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Based on interviews, and policy review, the Governing Body failed to ensure the facility properly discharged and transferred the patient (P#19) to receive emergency optometry services while the patient experienced an emergent condition of P#19's eyes upon discharge

Review of the "Emergency Services Physician ' s Privileges and Responsibilities" policy #301-7, last reviewed 3/19, revealed the Emergency Department (ED) offered emergency care 24 hours a day, with at least one physician experienced in emergency care on duty in the emergency care area, and with specialty consultation available within approximately 30 minutes by members of the medical staff or by senior-level residents. In addition, the policy revealed the hospital's scope of services included in-house capabilities for managing physical and related emotional problems, with provision for patient transfer to another facility when needed. A director would be appointed from among the full-time physicians to provide administrative coordination for the physicians group. Patients who require specialized definitive care will be referred to either the staff or private physicians according to the daily call list schedules of each service.

Review of the Call Center Procedure Handbook procedure titled, "Physician, Department and Practices On-Call Schedule," revealed the facility must maintain a list of physicians, including specialists and sub-specialists, who are on-call to evaluate and treat patients in the emergency department, as well as service patients for practices and hospital departments. Review of the handbook revealed, on-call schedules are entered into the computer system by practices or departments requiring shift coverage. On-call schedules are used by the call center to ensure staff is available to assist patients, aid during emergencies, and ensure systems are functioning throughout the hospital. A list of staff and physicians who are on-call for duty is maintained in the computer and monitored by call center personnel. Medical Staff avoiding on-call responsibility will be reported to the executive team. If there is a gap in the on-call schedule, the division chair for the specialty will be contacted and remain as the primary contact until such time an appropriate physician is selected to fill the gap. All on-call personnel are to be listed with a backup for each shift.

Review of the Medical Staff Bylaws Section 2 (5), approved 12/20/2007, revealed that providers who are appointed to the Medical Staff must provide appropriate call coverage of their specialty. Review of the "List of Inpatient Specialties" revealed that ophthalmology was not listed as an available inpatient specialty.

Review of the Exhibit 286, Facility Data Form, revealed the facility had ophthalmic surgery services provided through a combination of facility staff and agreements.

Review of a list of eight ophthalmologists provided by the facility, revealed all eight ophthalmologists listed were courtesy members of the medical staff.

Review of the Medical Staff Bylaws- Section 4, approved 12/20/2007 revealed the courtesy medical staff shall consist of practitioners who are eligible for active medical staff membership and who have not elected to become members of the active staff for the facility. In addition, practitioners whose practice does not customarily result in hospital admissions/discharges/procedures may, on a selected basis, be assigned to the courtesy medical staff as requested by the practitioner. Members of the courtesy medical staff are not eligible to vote or hold office and are not required to attend the regular meetings or accept committee assignments of the medical staff. Review of the Medical Staff By-laws revealed hese practitioners will have no required assigned duties. Further review of the Medical Staff By-laws revealed, , courtesy medical staff membership did not relieve the practitioner of his or her responsibility to adhere to the rules and regulations with respect to quality of patient care, medical records, and administrative procedures.



During an interview with the Director of Hospitalists on 6/30/21 at 1:19 p.m., in the Administrative Conference Room, the Director of Hospitalists said if a patient developed an Emergency Medical Condition (EMC) that was beyond the scope of the hospital, subspecialists at other facilities would be contacted by the physicians. In addition, the Director of Hospitalists stated if the specialists could help and if there was space available, the patient would be transferred. The Director of Hospitalists stated any time ophthalmology issues developed during hospitalization, there was not an ophthalmologist at the facility to help. In addition, the Director of Hospitalist stated if a patient was stable in other areas, the physician would attempt to reach an ophthalmologist in the community. The Director of Hospitalists stated the ophthalmologist would agree to help but would say he/she could not come to the hospital, and stated that sometimes, a patient would be transferred to the ophthalmologists ' clinic.

During an interview with the Chief Medical Officer on 7/1/21 at 11:38 a.m. in the Administrative Conference Room, the Chief Medical Officer said all specialists who had privileges at the facility must have provided call back for the active staff. The Chief Medical Officer stated if there were no staff in a specialty, the process was to treat, stabilize, and seek a hospital that had the appropriate level of capability. The Chief Medical Officer further said the facility had coverage for all life-threatening situations, but no ophthalmologist. The Chief Medical Officer further said many hospitals do not have ophthalmologists and stated that a true ophthalmology emergency such as an eye injury would be transferred to a trauma center, which would have ophthalmology services. The Chief Medical Officer said the facility would typically contact an ophthalmologist in town to see if the patient could be seen in the ophthalmologist ' s office. The Chief Medical Officer stated the ophthalmologists did not have an obligation to come to the hospital, did not have equipment they would use at the hospital, and most ophthalmological procedures would be done in the office.

A review of an email from Accreditation Specialist (FF) on 8/23/2021 at 3:39 p.m. revealed that
ophthalmologists listed in the medical staff directory did not have physician contracts with the facility; the ophthalmologists were courtesy members of the medical staff and did not take call. Ophthalmology was not listed as one of the facility ' s inpatient specialties.

Based on interviews, and policy review, the Governing Body failed to ensure the facility properly discharged and transferred the patient (P#19) to receive emergency optometry services while the patient experienced an emergent condition of P#19 ' s eyes upon discharge

Review of the Medical Staff Rules and Regulations, approved by the Governing Body on 5/28/09, revealed that if the hospital did not provide the services required by a patient, or for any reason the hospital could not admit a particular patient who required inpatient care, the hospital and/or the attending staff member would assist the patient in arranging care to an alternate facility so as not to jeopardize the health and safety of the patient. In addition, the Medical Staff Rules and Regulations revealed that if the patient was transferred to another health care facility, the responsible staff member would enter all appropriate information on the patient's medical record prior to the transfer. The Medical Staff Rules and Regulations revealed any transfer to another acute care hospital would be coordinated with the administrative nursing supervisor to ensure compliance with EMTALA ' s duty to stabilize and appropriately transfer any patient. A patient would not be transferred to another medical care facility until the receiving facility had consented to accept the patient and the patient was considered sufficiently stabilized for transport. Copies of clinical records of sufficient content to ensure continuity of care would accompany the patient.

Review of the "Patient Care Practice Standards" policy #6010-062, revised 1/21, revealed all transfers to an external facility required a physician ' s order. In addition, the policy revealed that the nurse assigned to the patient would call to report to the receiving facility and complete the "Inter-facility Infection Control Transfer Form". The case manager, social worker, or unit clerk would print the Transfer to External Facilities form. The policy revealed the transfer of a patient with an un-stabilized emergency condition would only be permissible when specific criteria had been satisfied. Further review of the policy revealed an Emergency Medical Condition (EMC) would be any medical condition of sufficient severity that in the absence of immediate medical attention, the patient or unborn child would reasonably be expected to be in serious jeopardy, suffer serious impairment to bodily functions, or serious dysfunction of any bodily organ or body part. The policy revealed that stabilized was defined as within a reasonable degree of medical probability, no material deterioration would likely result from or occur during the transfer. The policy revealed in the event orders were received to transfer a patient with an un-stabilized emergency medical condition, the appropriate transfer form would be completed prior to allowing the patient to depart.

Review of the medical record revealed P#19 was admitted to the hospital through the Emergency Department (ED) on 6/15/21 at 3:15 a.m., with acute chronic heart failure and stage 3 chronic kidney disease. Review of the "Discharge Summary" entered by MD DD on 6/18/21 at 3:56 p.m., revealed P#19 was in the process of discharging from the hospital but P#19 reported experiencing blurry vision. MD DD said that through long conversations and discussions with specialists, P#19 was discharged with instructions to report to a nearby hospital Emergency Department (ED) for treatment, as ophthalmologists would see P#19 at another hospital not affiliated with the facility(referred hospital). .

Review of a nurse note by RN HH revealed the outside hospital was on Medical-Surgical and Emergency Room diversion (not accepting patients). Review of MD DD ' s "Progress Notes" on 6/18/21 at 7:48 p.m., revealed the progress note was for documentation purposes and stated that MD DD had a discussion with Technician LL at the referred hospital ' s eye clinic of P#19 ' s condition; and revealed the patient could not be seen in the referred hospital ' s eye clinic urgently that day. Further review of MD DD ' s progress note revealed, Technician LL advised MD DD to have the patient go to the referred hospital ' s ED for evaluation, and that Technician LL would let the on-call ophthalmology resident know the patient was on the way to the referred hospital. Review of the progress note revealed MD DD affirmed the directions with Technician LL and proceeded to discharge P#19. Review of MD DD ' s progress note revealed MD DD called the ED and left the patient ' s name with the ED nurse who said she would watch out for P#19 when he came to the ER.

Review of RN II ' s "Narrative Notes" on 6/18/21 revealed P#19 was discharged with instructions to go to a nearby hospital due to detached retina concerns.

Review of "Case Management" notes on 6/18/21 at 4:05 p.m. revealed transport by ambulance was set up because P#19 did not have a ride.

A review of the referred hospital ' s medical record triage notes for P#19 revealed P#19 was transferred to the referred hospital ED due to retinal detachment. In addition, the triage notes revealed P#19 arrived at the ED by ambulance on 6/18/21 at 8:17 p.m. Review of the P#19 ' s triage began at 8:44 p.m. Review of an "Emergency Services Note" revealed a resident ED physician (DO)(PP) began a Medical Screening Exam on 6/18/21 at 8:56 p.m., and an ophthalmology consult was ordered due to concern for retinal detachment. Review of the ophthalmology consult notes revealed that P#19 was seen at another facility not affiliated with the referred hospital for Congestive Heart Failure (CHF) and transferred to the ED for an ophthalmology evaluation without prior notification of ophthalmology services. Review of (identifier ' s) emergency services note on 6/19/21 at 12:24 a.m., revealed that P#19 was evaluated by an ophthalmologist and diagnosed with a vitreous hemorrhage (bleeding into the jelly-like filling of the back part of the eye). Further review of the emergency services note revealed, P#19 was provided discharge instructions and advised to follow up with the hospital ' s eye clinic in 3-4 weeks. Review of P#19 ' s Emergency Medical record revealed P#19 was stable for discharge home and discharged on 6/19/2021 at 4:58 a.m.



Review of an attestation by on 6/22/21 at 11:27 a.m., revealed P#19 was discharged from an outside hospital ' s inpatient unit and that the referred hospital ' s charge nurse would discuss with the referred hospital ' s administration and/or legal departments of a possible EMTALA violation.



Review of a note by the attending ophthalmologist (MD) (NN) on 6/25/21 at 6:39 a.m. revealed P#19 was sent to the ED without prior notification of transfer for ophthalmology services or ED services, according to the ED charge nurse and attending in charge.



During a telephone interview with the complainant on 7/1/21 at 12:18 p.m., the complainant stated concern about a potential EMTALA violation when P#19 was transferred from a nearby facility not affiliated with the referred hospital without obtaining acceptance into the referred hospital. The complainant said to his/her knowledge, no one at the referred hospital had any idea that P#19 was in process of transferring into the referred hospital ' s ED. The complainant said there was awareness that P#19 was treated as an in-patient, discharged from a facility not affiliated with the referred hospital and that the non-affiliated facility arranged to have Emergency Medical Services (EMS) transport P#19 to the ED.

During an interview with the Director of Hospitalists on 6/30/21 at 1:19 p.m. in the Administrative Conference Room, the Director of Hospitalists said if a patient developed an Emergency Medical Condition (EMC) that was beyond the scope of the hospital, subspecialists at other facilities would be contacted by the physicians. In addition, the Director of Hospitalists stated that if the specialists could help, and if there was space available, the patient would be transferred. The Director of Hospitalists stated that sometimes a patient would be transferred to an ophthalmologist clinic(the facility ' s ophthalmologists ' clinics? or to any ophthalmologist clinic?)ophthalmologists ' clinic. The Director of Hospitalists further said, that when lateral transfers were requested to area hospitals, there were times the hospital did not have any beds available. The Director of Hospitalists stated when MD DD contacted a nearby hospital about a lateral transfer of P#19, the nearby hospital was on diversion. The Director of Hospitalists stated when there is diversion, the doctor would have two options: keep the patient and risk worsening of the medical condition or talk to the patient and tell them there is no expert there who can help; or worse case would be to discharge the patient to go to a nearby hospital. The Director of Hospitalists said the nurse and doctor communicated with a nearby hospital clinic, and P#19 was discharged after those communications.

An interview took place with the Clinical Director of Case Management on 6/30/21 at 2:32 p.m. in the Administration Conference Room. The Clinical Director of Case Management said she remembered P#19 had a complaint of blurred vision, and P#19 needed to be seen immediately by an ophthalmologist. The Clinical Director of Case Management said the facility did not have ophthalmology services, so the physician attempted to transfer P#19 to a nearby hospital. The Director of Hospitalists spoke to the clinic and physician at another hospital about the best plan of care for P#19. The Clinical Director of Case Management stated the physician at a nearby hospital agreed that P#19 needed to be seen, and that P#19 would be seen immediately if the facility could get P#19 to the emergency room. The Clinical Director of Case Management statedP#19 was transferred by ambulance to the Emergency Department (ED) a nearby hospital. The Clinical Director of Case Management said a transfer form was not done, because transfer forms are not dones as an inpatient. The Clinical Director of Case Management said when a patient is transferred, the facility sends an external transfer form with a summary of the patient ' s hospitalization. The Clinical Director of Case Management further said that if there was a patient who needed to go to a different hospital as an inpatient for a higher level of care, a physician would call the other hospital to obtain an accepting physician. The Clinical Director of Case Management stated when the physician at the other hospital agreed to the transfer, the nurse or physician would call (call whom?) to obtain a bed. The Clinical Director of Case Management further stated, once a bed was assigned at the other hospital, transportation would be worked out. The Clinical Director of Case Management said the other hospital must accept the patient. The Clinical Director of Case Management said if a facility is on total diversion (not accepting patients), they would move on to the next hospital.

During an interview with Registered Nurse (RN)(HH) on 7/1/21 at 10:08 a.m. in the Administrative Conference Room. RN HH said P#19 was in process of discharge and P#19 had some complaints about his vision. RN HH stated MD DD examined P#19 and asked RN HH to give a nearby hospital a call to see if they could accept the P#19, since the facility did not have an ophthalmologist. RN HH said she called the transfer office of a nearby hospital and was told the hospital was on diversion (not accepting patients) and did not have any beds. RN HH said she called the eye clinic of a nearby hospital to see if a nurse or technician would contact the eye doctor for a phone conference with MD DD.

During an interview with RN (II) on 7/1/21 at 10:24 a.m. in the Administrative Conference Room, RN II said that when she did her assessment of P#19, she let MD DD know P#19 had problems with vision in his right eye. MD DD assessed the P#19 ' s eye with an ophthalmoscope and said P#19 may have needed an emergency ophthalmological assessment. RN HH stated she initiated a call to a nearby hospital ' s eye clinic. RN HH stated she was told the attending physician at the eye clinic had been informed and would call MD DD back with what to do about P#19. RN II further said that because the nearby hospital was on diversion, P#19 would have to be discharged and report to the hospital ' s ED. RN II said transportation was set up because P#19 did not have transportation. RN II said she gave P#19 ' s discharge information, which included a history and physical and education on the importance of going to the nearby hospital emergency room.

During a telephone interview with the nearby hospital ' s on-call ophthalmologist MD (NN) on 7/8/21 at 1:05 p.m., MD NN said he got a call from the hospital ' s ED asking for details about P#19 and letting him know the patient was at the ED. MD NN said he had no details to give the ED, because he was never called about P#19. MD NN further said transfers are inpatient to inpatient, and the ophthalmology clinic cannot accept inpatient transfers.

During a telephone interview with the Ophthalmology Department Head MD (MM) on 7/8/21 at 3:57 p.m., MD MM said none of the physicians at the ophthalmology clinic or hospital had spoken to MD DD about P#19.

During a telephone interview with the Ophthalmology Technician LL on 7/8/21 at 4:10 p.m., Technician LL said she was the on-call technician on 6/18/21. Technician LL said RN HH called on 6/18/21 at 2:35 p.m. regarding a patient who was currently an inpatient at another hospital. Technician LL stated she was told P#19 had complained of spider-webs in his right eye for two days, and MD DD wanted to speak to the on-call ophthalmologist. Technician LL said she told the on-call resident MD OO about the request, and MD OO said the ophthalmologists do not take call for the other hospital. Technician LL notified MD DD that he would need to contact a hospitalist at the facility where the ophthalmology clinic was located to discuss treatment. Technician LL said another nurse from the facility called concerning P#19 and said there was a patient with retinal detachment. Technician LL told the nurse she had already spoken to MD DD and told him he needed to call the hospitalist. Technician LL stated the nurse said the patient would be discharged and sent to the ED where the ophthalmology clinic was located. Technician LL said she did not give any direction as to what the other hospital should do, and the second phone call was the last conversation she had with the other hospital concerning P#19. Technician LL stated P#19 did not enter the ophthalmology department on 7/18/21.

During a telephone interview with the on-call ophthalmology resident MD OO on 7/8/21 at 6:01 p.m., MD OO said residents were told not to contact anyone at the other hospital, and he did not have a conversation with anyone at the other hospital. MD OO said residents were not supposed to get involved in the transfer process. MD OO said ophthalmologists from the outpatient clinic only see inpatient and ED consults at the facility where the clinic is located, and patients come to the clinic through the facility ' s ED. MD OO further said communication is normally hospitalist to hospitalist or ED physician to ED physician.