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Based on record review, policy review and staff interview it was determined the facility failed to comply with 42 CFR 489.24 related to failure to ensure stabilization of a patient prior to and during transfer for 1 (#1) of 20 sampled patients.

Patient #1 presented to the Emergency Department on 6/18/11 with hemoptysis, following a surgical procedure. The physician documented there was no otolaryngology coverage available and that the patent would be transferred. The physician noted the patient was actively bleeding. Nursing documentation indicated the patient had a total of 250 milliliters (ml) of blood from the throat at the time of arrival as provided by the ambulance personnel. A note indicated the patient had lost another 300 ml of blood since his arrival. The nurse documented the patient "continues with copious amount of bleeding from throat". The blood pressure on arrival was 235/96 and had dropped to 109/73. A narrative note written by the Emergency Medical Technician (EMT) indicated that the ED physician said "I would give him blood, I don't want to lose a nurse to go with you." He further documented that he was handed a blood bag in a bag with a cold pack. There was no documentation by the ED physician regarding the decision to administer or not administer blood or that blood bag was given to the EMT.

Review of the medical record from the receiving facility revealed that the patient's blood pressure was 68/50 when received into the ED. Refer to A 2407

Based on record review, policy review and staff interview it was determined that the facility failed to ensure stabilization of an emergency medical condition (EMC) prior to and during transfer for 1 (#1) of 20 sampled patients.

Findings include:

Patient #1 presented to the facility's ED on 6/18/11 at 2:50 p.m. with hemoptysis, following a surgical procedure 3 days prior. The vital signs at the time of triage were blood pressure 235/96, pulse 93 and respiratory rate of 20. The medical screening examination was initiated at 3:01 p.m. The physician orders included a complete blood count and type and cross match. The blood for the laboratory studies was collected at 3:00 p.m. The physician documented at 3:41 p.m. that there was no otolaryngology coverage available and that the patent would be transferred. The physician noted the patient was actively bleeding. Nursing documentation at 2:50 p.m. indicated the patient had a total of 250 milliliters (ml) of blood from the throat at the time of arrival as provided by the ambulance personnel. A note at 3:26 p.m. indicated the patient had lost another 300 ml of blood since his arrival. The hemoglobin at 3:00 p.m. was 12.4, which was within the normal range. However, the patient had lost 300 ml of blood since the sample was taken. The nurse documented at 3:54 p.m. the patient "continues with copious amount of bleeding from throat". The blood pressure recorded at 3:54 p.m. had dropped from 235/96 to 109/73 and the heart rate had increased from 90 to 109. The patient had an intravenous infusion of normal saline infusing. The physician documented the patient was "stable" at 3:41 p.m. There was no documentation of his addressing the amount of blood loss or the change in vital signs. The nursing documentation indicated the patient was transferred at 4:00 p.m. via ground transport. The facility failed to ensure that stabilizing treatment was provided within the capabilities of the staff and the facilities available at the hospital for further medical examination and treatment as required to stabilize the emergency medical condition (Actively Bleeding and compromised airway) for patient #1 on 6/18/2011.

Review of the ambulance run sheet revealed that the ambulance crew arrived at 4:05 p.m. and left the transferring facility at 4:22 p.m. They arrived at the receiving facility at 4:50 p.m. A narrative note written by the Emergency Medical Technician (EMT) indicated that the ED physician said "I would give him blood, I don't want to lose a nurse to go with you." He further documented that he was handed a blood bag in a bag with a cold pack. There was no documentation by the ED physician regarding the decision to administer or not administer blood or that blood bag was given to the EMT. There was also no documentation about the blood by nursing.

The Director of the ED was interviewed on 7/28/11 at 1:20 p.m. She indicated that the nurse caring for the patient in the ED reported that the ED physician had insisted on sending the blood with the patient, even though the EMTs could not administer it. She stated that if a transfusion was to be administered during transport a nurse from the facility must go. She stated that would require a physician order.

Review of the medical record from the receiving facility revealed that the patient's blood pressure was 68/50 and the heart rate was 104 when received into the ED. Laboratory study done in the ED revealed the hemoglobin had fallen to 9.9. The ED physician ordered a blood transfusion which was started in the ED. The patient's condition was documented as guarded by the physician. The physician documented the patient had history of coronary artery disease and type II Diabetes. Review of the discharge summary dated 6/22/2011 indicated that patient #1 presented to Pasco Regional Medical Center on 6/18/2011 with Bleeding. Further review specified in part, "Apparently. . . there was no call coverage . . . He therefore was transferred to {another acute care hospital} Emergency Department. He was noted to have significant bleeding. The decision was therefore made to emergently take him to the operating room for control of bleeding."

The facility's policy "Stabilization", revised 2/11 indicated the patient was stable for transfer if the treating physician had determined within a reasonable clinical confidence that the Emergency Medical Condition had resolved and that no material deterioration of the condition was likely to result from, or occur during, the transfer of the patient from the hospital.

The ED physician decided to send the blood, but not the personnel to administer it, the bleeding had not subsided and the patient's condition deteriorated during the transfer.