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Based on review of facility policies, specialty on-call schedules, physician's credentials, medical records, observations, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital to diagnose and treat the Emergency Medical Conditions (EMC) of one (Patient #25) patient and failed to provide an appropriate transfer for one (Patient #25) of 33 patients reviewed. These failures led to Patient #3's being discharged home without his fractured neck being correctly diagnosed and treated at Hospital A. Additional, these failures led to Patient #25 being transferred 81 miles to Hospital B when Hospital A had the capability to treat his injuries.

The findings included:

Medical record review revealed Patient #3 presented to Hospital A's Emergency Department (ED) on 9/12/2021 at 6:25 PM for complaint of upper neck pain, and pain in both elbows following a fall at home on 9/12/2021. Review of a Computed Tomography (CT is a type of non-invasive medical imaging that provides detailed images of internal body parts) Report dated 9/12/2021 at 8:18 PM revealed no spinal fractures were identified. Review of the medical record revealed the patient was discharged home on 9/12/2021 at 9:50 PM. There was no documentation of consultations with any on-call specialist.

Review of Patient #3's medical record revealed he returned to the ED at Hospital A by ambulance on 9/13/2021 at 7:45 AM for complaints of weakness and poor coordination. Patient #3 was admitted to Hospital A with diagnoses which included: Cerebrovascular Accident (stroke), Right Upper Extremity (Right Arm) Weakness, Ataxia (poor coordination), Diabetes, and Prostate Cancer. Review of a Neurosurgery Consult Note dated 9/14/2021 at 7:23 AM revealed Patient #3 had a cervical spine fracture requiring surgical intervention. This was not identified initially by Radiology. Patient #3 had quadriparesis (muscle weakness in all four limbs).

Review of Patient #25's medical record revealed he presented to the ED at Hospital A on 6/13/2021 at 2:57 PM for complaint of falling approximately 12 feet from a ladder. Review of Physician's Documentation dated 6/13/2021 at 7:53 PM revealed Patient #25 had a lumbar spinal fracture and was transferred to Hospital B. Continued review revealed no documentation any of the On-Call Specialists were consulted or contacted regarding Patient #25's injuries. Patient #25 was transferred by ambulance from Hospital A on 6/13/2021 at 9:10 PM.

Review of medical records from Hospital B revealed Patient #25 arrived at Hospital B's ED on 6/13/2021 at 10:29 PM. Patient #25 was admitted to Hospital B on 6/13/2021 at 11:27 PM with diagnoses that included: Fall leading to fractures, Chronic Diarrhea, Unintentional Weight Loss, and Hypertension (high blood pressure). Review of Neurosurgeon's Consult Note dated 6/14/2021 at 4:16 AM revealed, "...I met with the patient this morning in the emergency room...I reviewed his imaging studies I agree that he is got a compression fracture but the age of this fracture is unknown this is a fairly stable appearance and I do not anticipate the need for back bracing or any further intervention. He is clear for discharge from our standpoint.."

The patient was discharged from Hospital B in stable condition on 6/21/2021 with no surgical intervention to correct the spinal fracture.

Based on review of facility policies, specialty on-call schedules, physician's credentials file, medical records, observations, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) within the capabilities of the hospital, to include ancillary services available, to diagnose the Emergency Medical Condition (EMC) of one (Patient #25) patient of 33 patients reviewed. The failure led to Patient #25's EMCs not being diagnosed and treated at Hospital A.

The findings included:

Review of facility policy titled "Emergency Medical Treatment and Active Labor Policy" effective date 10/2019 revealed, "...When an individual comes to the Emergency Department [ED]...and a request is made for a medical examination or treatment, the hospital must provide an Medical Screening Examination within the capabilities of the hospital's services...Further medical examination and treatment, including hospitalization, if necessary as required to stabilized the Emergency Medical Condition within the capabilities of the staff and facilities available..."

Review of the Emergency Room call roster revealed on 6/13/2021 there was a Neurosurgeon on call.

Physician #1 was the neurosurgeon on-call on 6/13/2021. Review of Physician #1's credentials revealed he was licensed as a Medical Doctor, he is board certified in neurosurgery, and his privileges included procedures to treat fractured spines and spinal cord injuries.

Review of Patient #25's medical record revealed he presented to the ED at Hospital A on 6/13/2021 at 2:57 PM for complaint of falling approximately 12 feet from a ladder.

Review of Physician's Documentation dated 6/13/2021 at 7:53 PM revealed, "...Disposition...Fracture of lumbar vertebra - 1st, 2nd, and 5th; Contusion of lower back and pelvis...Transfer Ordered...Transfer Location [Hospital B]..." Continued review revealed no documentation any of the On-Call Specialists were consulted or contacted regarding Patient #25's injuries. Patient #25 was transferred by ambulance from Hospital A on 6/13/2021 at 9:10 PM.

Review of medical records from Hospital B revealed Patient #25 arrived at Hospital B's ED on 6/13/2021 at 10:29 PM. Patient #25 was admitted to Hospital B on 6/13/2021 at 11:27 PM with diagnoses that included: Fall leading to fractures, Chronic Diarrhea, Unintentional Weight Loss, and Hypertension (high blood pressure).

Review of Neurosurgeon's Consult Note dated 6/14/2021 at 4:16 AM revealed, "...I met with the patient this morning in the emergency room...I reviewed his imaging studies I agree that he is got a compression fracture but the age of this fracture is unknown this is a fairly stable appearance and I do not anticipate the need for back bracing or any further intervention. He is clear for discharge from our standpoint.."

Review of a Physician's Progress Note dated 6/15/2021 at 1:14 PM revealed, "...Repeat CT scan showed no evidence of intracranial abnormality, cervical spine fracture, or injury to the chest, abdomen, or pelvis. CT did reveal osteophyte fractures in L1 [lumbar vertebrae] and L5, and concern for an endplate fracture and L2. Spine surgery saw the patient, and determined that the patient did not need surgery, and did not need bracing. Trauma reevaluated the patient, and felt that he would be best served on medicine team due to his report of...having greater than 20 bowel movements a day...Ultimately, the patient was admitted to the geriatric service in guarded condition for continued rehabilitation of his spinal injuries and further work-up of his gastrointestinal symptoms..." Patient #25 was discharged in stable condition on 6/21/2021.

Interview with Physician #1 (Neurosurgeon) on 10/7/21 at 2:55 PM in the Quality Department Conference Room revealed he was the Neurosurgeon on call on 6/13/2021. Continued interview revealed Physician #1 had not been consulted regarding Patient #25's injuries on 6/13/2021. Physician #1 stated, "...they probably transferred him due to him being a trauma patient...the distance of the fall and his age made the patient a trauma patient...the velocity of a fall from that height and his age made surgeons reluctant to accept patients such as this one due to possibility of there being additional injuries that have not been identified yet..." Physician #1 stated if he had been consulted on Patient #25's case, he would have admitted the patient and treated him at Hospital A instead of transferring him to Hospital B because the injuries were stable and not severe.

Interview with Physician #4 on 10/7/2021 at 3:50 PM in the ED Physician's Office revealed he was the ED Physician working on 6/13/2021 when Patient #25 arrived. Physician #4 examined Patient #25 and ordered X-rays and CT scans. Physician #4 turned Patient #25's care over to Physician #5 before the diagnostic images had been completed. Physician #4 reviewed Patient #25's medical records and CT Reports and stated Patient #25 had multiple stable lumbar fractures and "...none of these fractures were significant injuries..." Physician #4 stated he probably would have discharged the patient home with instructions to follow up as an outpatient with a neurosurgeon. Physician #4 stated the patient was probably transferred due to having fallen over 10 feet and due to his age. Physician #4 stated the fall would have qualified Patient #25 as a trauma patient, and indicated he needed to be transferred to a trauma center. Physician #4 did not consult or contact any of the on-call specialists regarding Patient #25's injuries.

Interview with Physician #5 by telephone on 10/11/2021 at 12:15 PM revealed he remembered Patient #25's ED visit on 6/13/2021. Physician #5 transferred Patient #25 to Hospital B because the patient met the criteria for trauma and needed to be transferred to a trauma center. Due to his age and the height of his fall, Patient #25 needed to be transferred to a trauma center. Physician #5 did not consult or contact any of the specialists on-call regarding Patient #25's injuries on 6/13/2021.

Interview with the Associate Chief Nursing Officer (ACNO) on 10/7/2021 at 8:35 AM in the Quality Conference Room confirmed on 6/13/2021 and 9/12/2021, there was a Neurosurgeon on call both dates. The ACNO confirmed there was no documentation in Patient #3's medical record of an On Call Specialist being consulted regarding the patient's injuries on 9/12/2021. The ACNO confirmed there was no documentation in Patient #25's medical record of an On Call Specialist being consulted regarding Patient #25's injuries on 6/13/2021.

Based on review of facility policies, review of medical records, review of Specialist On-Call Schedules, observations and interviews, the facility failed to provide stabilizing treatment within the capabilities of the hospital for one (#3) patient of 33 patients reviewed. This failure led to Patient #3's Emergency Medical Condition (EMC) not being stabilized and treated at Hospital A resulting in the patient being discharged home with an untreated neck fracture.

The findings included:

Review of facility policy titled "Emergency Medical Treatment and Active Labor Policy" effective date 10/2019 revealed, "...When an individual comes to the Emergency Department [ED]...and a request is made for a medical examination or treatment, the hospital must provide an Medical Screening Examination within the capabilities of the hospital's services...Further medical examination and treatment, including hospitalization, if necessary as required to stabilize the Emergency Medical Condition within the capabilities of the staff and facilities available..."

Review of the Emergency Room Call Roster revealed on 9/12/2021 there was a Neurosurgeon on call.

Medical record review revealed Patient #3 presented to Hospital A's Emergency Department (ED) on 9/12/2021 at 6:25 PM for complaint of upper neck pain, and pain in both elbows following a fall at home on 9/12/2021.

Review of Nurses Notes dated 9/12/2021 at 6:32 PM revealed, "...Complains of pain in right elbow, left elbow, right posterior aspect of neck and left posterior aspect of neck Pain currently is 10 out of 10 [on a scale of one to ten with 10 being the most severe pain] on a pain scale..."

Review of Physician Documentation dated 9/12/2021 at 7:11 PM revealed "...complaints of Neck Pain...long history of falls multiple bruises in various stages of healing...reports falling tonight...reports pain in his neck bilateral arms [and] left shoulder..."

Review of a Computed Tomography (CT is a type of non-invasive medical imaging that provides detailed images of internal body parts) Report dated 9/12/2021 at 8:18 PM revealed, "...evaluation of neck pain...post fall...No cervical spine fracture identified...No acute cervical spine injury..."

Review of the Discharge Assessment dated 9/12/2021 at 9:38 PM revealed, "...Patient awake, alert and oriented...No cognitive and/or functional deficits noted. Patient verbalized understanding of disposition instructions...Pain Assessment: 0/10 [no pain present]..."

Review of the medical record revealed the patient was discharged on 9/12/2021 at 9:50 PM. Continued review of the medical record revealed no documentation of consultations with any on-call specialist.

Review of Patient #3's medical record revealed he returned to the ED at Hospital A by ambulance on 9/13/2021 at 7:45 AM for complaints of weakness and poor coordination. Patient #3 was admitted to Hospital A with diagnoses which included: Cerebrovascular Accident (stroke), Right Upper Extremity (Right Arm) Weakness, Ataxia (poor coordination), Diabetes, and Prostate Cancer.

Review of a Neurosurgery Consult Note dated 9/14/2021 at 7:23 AM revealed, "...He came to the emergency room on the day that he fell. He came by ambulance. He was worked up with a CT scan, which is retrospect shows a fracture through an ankylosed [bones are fused] segment at C4-5 [neck bones called cervical vertebras number 4 and 5 which are located near the center of the neck]. This was not identified initially by Radiology. He was discharged and came back the following day with persistent neck pain and profound weakness...Patient has quadriparesis [muscle weakness in all four limbs] likely secondary to his cervical fractures..."

Review of an Operative Report dated 10/1/2021 revealed, "...PREOPERATIVE DIAGNOSIS: Fracture/dislocation C4-5 with Quadriparesis...PROCEDURE(S) PERFORMED: Posterior cervical laminectomy [surgical removal of spinal bones which place pressure on the spinal cord] C4 and C5...Posterolateral [back and side of neck] fusion [bones are attached to each other] C4-C5, internally fixation [secured inside the body] with lateral mass screws at C4 and C5 bilaterally [both sides]..."

Review of a Hospitalist's Progress Note dated 10/5/2021 at 6:22 AM revealed, "...Admitted on 9/13/2021 after a fall at home that resulted in a fracture of the C4-5 level for which a HALO [a large neck splint] was placed on the day of admission...NPO [nothing by mouth] after failing swallow evaluations. Overnight he had abrupt desaturations [blood oxygen levels dropped] and a rapid response [resuscitation measures] was called. He was subsequently intubated [a breathing tube was inserted into his airway] and transferred to ICU [Intensive Care Unit]..."

Observations of Patient #3 on 10/7/2021 at 3:15 PM revealed he was still an inpatient in Hospital A. Patient #3 was in a room on the Neurology Stepdown Unit. Observation revealed the patient was lying in bed and was able to respond with nods when spoken too, but his attempts at speech were unintelligible.

Interview with Patient #3's daughter by telephone on 10/11/2021 revealed the patient was still an inpatient in Hospital A on 10/11/2021. The patient's daughter stated Patient #3 had been independent with his activities of daily living, ambulated without difficulty, and had no difficulty speaking or swallowing prior to his fall on 9/12/2021. He had fallen at home on 9/12/2021, had been unable to get up off the floor, and had been transported by ambulance to the ED at Hospital A on 9/12/2021 with complaints of severe neck pain and tingling in his arms and hands. Patient #3 was discharged home that same afternoon and was unable to get out of the car when he arrived home. He had to be lifted by family into a wheelchair and then lifted into a bed. He had to be lifted into the wheelchair and lifted on and off the toilet overnight. He became weaker over night and on 9/13/2021 the family sent the patient to Hospital A by ambulance. The patient's daughter stated the patient had fractured his neck when he fell on 9/12/2021, and these fractures had not been diagnosed on 9/12/2021. She stated the neck fractures were visible on the CT scan performed on 9/12/2021 but were not noticed by physicians until 9/13/2021 when Patient #3 returned to Hospital A. She stated the patient had surgery on his neck, had difficulty speaking and swallowing, and was paralyzed in all four limbs. The family's goal was for Patient #3 to get physically strong enough for additional surgical repair of his neck fractures.

Interview with Physician #2 on 10/7/2021 at 2:35 PM in the Quality Department Conference Room revealed he was one of the Hospitalists treating Patient #3. Physician #2 had been treating Patient #3 the last 4 days. Physician #2 stated the patient had injured his spinal cord, had difficulty swallowing, had quadriplegia (paralysis in all 4 limbs), and was unable to tolerate tube feedings, so he was being given Total Parenteral Nutrition (TPN) (TPN is the feeding of nutritional products through the veins which bypasses the stomach and bowel). TPN was necessary to prevent the patient choking on tube feeding solutions. Patient #3 had recently been intubated (a tube placed in the airway to facilitate mechanical ventilation of the patient's lungs) due to a severe mucous plug occluding the patient's airway. He stated the patient's condition was primarily caused by his neck fractures and spinal cord injuries. The patient was waiting for additional surgery to stabilize his neck injuries but was currently too weak for anesthesia. The patient was on antibiotics for aspiration (material inhaled into lungs) pneumonia (infection in the lungs). Physician #2 stated the patient's condition was "...overall very poor..."

Interview with Physician #1 (Neurosurgeon) on 10/7/2021 at 2:55 PM in the Quality Department Conference Room revealed he was the neurosurgeon treating Patient #3's neck fractures. Physician #1 stated the patient had presented to the ED on 9/12/2021 following a fall and the CT scan done at that time revealed fractures to C4-C5, which were not noted by the radiologist reading the CT scan. The physician stated "...they just missed it..." Physician #1 had viewed the CT scan performed on 9/12/2021 and he confirmed the neck fractures were visible on the 9/12/2021 images. Physician #1 stated the patient had fractured his neck in a fused area at C4 -C5 and had probably hyperextended his spinal cord injuring the spinal cord. After the fractured neck was diagnosed, the patient was placed in a HALO (a large neck brace/splint) for stabilization. Physician #1 had performed surgery on the patient's neck once and the patient would need additional surgery on his neck if he ever became medically strong enough to tolerate anesthesia. The patient had been on comfort measures only for a while, but as he became stronger, the family changed the patient to a full code (resuscitation) and requested additional surgical procedures be done in an attempt to improve the patient's condition. There was an attempt to take the patient to surgery for additional neck surgery on 10/6/2021, but he had not been medically stable enough for the procedure. The patient was having trouble swallowing which made his saliva and other secretion difficult for the patient to manage, and Physician #1 believed this was due to the HALO. The patient's swallowing was improving since the HALO had been removed. Physician #1 stated the patient was currently quadriparetic (weakness and diminished mobility in all four limbs), he probably needed a tube inserted through his abdominal wall for feeding, and his prognosis was described as guarded. Physician #1 confirmed he was on call for neurosurgery on 9/12/2021 but he was not consulted on Patient #3. Physician #1 stated had he been consulted, he would have examined the patient and viewed the images. Physician #1 stated he was able to view CT scans and other imaging studies from his home and office.

Telephone interview with Physician #3 on 10/11/2021 at 11:53 AM revealed he was the ED Physician that examined and treated Patient #3 on 9/12/2021 in the ED. Physician #3 remembered Patient #3's 9/12/2021 ED visit. The patient had arrived following a fall at home, and he was complaining of pain in his arms and neck. The patient did not have any neurological or muscular issues. The patient refused any laboratory tests and would only allow diagnostic images to be performed. The X-rays and CT scan, including the CT of the Cervical Spine were all negative for any fractures. The X-rays and CT scans were all read by a Tele-radiologist and no fractures were found. Physician #3 did not consult with any of the on-call specialists regarding Patient #3 on 9/12/2021.

Interview with the Associate Chief Nursing Officer (ACNO) on 10/7/2021 at 8:35 AM in the Quality Conference Room confirmed on 9/12/2021 there was a Neurosurgeon on call and available for consultation and treatment of ED patients. The ACNO confirmed there was no documentation in Patient #3's medical record of an On Call Specialist being consulted regarding treatment of the patient's injuries on 9/12/2021.

Based on review of facility policies, specialist on-call schedules, physician's credentials, medical records, and interviews, the facility transferred one (Patient #25) patient of 33 patients reviewed when Hospital A had a neurosurgeon available to evaluate and treat Patient #25. This failure led to Patient #25's injuries not being treated at Hospital A, resulting in the patient being transferred 81 miles to Hospital B for treatment and stabilization.

The findings included:

Review of facility policy titled "Emergency Medical Treatment and Active Labor Policy" effective date 10/2019 revealed, "...An appropriate Transfer occurs when...The transferring hospital provides medical treatment within its capacity and capability...When an individual comes to the Emergency Department [ED]...and a request is made for a medical examination or treatment, the hospital must provide an Medical Screening Examination within the capabilities of the hospital's services...Further medical examination and treatment, including hospitalization, if necessary as required to stabilized the Emergency Medical Condition within the capabilities of the staff and facilities available..."

Review of the Emergency Room Call Roster revealed on 6/13/2021 there was a Neurosurgeon on call.

Physician #1 was the neurosurgeon on-call on 6/13/2021. Review of Physician #1's credentials revealed he was licensed as a Medical Doctor, he was board certified in neurosurgery, and his privileges included procedures to treat fractured spines and spinal cord injuries.

Review of Patient #25's medical record revealed he presented to the ED at Hospital A on 6/13/2021 at 2:57 PM for complaint of falling approximately 12 feet from a ladder.

Review of Physician's Documentation dated 6/13/2021 at 7:53 PM revealed, "...Disposition...Fracture of lumbar vertebra - 1st, 2nd, and 5th; Contusion of lower back and pelvis...Transfer Ordered...Transfer Location [Hospital B]..." Continued review revealed no documentation of any of the On-Call Specialists being consulted or contacted regarding Patient #25's injuries. Patient #25 was transferred by ambulance from Hospital A on 6/13/2021 at 9:10 PM.

Review of medical records from Hospital B revealed Patient #25 arrived at Hospital B's ED on 6/13/2021 at 10:29 PM. Patient #25 was admitted to Hospital B on 6/13/2021 at 11:27 PM with diagnoses that included: Fall leading to fractures, Chronic Diarrhea, Unintentional Weight Loss, and Hypertension (high blood pressure).

Review of Neurosurgeon's Consult Note dated 6/14/2021 at 4:16 AM revealed, "...I met with the patient this morning in the emergency room...I reviewed his imaging studies I agree that he is got a compression fracture but the age of this fracture is unknown this is a fairly stable appearance and I do not anticipate the need for back bracing or any further intervention. He is clear for discharge from our standpoint..."

Review of a Physician's Progress Note dated 6/15/2021 at 1:14 PM revealed, "...Repeat CT scan showed no evidence of intracranial abnormality, cervical spine fracture, or injury to the chest, abdomen, or pelvis. CT did reveal osteophyte fractures in L1 [lumbar vertebrae] and L5, and concern for an endplate fracture and L2. Spine surgery saw the patient, and determined that the patient did not need surgery, and did not need bracing. Trauma reevaluated the patient, and felt that he would be best served on medicine team due to his report of...having greater than 20 bowel movements a day...Ultimately, the patient was admitted to the geriatric service in guarded condition for continued rehabilitation of his spinal injuries and further work-up of his gastrointestinal symptoms..." Continued review revealed the patient was discharged in stable condition on 6/21/2021.

Interview with Physician #1 (Neurosurgeon) on 10/7/21 at 2:55 PM in the Quality Department Conference Room revealed he was the Neurosurgeon on call on 6/13/2021. Continued interview revealed Physician #1 had not been consulted regarding Patient #25's injuries on 6/13/2021. Physician #1 stated, "...they probably transferred him due to him being a trauma patient...the distance of the fall and his age made the patient a trauma patient...the velocity of a fall from that height and his age made surgeons reluctant to accept patients such as this one due to possibility of there being additional injuries that have not been identified yet..." Physician #1 stated if he had been consulted on Patient #25's case, he would have admitted the patient and treated him at Hospital A instead of transferring him to Hospital B because the injuries were stable and not severe.

Interview with Physician #4 on 10/7/2021 at 3:50 PM in the ED Physician's Office revealed he was the ED Physician working on 6/13/2021 when Patient #25 arrived. Physician #4 examined Patient #25 and ordered X-rays and CT scans. Physician #4 turned Patient #25's care over to Physician #5 before the diagnostic images had been completed. Physician #4 reviewed Patient #25's medical records and CT Reports and stated Patient #25 had multiple stable lumbar fractures and "...none of these fractures were significant injuries..." Physician #4 stated he probably would have discharged the patient home with instructions to follow up as an outpatient with a neurosurgeon. Physician #4 stated the patient was probably transferred due to having fallen over 10 feet and due to his age. Physician #4 stated the fall would have qualified Patient #25 as a trauma patient, and indicated he needed to be transferred to a trauma center. Physician #4 did not consult or contact any of the on-call specialists regarding Patient #25's injuries.

Interview with Physician #5 by telephone on 10/11/2021 at 12:15 PM revealed he remembered Patient #25's ED visit on 6/13/2021. Physician #5 transferred Patient #25 to Hospital B because the patient met the criteria for trauma and needed to be transferred to a trauma center. Due to his age and the height of his fall, Patient #25 needed to be transferred to a trauma center. Physician #5 did not consult or contact any of the specialists on-call regarding Patient #25's injuries on 6/13/2021.

Interview with the Associate Chief Nursing Officer (ACNO) on 10/7/2021 at 8:35 AM in the Quality Conference Room confirmed on 6/13/2021 there was a Neurosurgeon on call and available to consult and treat patients in the ED. The ACNO confirmed there was no documentation in Patient #25's medical record of an On Call Specialist being consulted regarding treatment of Patient #25's injuries on 6/13/2021.