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Based on review of facility policy, review of on-call general surgery schedules, medical record review, review of transfer center audio communication, and interviews, the facility failed to provide an appropriate medical screening examination and provide an appropriate transfer for 1 patient (#5) who presented with abdominal pain of 22 Emergency Department (ED) records reviewed.

The findings include:

Patient #5 was admitted to Facility A's ED on 10/14/2024 at 8:46 PM with complaints of abdominal pain. The patient had previous abdominal surgeries. Diagnostic testing showed a Bowel Obstruction, a Fecal Impaction, and Sepsis. The facility had on-call general surgery capacity and capabilities. The patient developed hypotension (low blood pressure) requiring the use of vasopressors (medications to treat low blood pressure), intravenous fluids, oxygen, and antibiotics. Facility B was called and accepted Patient #5 for transfer without consulting Facility A's on-call general surgeon for intervention and/or stabilization. On arrival at Facility B, the patient required intubation, the insertion of a central venous and arterial line, and intravenous fluid resuscitation. The patient was taken emergently to surgery for a bowel resection where she deteriorated. The surgery was completed and she was admitted to the surgical intensive care unit with plans to return to the operating room once the patient stabilized. The patient suffered a cardiac arrest and expired on 10/15/2024.

Cross Refer to A-2407 and A-2409.

Based on review of facility policy, review of facility on-call schedules, medical record review, review of transfer audio communication, and interviews, the facility failed to provide stabilizing treatment for one (1) patient (#5) who presented with abdominal pain of 22 Emergency Department (ED) records reviewed.

The findings include:

Review of facility policy, "Emergency Medical Treatment Active Labor Act," revised 2/5/2021, showed "...medical screening examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an emergency medical condition exists...is a ongoing process, and the medical records must reflect continued monitoring based on the patient's needs and must continue until the patients is either stabilized, admitted to inpatient care, or appropriately transferred...stabilized means, with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer or the individual from a facility...this includes coverage available through the hospital's on-call physician roster. The hospital is responsible for treating the individual within the capabilities of the hospital as a whole..."

Review of the facility's On-Call Provider Schedules for 10/14/2024 and 10/15/2024 showed the facility had a general surgery on-call provider. The surgeon was not called or consulted in relation to Patient #5.

Medical record review of an ED Nursing Triage Record for Patient #5, dated 10/14/2024 at 8:46 PM, showed the patient presented by Emergency Medical Services (EMS) with a distended abdomen and diarrhea for 4 weeks.

Medical record review of an ED Provider Note, dated 10/14/2024 at 8:48 PM, showed the patient had an onset of abdominal pain which started 3 hours prior to arrival. Her physical examination showed an distended abdomen with marked tenderness.

Medical record review of the diagnostic testing dated 10/14/2024, showed the following:
9:16 PM - Complete Blood Count (CBC) with an elevated white blood count of 15.2 (normal 5-10) and elevated Neutrophils 13.2
9:16 PM - Comprehensive Metabolic Panel (CMP): BUN 24 (normal 6-24), Creatinine 1.37 (normal 0.7-1.3)
9:16 PM - Lipase 84 (normal 13-78)
9:16 PM - Elevated Lactic Acid 5.7 (normal 0.5-2.2).
11:08 PM - Computed Tomography (CT) scan of the abdomen and pelvis: severe distention of the colon with stool and air, fecal impaction, possible colonic ileus (lack of movement in the intestines) versus metabolic pseudoobstruction considered. There was no colitis (inflammation of the colon) or diverticulitis (infection in the colon). Possible stricture or mass at the gastroesophageal junction of the esophagus, and no pneumoperitoneum (air in peritoneum).

Medical record review of the Medication Administration Record, dated 10/14/2024, showed the following medications were administered:
Dilaudid (pain medication) 1 mg IV at 9:18 PM
Zofran 4 mg IV at 10:10 PM
Zosyn (antibiotic) 3.375 grams IV at 10:53 PM
Normal Saline IV fluids started at 10:54 PM; total of 2449 milliliters.
Norepinephrine (vasopressor) drip at 0.5 micro kilograms per kilogram (mcg.kg/min) started at 11:27 PM
10/15/2024
Fleets enema at 12:06 AM
Norepinephrine drip decreased to 0.3 micro mcg/kg/min at 1:29 AM.

Medical record review of an ED Provider Note, dated 10/15/2024 at 1:21 AM, showed "...attempted removal of fecal impaction. I removed a very large amount of soft stool and patient passed a minimal amount of gas. She has a rectal mass or hemorrhoids which bleed mildly at the time of the procedure..." Her diagnoses included Abdominal Pain, Large Bowel Obstruction, and Sepsis. The patient was accepted at [Facility B]..."

Medical record review of an EMTALA transfer form, dated 10/15/2024 at 1:22 AM, showed Patient #5 was transferred to Facility B and was transported by EMS on 10/15/2024.

Medical record review of an admission History and Physical from Facility B, dated 10/15/2024 at 3:01 AM, showed the patient presented from an outside facility with abdominal pain. The patient's family reported increased abdominal pain for the past few days with no bowel movements for 10 days. The labs showed severe distention of the colon with stool and air, a fecal impaction, and possible stricture or mass in the gastroesophageal junction. On arrival at Facility B's Surgical Intensive Care Unit the patient was "...grossly hypotensive requiring multiple pressors and required intubation and a central line and arterial line placement. The patient had a Lactate of 10 and a leukocytosis of greater than 25. Patient was already starting to develop acute kidney injury with a creatinine of 1.6 and she had a PH that was below 7...plan is to take the patient emergently to the operating room and continue sepsis resuscitation..."

Medical record review of an Operative Report, dated 10/15/2024 at 6:57 AM, showed Subtotal Abdominal Colectomy (bowel resection), Enterorrhaphy (stitching of the intestine), Extensive Lysis of adhesions, and application of temporary abdominal closure with negative pressure dressing was performed. The patient was "...unstable at the time of the conclusion of the case and was taken to the ICU for ongoing resuscitation..."

Medical record review of a Discharge Summary, dated 10/15/2024 at 12:29 PM, showed Patient #5 had multi-system failure related to bowel ischemia/perforation and expired. She had been taken to surgery and then transferred to the SICU. She suffered a cardiac arrest where resuscitation was unsuccessful. She expired on 10/15/2024.

Review of an audio recording from the transfer center at Facility B showed the transfer center was contacted on 10/15/2024 by ED Provider #1 from Facility A. ED provider #1 stated the patient was a long-term surgery patient from Erlanger Medical Center which needed transfer. Her diagnoses included Ischemic Bowel and Sepsis. The patient would require ICU admission and probable emergent surgical intervention. The patient presented with abdominal pain and distention. The patient stated she had not had a bowel movement for several weeks. The patient's labs were "...crappy...WBC was 15 thousand, Lactic Acid 5.7...ischemic bowel possibly necrotic bowel and septic..." Her blood pressure had dropped where she was started on a Levophed drip and her blood pressure had stabilized. The physician stated "...I would not be surprised if the patient did not survive...there is nothing we do for her here..." The patient was hypothermic (low temperature) and "circling the drain."

During an interview on 12/11/2024 at 9:50 AM, the Risk Manager stated the patient presented with abdominal pain with distention. Her CT showed a bowel obstruction and an elevated Lactic Acid. The ED provider felt the patient needed surgical intervention and called Facility B. The ED provider did not call the on-call surgeon for the patient. The patient developed hypotension, she was started on Levophed and transferred to Facility B. On 10/18/2024, Facility B called about questions related to patient's transfer. On arrival at Facility B the patient had decompensated. There was discussion related to whether the facility had an on-call surgeon who could have evaluated and treated the patient. The on-call surgeon was not called or consulted for the patient. The ED Medical Director spoke with ED Provider #1 who confirmed he had not called the on-call surgeon for evaluation and arranged the transfer to Facility B.

During a telephone interview on 12/11/2024 at 1:00 PM, ED Provider #1 stated the patient arrived by EMS with abdominal pain and distention. Diagnostic testing was completed where the CT scan showed a bowel obstruction and a fecal impaction. Her laboratory diagnostic testing showed an elevated Lactic Acid and White Blood Count. The patient developed hypotension and a Levophed drip was started. She was given IV antibiotics and IV fluids. He called Facility B to initiate a transfer related to possible surgical intervention. Facility B accepted the patient for transfer. ED Provider #1 stated the facility did have on-call surgery capabilities and confirmed he had not consulted with the on-call surgeon prior to transfer.

During a telephone interview on 12/11/2024 at 1:15 PM, the ED Medical Director stated the patient had a bowel obstruction and deterioated while in the ED. He confirmed the facility did have on-call surgery capabilities and the on-call provider should be consulted for potential surgical cases.

During a telephone interview on 12/11/2024 at 4:30 PM, Facility B's Risk Manager stated there were concerns related to the patient was transferred with an unstable condition and in need of surgical intervention. Facility A had confirmed on-call general surgery was not consulted and did not evaluate the patient. The delay could have contributed the increased risk of mortality for the patient. Patient #5 was unstable on arrival Facility B's Intensive Care Unit (ICU), she required intubation, the insertion of central and arterial lines, and aggressive fluid resuscitation. The patient was taken for emergent surgery where she remained critical. The surgery was completed and she was taken back to SICU. The patient suffered a cardiac arrest and expired on 10/15/2024.

Cross Refer to 2409.

Based review of facility policy, review of on-call schedules, medical record review, review of transfer center audio communication, and interviews, the facility inappropriately transferred Patient #5, one of 22 sampled patients, to Facility B when the hospital had the capability and capacity to provide treatment for the identified emergency medical condition.

The findings include:

Review of facility policy, "Emergency Medical Treatment Active Labor Act," revised 2/5/2021, showed "...capability...the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes coverage available through the hospital's on-call physician roster. The hospital is responsible for treating the individual within the capabilities if the hospital as a whole...Appropriate transfer...the transferring hospital provides medical treatment within its capacity that minimizes the risks of individual's health...if a patient is determined to have an Emergency Medical Condition (EMC) and ...the treating physician determines that the hospital has exhausted all capabilities to stabilize the patient's EMC, and that the benefits of an appropriate transfer outweigh the risks of transfer, the hospital shall take reasonable steps to initiate an appropriate transfer..."

Review of the facility's On-Call Provider Schedules for 10/14/2024 and 10/15/2024, showed the facility had a general surgery on-call provider. The surgeon was not called or consulted in relation to Patient #5.

Medical record review of an ED Nursing Triage Record dated 10/14/2024 at 8:46 PM, showed Patient #5 presented by Emergency Medical Services (EMS) with a distended abdomen and diarrhea for 4 weeks.

Medical record review of an ED Provider Note dated 10/14/2024 at 8:46 PM, showed Patient #5 had an onset of abdominal pain, which started 3 hours prior to arrival. Her physical examination showed a distended abdomen with marked tenderness.

Medical record review of an ED Provider Note dated 10/15/2024 at 1:21 AM, showed "...attempted removal of fecal impaction. I removed a very large amount of soft stool and patient passed a minimal amount of gas. She has a rectal mass or hemorrhoids which bleed mildly at the time of the procedure..." Her diagnoses included Abdominal Pain, Large Bowel Obstruction, and Sepsis. The patient was accepted at [Facility B]..."

Medical record review of an EMTALA transfer form, dated 10/15/2024 at 1:22 AM, showed Patient #5 was transferred to Facility B and was transported by EMS on 10/15/2024.

Medical record review of an admission History and Physical from Facility B, dated 10/15/2024 at 3:01 AM, showed the patient presented from an outside facility with abdominal pain. The patient's family reported increased abdominal pain for the past few days with no bowel movements for 10 days. The labs showed severe distention of the colon with stool and air, a fecal impaction, and possible stricture or mass in the gastroesophageal junction. On arrival at Facility B's Surgical Intensive Care Unit the patient was "...grossly hypotensive requiring multiple pressors and required intubation and a central line and arterial line placement. The patient had a Lactate of 10 and a leukocytosis of greater than 25. Patient was already starting to develop acute kidney injury with a creatinine of 1.6 and she had a PH that was below 7...plan is to take the patient emergently to the operating room and continue sepsis resuscitation..."

Medical record review of an Operative Report, dated 10/15/2024 at 6:57 AM, showed Subtotal Abdominal Colectomy (bowel resection), Enterorrhaphy (stitching of the intestine), Extensive Lysis of adhesions, and application of temporary abdominal closure with negative pressure dressing was performed. The patient was "...unstable at the time of the conclusion of the case and was taken to the ICU for ongoing resuscitation..."

Medical record review of a Discharge Summary, dated 10/15/2024 at 12:29 PM, showed the patient had multi-system failure related to bowel ischemia/perforation and expired. She was taken to surgery and then transferred to the SICU. She suffered a cardiac arrest where resuscitation was unsuccessful. She expired on 10/15/2024.

Review of an audio recording from the transfer center at Facility B showed the transfer center was contacted on 10/15/2024 by ED Provider #1 from Facility A. Her diagnoses included Ischemic Bowel and Sepsis. The patient would require ICU admission and probable emergent surgical intervention. The patient presented with abdominal pain and distention. The patient stated she had not had a bowel movement for several weeks. The patient's labs were "...crappy...WBC was 15 thousand, Lactic Acid 5.7...ischemic bowel possibly necrotic bowel and septic..." Her blood pressure had dropped where she was started on a Levophed drip and her blood pressure had stabilized. The physician stated "...I would not be surprised if the patient did not survive...there is nothing we do for her here..." The patient was hypothermic (low temperature) and "circling the drain."

During an interview on 12/11/2024 at 9:50 AM, the Risk Manager stated the patient presented with abdominal pain with distention. Her CT showed a bowel obstruction and an elevated Lactic Acid. The ED provider felt the patient needed surgical intervention and called Facility B. The patient developed hypotension, she was started on Levophed and transferred to Facility B. On 10/18/2024 Facility B called about questions related to Patient #5's transfer. On arrival at Facility B, the patient had decompensated. There was discussion related to whether Facility A had an on-call surgeon who could have evaluated and treated the patient. The on-call surgeon was not called or consulted for the patient. The ED Medical Director spoke with ED Provider #1 who confirmed he had not called the on-call surgeon for evaluation and arranged the transfer to Facility B.

During a telephone interview on 12/11/2024 at 11:20 AM, RN #2 stated the patient presented with abdominal pain and distention. The patient developed hypotension and an elevated heart rate. The patient was started on Levophed drip related to her blood pressure. The patient was transferred to Facility B.

During a telephone interview on 12/11/2024 at 1:00 PM, ED Provider#1 stated the patient arrived by EMS with abdominal pain and distention. Diagnostic testing was completed and the CT scan showed a bowel obstruction and a fecal impaction. Her laboratory diagnostic testing showed an elevated Lactic Acid and White Blood Count. The patient developed hypotension where a Levophed drip was started. She was given IV antibiotics and IV fluids. He called Facility B to initiate a transfer related to possible surgical intervention. Facility B accepted the patient for transfer. ED Provider #1 stated the facility did have on-call surgery capabilities and confirmed he had not consulted with the on-call surgeon prior to transfer.

During a telephone interview on 12/11/2024 at 1:15 PM, the ED Medical Director stated the patient had a bowel obstruction and deterioated while in the ED. He confirmed the facility did have on-call surgery capabilities and the on-call provider should be consulted for potential surgical cases.

During a telephone interview on 12/11/2024 at 4:30 PM, Facility B's Risk Manager stated there were concerns related to Patient #5's transfer with an unstable condition and in needed surgical intervention. Facility A had confirmed he on-call general surgeon was not consulted and did not evaluate the patient. The delay could have contributed the increased risk of mortality for the patient. The patient was unstable on arrival Facility B's Intensive Care Unit (ICU), she required intubation, the insertion of central and arterial lines, and aggressive fluid resuscitation. The patient was taken for emergent surgery where she remained critical. The surgery was completed and she was taken back to SICU. The patient suffered a cardiac arrest and expired on 10/15/2024.

Cross Refer to 2407.