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Based on policy review, medical record review and interview, the facility failed to provide an appropriate medical screening exam and transfer for 1 of 3 (Patient #1) sampled patients requiring a higher level of care, out of 20 total patients reviewed.

The findings included:

1. Review of the facility's, "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" policy (11/16/2023) revealed, " ...Medical Screening Examination is the process to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists ...Such screening must be done within the facility's capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred ..."

Review of the facility's "EMTALA -Transfer Policy" (9/25/2023) revealed, " ...The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility... The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual... The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment... The transferring hospital must send copies of all available medical records pertaining to the individual's emergency condition to the hospital where the patient is being transferred... If the hospital offers to transfer a patient to another hospital for services the hospital does not offer and informs the patient or the legally responsible person of the risks and benefits to the person of the transfer but the patient or the person acting on the patient's behalf refuses to consent to the transfer, the facility must take all reasonable steps to secure a written refusal from the patient or the person acting on the patient's behalf. The written refusal should indicate the person has been informed of the risks and benefits of the transfer and state the reasons for such refusal..."

2. Medical record review revealed Patient #1 presented to the Emergency Department (ED) on 11/18/2023 at 5:07 PM with a chief complaint of back abscess with nausea and general malaise. A Medical Screening Examination (MSE) was initiated on 11/18/2023 at 5:45 PM by Physician #1. Physician #1 documented Patient #1 had a history of type 2 diabetes mellitus and presented to the ED with an abscess on his back with increased pain, swelling, fever, and chills causing him to feel sick to his stomach. Physician #1 documented Patient #1 reported he saw his primary care physician two days prior (11/16/2023) and was placed on Bactrim (antibiotic). Physician #1 documented the abscess was approximately 3 centimeters (cm) but was now almost 10 cm. Physician #1 documented Patient #1 had a past medical history of diabetes mellitus and hypertensive disorder. Physician #1 documented Patient #1 needed a higher level of care not available at Facility #1. Physician #1 discharged Patient #1 from the Facility #1 ED, and Patient #1 left the ED on 11/28/2023 at 6:09 PM. While at Facility #1 ED, there was no fingerstick glucose performed to assess if Patient #1 was hyperglycemic and at risk for diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids [ketones]) since Patient #1 presented with a history of abscess, fevers, and chills in a diabetic patient. Physician #1 documented Patient #1 needed admission and surgical evaluation for the worsening abscess. Physician #1 did not order admission or a transfer for the surgical evaluation but ordered discharge home. There was no lab work ordered or drawn to further assess Patient #1's condition. The MSE was not complete or appropriate.

Refer to A2406

3. Medical record review revealed Physician #1 documented the abscess would require intravenous (IV) antibiotics and surgical evacuation (removal). Physician #1 documented Patient #1 would need to be transferred to a higher level of care due to the facility (Facility #1) did not have surgical coverage. Patient #1 and spouse chose to expedite care and go directly to another hospital (Facility #2) by private vehicle. Physician #1 discharged Patient #1 from the ED. Patient #1 left Facility #1 on 11/18/2023 at 6:09 PM. There was no documentation Facility #1 reached out to Facility #2 to inquire if surgical coverage was available, or if another physician was willing to accept Patient #1 at Facility #2. There was no documentation Facility #1 obtained a written refusal from Patient #1 regarding refusal of transfer by ambulance.

Refer to A2409

Based on policy review, medical record review, and interview, the facility failed to provide a complete or appropriate medical screening exam (MSE) for 1 of 20 (Patient #1) sampled patients who presented to the facility's Emergency Department (ED) seeking medical care.

The findings included:

1. Review of the facility's, "EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" policy (11/16/2023) revealed, " ...Medical Screening Examination is the process to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition exists ...Such screening must be done within the facility's capability and available personnel, including on-call physicians. The Medical Screening Examination must be performed by a Physician or other Qualified Medical Personnel. The Medical Screening Examination is an ongoing process and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patient is either stabilized or appropriately transferred ..."

2. Medical record review revealed Patient #1 presented to the ED on 11/18/2023 at 5:07 PM with a chief complaint of back abscess with nausea and general malaise. Patient #1's vital signs at 5:19 PM were: temperature 99.1 degrees Fahrenheit, pulse 97, respirations 18, blood pressure 134/82, and oxygen saturation 97%. Patient #1 reported a pain level of 7 on a 0-10 pain scale (10 being the most severe pain).

A Medical Screening Examination was initiated on 11/18/2023 at 5:21 PM by Physician #1. Physician #1 documented Patient #1 had a history of type 2 diabetes mellitus and presented to the ED with an abscess on his back with increased pain, swelling, fever, and chills causing him to feel sick to his stomach. Physician #1 documented Patient #1 reported he saw his primary care physician two days prior (11/16/2023) and was placed on Bactrim (antibiotic). Physician #1 documented the abscess was approximately 3 centimeters (cm) but was now almost 10 cm. Physician #1 documented Patient #1 had a past medical history of diabetes mellitus and hypertensive disorder with home medications of Novolog insulin (medication injection given beneath the skin to help control blood sugar spikes) and Lexapro (medication which can be used to treat depression and generalized anxiety disorder) 20 milligrams 1 tablet daily.

Physician #1 documented upon physical exam, Patient #1, "...appears alert, awake, anxious, obviously ill, in obvious pain, uncomfortable ...Skin: abscess, that is large, approximately 12 cm(s), of the Mid and lower thoracic area, with fluctuance [a tense area of skin with a wave-like or boggy feeling upon palpation], that is marked, with surrounding cellulitis, that is moderate ..."

Physician #1 documented the ED course for Patient #1, "...He is diabetic and already been on Bactrim for couple of days. He is feeling worse now. He definitely need [sic] IV [intravenous] antibiotics and surgical evacuation of this deep abscess on his back. I told him we will start the workup and finally had to transfer him for higher level of care because we do not have a surgeon here. Him and his wife decided to go directly to the ER [emergency room] to expedite the care. He is stable to go by POV [privately owned vehicle]. I am giving him oral antibiotic for pain relief ..."

Physician #1 documented in the Disposition Summary for Patient #1, " ...11/18/2023 17:53 [5:53 PM] ...Discharge Ordered ...Location: Home ...Symptoms: have worsened ...Diagnosis ...Deep abscess of back wall thorax ..."

3. In an interview on 11/28/2023 at 10:30 AM, the ED Director verified Patient #1 was discharged from the ED and was to go by private vehicle to the next facility. The ED Director stated, "...but how do you know they actually go is always my concern ..."

In an interview on 11/28/2023 at 1:25 PM, Physician #1 stated he informed Patient #1 and his wife that he would order lab work and a computed tomography (CT) scan (imaging test that helps healthcare providers detect diseases and injuries), but Patient #1 would need to transfer elsewhere afterwards for surgeon coverage. Physician #1 stated Patient #1's wife asked why they couldn't just go to another hospital with a surgeon, and Physician #1 told them Patient #1 was okay to go to the other facility per their vehicle, if that was their choice. Physician #1 stated he screened Patient #1, and there was no reason he could not be driven per private vehicle to the other facility.

In an interview on 11/30/2023 at 11:00 AM, the ED Medical Director stated he reviewed Patient #1's medical record. The ED Medical Director stated he felt there was an urgent medical condition present but not an emergent condition. The ED Medical Director stated Patient #1 was in stable condition at the time of discharge, and Patient #1 was apparently undecided where exactly he wanted to go and wanted to consider that decision further.

Patient #1 presented to the Facility #1 ED on 11/28/2023 at 5:07 PM and was discharged home on 11/28/2023 at 6:09 PM (1 hour 2 minutes). Patient #1 needed a higher level of care not available at Facility #1. While at Facility #1 ED, there was no fingerstick glucose performed to assess if Patient #1 was hyperglycemic and at risk for diabetic ketoacidosis (a serious diabetes complication where the body produces excess blood acids [ketones]) since Patient #1 presented with a history of abscess, fevers, and chills in a diabetic patient. Physician #1 documented Patient #1 needed admission and surgical evaluation for the worsening abscess. Physician #1 did not order admission or a transfer for the surgical evaluation but ordered discharge home. There was no lab work ordered or drawn to further assess Patient #1's condition. The MSE was not complete or appropriate.

Based on policy review, medical record review and interview, the facility failed to appropriately transfer a patient requiring a higher level of care for 1 of 3 (Patient #1) sampled patients requiring a higher level of care, out of 20 total patients reviewed.

The findings included:

1. Review of the facility's "EMTALA-Medical Screening and Treatment of Emergency Medical Conditions" policy (11/16/2023) revealed, " ...PURPOSE: To ensure that individuals coming to an affiliated Hospital's Dedicated Emergency Department seeking assessment or treatment for a medical condition, or coming to Hospital Property requesting (or obviously requiring) treatment for an Emergency Medical Condition receive an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and Labor Act ...and, if an Emergency Medical Condition is determined to exist, such individuals are offered stabilizing treatment within the Hospital's capabilities and/or are transferred if appropriate ..."

2. Review of the facility's "EMTALA -Transfer Policy" (9/25/2023) revealed, " ...PURPOSE: To ensure that a patient requesting or requiring a transfer for further medical care and follow-up in connection with treatment for an Emergency Medical Condition ("EMC") is transferred appropriately ...The four requirements of an appropriate transfer must be met before a patient can be transferred to a second facility ...The transferring hospital must, within its capability, provide treatment to minimize the risks to the health of the individual ...The receiving hospital must have available space and qualified personnel for the treatment of the individual, and must have agreed to accept the transfer and provide appropriate treatment ...The transferring hospital must send copies of all available medical records pertaining to the individual's emergency condition to the hospital where the patient is being transferred ...If the hospital offers to transfer a patient to another hospital for services the hospital does not offer and informs the patient or the legally responsible person of the risks and benefits to the person of the transfer but the patient or the person acting on the patient's behalf refuses to consent to the transfer, the facility must take all reasonable steps to secure a written refusal from the patient or the person acting on the patient's behalf. The written refusal should indicate the person has been informed of the risks and benefits of the transfer and state the reasons for such refusal ..."

3. Medical record review revealed Patient #1 presented to the Emergency Department (ED) at Facility #1 on 11/18/2023 at 5:07 PM via "walk-in". A triage assessment beginning at 5:19 PM documented the chief complaint for Patient #1 was a back abscess with nausea and general malaise. Further triage assessment revealed Patient #1's skin was hot, with an abscess located on the thoracic area, golf ball sized. Patient #1's temperature during triage was 99.1 degrees Fahrenheit.

A Medical Screening Exam (MSE) was initiated on 11/18/2023 at 5:21 PM by Physician #1 with documentation that revealed Patient #1 was a type 2 Diabetic that presented with increased pain and swelling to his mid-back area, that was associated with fever, chills and feeling sick to his stomach. Physician #1 documented Patient #1 saw his personal physician two days prior to coming to the ED. The personal physician started Patient #1 on Bactrim (antibiotic) by mouth. Patient #1 told Physician #1 the swelling was 3 centimeters (cm), but was now almost 10 centimeters. Patient #1 also complained of throbbing pain, spiking fevers and chills.

A continuing MSE on 11/18/2023 at 5:47 PM by Physician #1 revealed Patient #1's skin was positive for cellulitis (common and potentially serious bacterial skin infection), erythema (superficial reddening of the skin), and swelling to the middle of the lower thoracic area. Physician #1 also documented, "The patient appears alert, awake, obviously ill, in obvious pain, uncomfortable. Skin: abscess, that is large, approximately 12 cm(s), of the Mid and lower thoracic area, with fluctuance, that is marked, with surrounding cellulitis, that is moderate".

Physician #1 documented the ED course as Patient #1 had a large, deep abscess over the mid and lower thoracic area, with associated fever and chills. Patient #1 was diabetic, and had been on an antibiotic for a couple of days. Further documentation stated, "He is feeling worse now. He definitely need IV [intravenous] antibiotics and surgical evacuation of this deep abscess on his back. I told him we will start the workup and finally had to transfer him for higher level of care because we do not have a surgeon here. Him and his wife decided to go directly to the ER to expedite the care. He is stable to go by POV [privately owned vehicle] ..."

Review of the Disposition Summary on 11/18/2023 at 5:53 PM revealed, "Discharge Ordered. Location: Home. Problem: new. Symptoms: have worsened. Condition: Stable. Diagnosis: Deep abscess of back wall of thorax. Follow-up: With: Emergency Department. When: Today. Reason: Recheck today's complaints, Continuance of care, you opted to go by POV to [named facility #2] to expedite care since we do not have surgeon on call. You should go directly their [there] ..."

Review of Patient #1's Discharge Instructions revealed, "SPECIAL NOTES ...So you have a large deep abscess in the back wall of thorax associated with possible sepsis. We have offered you initial workup and then transferred by ambulance for a surgical consult since there is no on-call surgeon [at] your facility. You have opted to go by your own vehicle to expedite care. You should go directly to emergency room either in [named facility] or [named facility] where there is surgeon on-call". Physician #1 discharged Patient #1 from the ED, and Patient #1 left facility on 11/18/2023 at 6:09 PM.

In an interview on 11/28/2023 at 1:25 PM, Physician #1 stated he informed Patient #1 and his wife they could go ahead and get started on the work up needed for the abscess, which would include labs and imaging, but would still need to transfer to another facility afterwards for surgeon coverage. Physician #1 stated he explained how the transfer process worked. Patient #1's wife asked why they couldn't just go on to a hospital with a surgeon. Physician #1 stated he believed Patient #1 was stable and was okay to be discharged to go to another facility per vehicle, if that was their choice.

Patient #1 was discharged from Facility #1 per private vehicle on 11/18/2023. Patient #1 needed a higher level of care not available at Facility #1. Patient #1 required transfer to another facility. There was no documentation Facility #1 reached out to Facility #2 to verify specialized services required (surgical services) were available, and if a physician was willing and able to accept Patient #1 at Facility #2. There was also no documentation of a written refusal for transfer by Patient #1, as specified per Facility #1's policy.