ED (Emergency Department) on 8/10/16 at 1742 (5:42 PM) and dismissed at 2230 (10:30 PM). The Emergency Nursing Record form identified Patient 19's chief complaint as "Can't Swallow." Patient 19's vital signs were 125/70 blood pressure, 96 pulse, 16 respirations, 97.9 temperature, 96% oximetry on room air and pain level 9/10.

The PA-C (Physician Assistant-Certified) assessed the patient at 6:05 PM. The Emergency Physician Record form identified Patient (Pt) 19's chief complaint as "sore throat unable to swallow with a 4 day onset of symptoms." The physical exam identified pharyngeal erythema (back of throat redness) with no respiratory distress.

The Medical Screening Examination (MSE) included a Complete Blood Count (CBC-A blood test to check for anemia and infection.); Basic Metabolic Panel (BMP-Blood tests used to check the pt's kidneys, electrolytes and blood sugar.), I stat (immediate result lab test); CT (Computerized Tomography-series of computerized X-rays) Scan of neck with contrast; start an IV (intravenous access); give a 1 liter bolus of NS (normal saline); Morphine (pain medication) 1-5 mg (milligram) IV PRN (as needed) every 5 minutes up to 15 mg per hour- pain 3/10 or less 1-3 mg and pain 4/10 or greater 4-5 mg; Clindamycin (antibiotic) 900 mg IV and Decadron (steroid) 20 mg IV. The results included:

-CT Scan of neck (special type of x-ray)
1. Retropharyngeal fluid, C2-C6 (cervical spine) level. The fluid does not extend into the mediastinum. Cannot exclude developing retropharyngeal abscess (infection in the back of the throat capable of obstructing the airway, causing death).
2. Mild bilateral cervical lymphadenopathy (swelling of the lymph nodes in the neck)
3. Moderate life-sided pleural effusion (fluid build up around the lungs) incompletely imaged.
4. Emphysema with probable scarring at the right apex, although comparison with prior studies to ensure stability could be helpful.
-CBC- White blood count (indictor of infection) 12.7 High (normal 5.0-10.0)
-BMP-normal

A review of the Addendum dictation from the PA-C on 8/10/16 revealed:
-History of present illness: Identified that Patient 19 had followed up with her Primary Care Physician on 8/10/16 and had an appointment with an ENT (ear, nose and throat) physician tomorrow. The reason the patient came to ER (Emergency Room) today, was that "she really just cannot swallow anything, she cannot even swallow water."
-Course in Emergency room: CBC and BMP were done. White count was elevated at 12.7. CT of neck did show some retropharyngeal fluids above the anterior cervical spine fusion at C6-C7, extending superior to C2, measuring at 3 x 0.5 CM (centimeters).
-Plan: Gave Clindamycin 900 mg IV and Decadron 10 mg IV. Tried to transfer (Patient 19) to (Hospital B) ENT due to (this hospital) not having any ENT available here at this time. The (Hospital B) ENT did not feel comfortable taking the patient. At that time, (the PA-C) called a (Hospital K) ENT, who did not feel comfortable taking the patient. The PA-C also talked with the (Hospital M), they had no beds available. (The PA-C) then tried (Hospital S) and (Hospital D). Neither hospital had a bed available. "(Hospital A) was called and the ENT at this hospital said they would not directly admit the patient but the patient could come by private car and check into the ER. At this time the patient was discharged from the ER and drove by private car to (Hospital A)."
-CLINICAL IMPRESSION: Retropharyngeal abscess.

An interview on 12/20/16 at 12:10 PM with the PA-C confirmed PA-C was Patient 19's ED provider on 8/10/16. PA-C related that (gender) recalls this patient well. PA-C related that (gender) called many places and no ENT wanted to touch (Patient 19). They just felt that this was too complex a case and needed a higher level of care. Many hospitals had no beds, the "CHI (Catholic Health Initiatives) one call" operator was contacted and they talked to the ENT at (Hospital A) and physician F refused to talk to me but told them to tell me that I could send the patient by private car to the ER and the patient would be seen in ER. "I had Dr (doctor) O, the ED doctor that night, see the patient and evaluate if (gender) felt the patient was stable to go by private car to (Hospital A). (Patient 19) may need a thoracic surgeon." Dr O felt the patient was stable to go by car. "There was no airway issue." When asked if PA-C felt that Patient 19 had an EMC (Emergency Medical Condition) when discharged, PA-C replied "Yes." PA-C verified that no EMTALA (A Federal law requiring hospitals to treat and stabilize patients with emergencies) paperwork was completed for Patient 19.

The Emergency Nursing Record form dated 8/10/16 with no time indicated revealed an entry from ER RN (Registered Nurse) H, "(PA-C name) had multiple attempts to transfer the Pt with no admitting doc (Medical Doctor) willing to accept the transfer. The Pt's family was very upset about having to go by private vehicle to (Hospital A). Please refer to physician order sheet on call list with times. Report called to (Hospital A) ER, spoke to (name) notified of pt arrival, faxed paperwork to (number)."

An interview on 12/20/16 at 12:00 noon with RN H confirmed (gender) was Patient 19's nurse on 8/10/16 from 5:42 PM to 10:30 PM. RN H indicated that (gender) recalled this patient because it was a frustrating case. It was frustrating because (PA-C) tried several hospitals to accept this patient and none of them would. Finally the (Hospital A [149 miles away]) ENT said that (gender) wouldn't accept the patient as a transfer, but if (Patient 19) presents to their ER she would be seen. "(Patient 19) had difficulty swallowing but did not have airway compromise, was able to drink in the ER and manage her oral secretions." RN H indicated that the family was upset/frustrated that they had to go by car to the ER of (Hospital A) because that meant they had to start all over in (Hospital A) ER. Physician O was in charge of ER that night and said (Patient 19) could go by private vehicle after (gender) evaluated (Patient 19). "I discharged (Patient 19) from the ER, and no we didn't do any EMTALA paperwork." When asked if RN H felt that Patient 19 had an EMC at the time of discharge, RN H stated, "Yes and no. Yes the patient needed to get there for treatment, but no because her airway was not yet compromised, vital signs were stable and she could swallow." RN H confirmed that Patient 19 received IV Decadron, Clindamycin, NS and Morphine before discharge and that the IV was removed prior to discharge.

An interview on 12/20/16 at 10:07 AM with the Dr N who is the local ENT physician at the hospital revealed, "I am the only ENT in (town) and when I am off (Hospital B) ENT or (Hospital K) ENT cover for me. We also have an ENT from Lincoln that comes and covers one weekend a month." When inquired why the (Hospital B) ENT and (Hospital K) ENT declined the patient due to not feeling comfortable taking the patient, Dr N stated, "Sometimes these patients with this condition (Retropharyngeal Abscess) require a surgery by a cardio-thoracic surgeon because if the abscess extends to the mediastinum (The middle section of the chest cavity which contains the heart, the lungs and major blood vessels.) they need emergency cardio-thoracic surgery."

Review of the facility Database paperwork, identified that this facility lacked the capability to treat (Patient 19) as they do not provide cardio-thoracic surgery.

B. Record review revealed Patient 9 came to the ED on 12/7/16 at 8:32 PM. The patient arrived by car with family. The patient's chief complaint is "tonsil bleed" that started 2 hours ago on the right side. The patient was not examined by the one Emergency Department physician on duty or either of the PA's on duty in the ED on 12/7/16 that were qualified to perform examinations. The only assessment documented in the medical record was performed by Resident (physician) A. The admission vitals were Blood Pressure (BP) 154/91 pulse 108, respirations 16, temperature 98.5 Fahrenheit and Oxygen saturation of 100%. The "Nursing Record" documentation by Registered Nurse RN V notes that Ear Nose and Throat (ENT) Resident (Physician) examined the patient at 9:00 PM. The Resident documented that the patient was 7 days post tonsillectomy and presented with oral bleeding and vomiting blood. The patient had been seen earlier in the day at the clinic for right sided throat pain. The Resident's assessment was "active post tonsillectomy bleed." The Resident noted that the bleeding was from an area in the patient's throat that was not possible to cauterize, seal the bleeding area with a heat source in the ER, and that after discussion with the ENT (MD C) at hospital B, the patient would be sent to Hospital B for evaluation by ENT C. The notes state the patient had "active bleeding from the inferior pole." The patient was given 400 milliliters of intravenous fluid before discharge and Zofran, a medication for nausea while in the ER. Vital signs before discharge at 10 PM were BP 140/86, pulse 105, respirations 16 and Oxygen saturation of 100%. Discharge instructions were provided to the patient and stated "[Name of ENT MD C] is to see you in the [Name of Hospital B] ER in [city of Hospital B] now." Prior to discharge RN V noted the patient was nauseous (swallowing blood will cause nausea). RN V noted that Resident A agreed the patient's Mother could take the patient by car to Hospital B, approximately a 25 minute drive away. The record does not contain any evidence of ED visit records being sent with the patient or sent to Hospital B.

Interview with Resident A on 12/20/16 at 10:07 AM confirmed examining Patient 9 in the ED on 12/7/16. The Resident confirmed consulting by phone with ENT MD C. Review of the facility list of active medical staff revealed MD C is not on staff at the hospital. Resident A recalled seeing Patient 9 earlier in the day at a physician clinic with MD C. The patient complained of a sore throat but was not bleeding. Resident A confirmed the patient had an Emergency Medical Condition (EMC) that needed treatment "sooner than later." Resident A confirmed that after conferring with MD C, an ENT physician at Hospital B, that the patient needed surgery to stop the bleeding. The patient was sent to Hospital B.

Record review Hospital B, the receiving hospital record, dated 12/7/16 notes the patient arrived by car at 10:51 PM. The notes state the patient arrived with an intravenous catheter in place in the left forearm. The patient was seen by ENT MD C and admitted to surgery at 11:15 PM for cauterization of a tonsil bleed. The surgery was completed at 11:52 PM.

On 12/15/16 Hospital B reported to the Centers for Medicare and Medicaid Services their receipt of an inappropriate transfer. EMTALA regulations require the reviewing hospital to report an inappropriate transfer. The facility requested the medical record from CHI St. Frances and were told a week later that "we didn't fill out the appropriate paperwork." The medical record was not sent with the patient to facilitate treatment.

Interview on entrance on 12/19/16 at 11 AM with the Vice President of Patient Care Services and the Corporate Responsibility Officer revealed they received a call from Hospital B on 12/14/16 requesting the medical record paperwork for Patient 9's visit on 12/7/16. The staff confirmed the patient went from their ER directly to Hospital B's and that the EMTALA paperwork does not exist. The staff revealed their internal investigation of the incident found that the ER physician at Hospital B was not notified of the transfer only the ENT on call MD C was aware.

RN V confirmed on interview 12/20/16 at 8:25 AM that the patient was still bleeding at the time they left the ER. RN V also confirmed the patient had an EMC. RN V reported calling the RN in the ED at Hospital B to let them know the patient was coming but neglected to send records/paperwork. The nurse confirmed the patient was discharged and sent by private car to Hospital B. RN V confirmed the patient was anxious, uncomfortable with nausea, and bleeding at the time of discharge with instructions to go to Hospital B.

C. Record Review of the facility policy titled "Treatment and Transfer of Individuals in Need of Emergency Medical Treatment" effective 01/2004 identified:
-"Transfer " as: The movement (including the discharge) of an individual outside the Hospital's facilities at the direction of any person employed by or associated, directly or indirectly, with the Hospital, but does not include such a movement of an individual who: (1) has been declared dead; or (2) leaves the Hospital without permission or against medical advice.
-"Stable for Discharge" as:
1) "The physician has determined that the patient has reached the point where his continued medical treatment could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instruction; or
2) With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer considered to be a threat to himself/herself or others."
-"An Individual Who Has An Emergency Medical Condition" as"
1) When it is determined that the individual has an emergency medical condition, the Hospital shall:
a. Within the capability of the staff and facilities available at the Hospital, stabilize the individual to the point where the individual is either "stable for discharge" or "stable for transfer,"as defined; or
b. Provide for an appropriate transfer of the unstabilized individual to another medical facility in accordance with these procedures. Transfers of unstabilized individuals are permitted only pursuant to individual request, or when a physician, or a Qualified Medical Person in consultation with a physician, certifies that the expected benefits to the transfer outweigh the risks of transfer.
2) If an individual has an emergency medical condition that has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth below; the individual may be transferred: a) Upon individual request;
b) With certification.
3) When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures: a) The hospital shall, within its capability, provide medical treatment, which minimizes the risks to the individual's health and, in the case of a woman who is having contractions, the health of the unborn child.
b) A representative of the receiving facility must confirm that : the receiving facility has available space and qualified personnel to treat the individual; and The receiving facility agrees to accept the transfer of the the individual and to provide appropriate treatment.
c) The Hospital shall send the receiving facility copies of the pertinent medical records available at the time of transfer.
d) If an on-call physician has refused or failed to appear within a reasonable time after being requested to provide necessary stabilizing treatment and the transfer is necessary as a result of the unavailable on-call physician, the ED physician or designee shall provide the name and address of that physician to the receiving facility on the "Patient Request/Refusal/Consent to Transfer.
e) The transfer shall be effected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer.
f) Unless the individual acting on the individual's behalf requested the transfer, the Hospital shall if at all possible notify the individual or, where applicable, the individual's person acting on the individual's behalf, both orally and in writing of the decision and reasons for the transfer.

Based on staff interviews, record review and review of Emergency Department (ED) Physician On-Call schedule of physicians available to respond to the ED to provide additional stabilizing treatment to patients, the facility failed to ensure the identified practitioner On-Call was a privileged practitioner who could provide stabilizing treatment. On 12/7/16 the only identified practitioner On-call for ENT (Ear Nose and Throat) specialty was identified as Resident A. The Resident did not have surgical privileges to independently perform stabilizing treatment to a patient presenting to the ED on 12/7/16 requiring ENT surgery to stabilize the patient (Patient 9). The total sample was 30. Findings are:

A. Record review of the ED call schedule for specialty practitioners identified to provide stabilizing treatment to ED patients on 12/7/16 lists Resident A. The facility staff verified the person on call is the one with the asterisk by their name. The only provider under ENT services with an asterisk is Resident A.
Review of the on-call specialty provider list found all were active members of the medical staff except Resident A.

B. Record review of the ED patient record for Patient 9 revealed the patient arrived to the ED on 12/7/16 at 8:32 PM. The patient was examined by Resident A per nursing documentation at 9:00 PM. The dictated note by Resident A at 10:01 PM on 12/7/16 titled "Emergency Room Report" notes the patient is "post op day 7 from tonsillectomy with an active post tonsillectomy bleed." The note further states that "the active bleed is at the inferior pole, thus is not amenable to cauterization [sealing of the bleeding vessel using a heat source] in the ER [Emergency Room]. The patient was directed to go to Hospital B for further evaluation by Medical Doctor (MD) C who was on call for ENT at Hospital B.

C. Interview with MD N, the supervising physician for Resident A, on 12/20/16 at 10:07 AM revealed that MD N is the sole provider of ED on-call coverage for ENT at the hospital. MD N related that when unavailable there is no call coverage and the patient needing ENT services must transfer to another hospital for ENT specialty services. MD N stated that due to illness there was not an attending ENT physician on call for ENT on 12/7/16.

D. Interview with Resident A on 12/20/16 at 10:07 AM confirmed examining Patient 9 in the ED on 12/7/16. The Resident confirmed consulting by phone with ENT MD C. Review of the facility list of active medical staff revealed MD C is not on staff at the hospital. Resident A recalled seeing Patient 9 earlier in the day at a physician clinic with MD C. The patient complained of a sore throat but was not bleeding. Resident A confirmed the patient had an Emergency Medical Condition that needed treatment "sooner than later." Resident A confirmed that after conferring with MD C that the patient needed surgery to stop the bleeding. The patient was sent to Hospital B.

E. Record review of the document titled "Medical Staff Rules and Regulations" adopted by the Medical Staff on 4/26/16 state that "The Medical Staff shall adopt a method of providing medical coverage in the department of emergency medicine." The Rules and Regulations do not allow a Resident to perform a Medical Screening Examination. The document notes that the ED physician on duty, Physician Assistant, Certified Nurse Practitioner or Registered Nurse in the Maternal/Child department and/or "physician or the specialist on call is designated as a person qualified to conduct the medical screening examination under EMTALA [Emergency Medical Treatment and Labor Act].

F. Interview with the Corporate Responsibility Officer on 12/19/16 at 3:50 PM confirmed a Resident is not a member of the Medical Staff or credentialed by the medical staff and so are not an appropriate qualified medical person to perform a medical screening examination.

An unannounced onsite Emergency Treatment and Labor Act (EMTALA) investigation began on 12/19/16 and continued until 12/20/16. Based on medical record review, staff interviews, provider interviews and review of receiving facility records the facility failed to ensure 2 of 11 sampled patients (Patient #9 and 19) who were transferred for further stabilizing treatment, were transferred by an appropriate method with qualified personnel present to prevent potential further risk to the patient's health and safety. This failure posed an immediate threat to both patients. The providers conducting the Medical Screening Examinations (MSE's) confirmed the patients had Emergency Medical Conditions requiring transfer. Patient 9 was actively bleeding and in need of emergent surgery. Patient 19 had an abscess in the throat causing difficulty swallowing and in need of specialized medical services. Both Patient 9 and 19 were transferred by private car without medical personnel. Advanced acceptance and physician certification that the benefits of transfer outweighed the risks were not obtained for Patients 9 and 19. Medical records to facilitate immediate treatment was not provided to the receiving Emergency Room (ER) for Patient 19. The total sample was 30.

Findings are:

A. Record review of Patient 19's medical record revealed the patient was brought to the ED (Emergency Department) on 8/10/16 at 1742 (5:42 PM) and dismissed at 2230 (10:30 PM). The Emergency Nursing Record form identified Patient 19's chief complaint as "Can't Swallow." Patient 19's vital signs were 125/70 blood pressure, 96 pulse, 16 respirations, 97.9 temperature, 96% oximetry on room air and pain level 9/10.

The PA-C (Physician Assistant-Certified) assessed the patient at 6:05 PM. The Emergency Physician Record form identified Patient (Pt) 19's chief complaint as "sore throat unable to swallow with a 4 day onset of symptoms." The physical exam identified pharyngeal erythema (back of throat redness) with no respiratory distress.

The Medical Screening Examination (MSE) included a Complete Blood Count (CBC-A blood test to check for anemia and infection.); Basic Metabolic Panel (BMP-Blood tests used to check the pt's kidneys, electrolytes and blood sugar.), I stat (immediate result lab test); CT (Computerized Tomography-series of computerized X-rays) Scan of neck with contrast; start an IV (intravenous access); give a 1 liter bolus of NS (normal saline); Morphine (pain medication) 1-5 mg (milligram) IV PRN (as needed) every 5 minutes up to 15 mg per hour- pain 3/10 or less 1-3 mg and pain 4/10 or greater 4-5mg; Clindamycin (antibiotic) 900mg IV and Decadron (steroid) 20 mg IV. The results included:
-CT Scan (special type of x-ray) of neck-

1. Retropharyngeal fluid, C2-C6 (cervical spine) level. The fluid does not extend into the mediastinum. Cannot exclude developing retropharyngeal abscess (infection in the back of the throat that can obstruct the airway causing death).
2. Mild bilateral cervical lymphadenopathy (swelling of the lymph nodes in response to an infection).
3. Moderate life-sided pleural effusion (collection of fluid around the lungs) incompletely imaged.
4. Emphysema with probable scarring at the right apex, although comparison with prior studies to ensure stability could be helpful.
-CBC- White blood count (indicator of infection) 12.7 High (normal 5.0-10.0)

A review of the Addendum dictation from the PA-C on 8/10/16 revealed:
-History of present illness: Identified that Patient 19 had followed up with her Primary Care Physician on 8/10/16 and had an appointment with an ENT (ear, nose and throat) physician tomorrow. The reason the patient came to ER (Emergency Room) today, was that "she really just cannot swallow anything, she cannot even swallow water."

-Course in Emergency room: CBC and BMP were done. White count was elevated at 12.7. CT of neck did show some retropharyngeal fluids above the anterior cervical spine fusion at C6-C7, extending superior to C2, measuring at 3 x 0.5 CM (centimeters).
-Plan: Gave clindamycin (antibiotic) 900 mg IV and Decadron (anti-inflammatory) 10 mg IV. Tried to transfer (Patient 19) to (Hospital B) ENT due to (this hospital) not having any ENT available here at this time. The (Hospital B) ENT did not feel comfortable taking the patient. At that time, (the PA-C) called a (Hospital K) ENT, (gender) did not feel comfortable taking the patient. The PA-C also talked with the (Hospital M), they had no beds available. (The PA-C) then tried (Hospital S) and (Hospital D). Neither one of the hospitals had a bed available. "(Hospital A) was called and the ENT at this hospital said he would not directly admit the patient but the patient could come by private car and check into the ER. At this time the patient was discharged from the ER and drove by private car to (Hospital A)", located approximately 149 miles away.

-CLINICAL IMPRESSION: Retropharyngeal abscess.

An interview on 12/20/16 at 12:10 PM with the PA-C confirmed PA-C was Patient 19's ED provider on 8/10/16. PA-C related that (gender) recalls this patient well. PA-C related that (gender) called many places and no ENT wanted to touch (Patient 19). They just felt that this was too complex a case and needed a higher level of care. Many hospitals had no beds, the "CHI (Catholic Health Initiatives) one call" operator was contacted and they talked to the ENT at (Hospital A) and Physician F refused to talk to me but told them to tell me that we could send patient # 19 by private car to the ER and they would be seen. "I had Dr (doctor) O, the ED doctor that night, see the patient and evaluate if (gender) felt the patient was stable to go by private car to (Hospital A). (Patient 19) may need a thoracic surgeon." Dr O felt the patient was stable to go by car. When asked if PA-C felt that Patient 19 had an EMC (Emergency Medical Condition) when discharged, PA-C replied "Yes." PA-C verified that no EMTALA (a Federal law that requires pts coming to an ED department be stabilized and treated) paperwork was completed for Patient 19 or that ER Dr. O certified that the benefits of transfer outweighed the risks.

The Emergency Nursing Record form dated 8/10/16 with no time indicated revealed an entry from ER RN (Registered Nurse) H, "(PA-C name) had multiple attempts to transfer the Pt with no admitting doc (Medical Doctor) willing to accept the transfer. The Pt's family was very upset about having to go by private vehicle to (Hospital A). Please refer to physician order sheet on call list with times. Report called to (Hospital A) ER, spoke to (name) notified of pt arrival, faxed paperwork to (number)."

An interview on 12/20/16 at 12:00 Noon with RN H confirmed (gender) was Patient 19's nurse on 8/10/16 from 5:42 PM to 10:30 PM. RN H indicated that (gender) recalled this patient because it was a frustrating case. It was frustrating because (PA-C) tried several hospitals to accept this patient and none of them would. Finally the ENT at Hospital A, (located 149 miles away) said that he wouldn't accept the patient as a transfer, but if (Patient 19) presents to their ER she would be seen." Patient 19 had difficulty swallowing but while in the ER did not have any airway compromise, was able to drink and manage her secretions." RN H indicated that the family was upset/frustrated that they had to go by car to Hospital A's ER because that meant they had to start all over in (Hospital A) ER. Dr O was in charge of ER that night and said (Patient 19) could go by private vehicle after (gender) evaluated (Patient 19). "I discharged (Patient 19) from the ER, and no we didn't do any EMTALA paperwork." When asked if RN H felt that Patient 19 had an EMC at the time of discharge, RN H stated, "Yes and no. Yes the patient needed to get to Hospital A for treatment, but no because her airway not compromised and she could swallow before she left the ER.

An interview on 12/20/16 at 10:07 AM with the Dr N who is the local ENT Dr at the hospital revealed, "I am the only ENT in (town) and when I am off (Hospital B) ENT or (Hospital K) ENT cover for me. We also have an ENT from Lincoln that comes and covers one weekend a month." When asked why the ENT at Hospital B and K declined the patient because they were not comfortable providing care, Dr N stated, "Sometimes these patients with this condition (Retropharyngeal Abscess) require a surgery by a cardio-thoracic surgeon because the abscess can extend to the mediastinum (the middle section of the chest cavity which contains the heart, the lungs and major blood vessels) requiring emergency cardio-thoracic surgery."

Record Review of the facility policy titled "Treatment and Transfer of Individuals in Need of Emergency Medical Treatment" effective 01/2004 identified:
-"Transfer " as: The movement (including the discharge) of an individual outside the Hospital's facilities at the direction of any person employed by or associated, directly or indirectly, with the Hospital, but does not include such a movement of an individual who: (1) has been declared dead; or (2) leaves the Hospital without permission or against medical advice.
-"Stable for Discharge" as:
1) "The physician has determined that the patient has reached the point where his continued medical treatment could reasonably be performed as an outpatient or later as an inpatient, as long as the patient is given a plan for appropriate follow-up care with discharge instruction; or
2) With respect to an individual with a psychiatric condition, the physician has determined that the patient is no longer considered to be a threat to himself/herself or others."
-"An Individual Who Has An Emergency Medical Condition" as"
1) When it is determined that the individual has an emergency medical condition, the Hospital shall:
a. Within the capability of the staff and facilities available at the Hospital, stabilize the individual to the point where the individual is either "stable for discharge" or "stable for transfer,"as defined; or
b. Provide for an appropriate transfer of the unstabilized individual to another medical facility in accordance with these procedures:
1) Transfers of unstabilized individuals are permitted only pursuant to individual request, or when a physician or a Qualified Medical Person in consultation with a physician, certifies that the expected benefits to the transfer outweight the risks of the transfer.
2) If an individual has an emergency medical condition that has not been stabilized, the individual may be transferred only if the transfer is carried out in accordance with the procedures set forth below; the individual my be transferred:
a. Upon individual request.
b. With certification:
1. The individual may be transferred if a physician or, should a physician not physically be present at the time of transfer, a Qualified Medical Person in consultation with a physician, has documented on the "Physician Certification" section of Patient Request/Refusal/Consent to Transfer form, that the medical benefits expected from transfer outweigh the risks.
a. The date and time of the certification should be close in time to the actual transfer.
b. A certification that is signed by a Qualified Medical Person shall be countersigned by the responsible physician within 24 hours.
c. The transfer shall be effected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer.
The record for Patient 19 does not include the EMTALA documentation as required by facility policy.


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B. Record review revealed Patient 9 came to the ED on 12/7/16 at 8:32 PM. The patient arrived by car with family. The patient's chief complaint was "tonsil bleed" that started 2 hours ago on the right side. The patient was not examined by the one Emergency Department physician on duty or either of the PA's on duty in the ED on 12/7/16. The only assessment documented was performed by Resident (physician) A. The admission vitals were Blood Pressure (BP) 154/91 pulse 108, respirations 16, temperature 98.5 Fahrenheit and Oxygen saturation of 100%. The "Nursing Record" documentation by Registered Nurse RN V noted that Ear Nose and Throat (ENT) Resident (Physician) examined the patient at 9:00 PM. The Resident documented that the patient was 7 days post tonsillectomy and presented with oral bleeding and vomiting blood. The patient had been seen earlier in the day at the clinic for right sided throat pain. The Resident's assessment was "active post tonsillectomy bleed". The Resident noted that the bleeding was from an area in the throat that was not possible to cauterize, seal the bleeding area with a heat source in the ER, and that after discussion with the ENT (MD C) at hospital B, the patient would be sent to Hospital B for evaluation by ENT C. The notes indicated the patient had "active bleeding from the inferior pole." The patient was given 400 milliliters of intravenous fluid before discharge and Zofran a medication for nausea while in the ER. Vital signs before discharge at 10 PM were BP 140/86, pulse 105, respirations 16 and Oxygen saturation of 100%. Discharge instructions were provided to the patient and stated "[Name of ENT MD C] is to see you in the [Name of Hospital B] ER in [city of Hospital B] now." Prior to discharge RN V noted the patient was nauseous (swallowing blood will cause nausea). RN V noted that Resident A agreed the patient's Mother could take the patient by car to Hospital B, approximately a 25 minute drive away. The record does not contain any evidence of ED visit records being sent with the patient or sent to Hospital B, or that a physician certified the benefits of transfer outweighed the risks or determined the appropriate mode of transport.

Interview with Resident A on 12/20/16 at 10:07 AM confirmed examining Patient 9 in the ED on 12/7/16. The Resident confirmed consulting by phone with ENT MD C. Review of the facility list of active medical staff revealed MD C is not on staff at the hospital. Resident A recalled seeing Patient 9 earlier in the day at a physician clinic with MD C. The patient complained of a sore throat but was not bleeding. Resident A confirmed the patient had an Emergency Medical Condition (EMC) that needed treatment "sooner than later." Resident A confirmed that after conferring with MD C, an ENT physician at Hospital B, that the patient needed surgery to stop the bleeding. The patient was sent to Hospital B.

Review of Patient 9's Hospital B medical record, dated 12/7/16 noted the patient arrived by car at 10:51 PM. The notes indicated the patient arrived with an intravenous (IV) catheter in place in the left forearm. ENT C examined the patient and determined surgery was indicated. Patient 9 was taken to surgery at 11:15 PM for cauterization of a tonsil bleed. The surgery was completed at 11:52 PM.

Interview on entrance on 12/19/16 at 11 AM with the Vice President of Patient Care Services and the Corporate Responsibility Officer revealed they received a call from Hospital B on 12/14/16 requesting the medical record paperwork for Patient 9's visit on 12/7/16. The staff confirmed the patient went from their ER directly to Hospital B's and that the EMTALA paperwork does not exist. The staff revealed their internal investigation of the incident found that the ER physician at Hospital B was not notified of the transfer, only the ENT on call MD C was aware.

RN V confirmed during an interview on 12/20/16 at 8:25 AM that the patient was still bleeding at the time they left the ER. RN V also confirmed the patient had an EMC. RN V reported she neglected to send records/paperwork with the patient. The nurse confirmed the patient was discharged and sent by private car to Hospital B. RN V confirmed the patient was anxious, uncomfortable with nausea, and bleeding at the time of discharge with instructions to go to Hospital B.