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Based on interview and document review, the Emergency Department (ED) failed to restrict the transfer for 2 of 27 sampled patients (Patient 1 and 11) when:

1. The ED had the capacity and capability to stabilize and treat Patient 1's emergency medical condition (EMC) for sepsis and septic shock (a potentially life threatening condition that occurs when the body's response to an infection damages its own tissues) before Patient 1 was transferred to another hospital where Patient 1 required immediate intervention and treatment for septic shock; and

2. The ED had the capacity and capability to first stabilize and treat Patient 11's EMC for a right sided massive hemothorax (a serious condition in which blood collects in your lungs and rib cage) and associated hemorrhagic shock (a potentially life-threatening condition that occurs from severe bleeding resulting in reduced tissue perfusion preventing cells from adequate nutrients and oxygen) before Patient 11 was transferred to another hospital where Patient 11 required immediate intervention and treatment for hemorrhagic shock.

These failures resulted in delay of treatment and stabilization of an immediate EMC prior to transfer for Patient 1 and Patient 11 which contributed to their medical deterioration and had the potential to contribute to poor outcomes and death.

1. A review of Patient 1's medical record included a note titled "Emergency Documentation - [MD]" which indicated Patient 1 presented to the emergency department on 7/28/23 at 3:13 a.m. with a family member. Patient 1 complained of a 4-5-day history of right upper quadrant abdominal pain with nausea and diarrhea. The note indicated "Pt [Patient 1] diaphoretic (clammy) upon arrival and c/o [complaint of] lightheaded."

Patient 1's initial vital signs were a temperature 36.7 Celsius (98.1 Fahrenheit), blood pressure 113/81 (BP is the amount of force blood uses to get through arteries- normal approximately 120/80), pulse of 98 (pulse, is the beating of blood through body- normal 60-100 beats per minute (bpm), respiratory rate of 18, (Respiratory Rate is the rate of breaths per minute- normal 12-18 per minute), and SPO2 of 98% (a measurement of how much oxygen your blood is carrying).

SIRS criteria (Systemic Inflammatory Response Syndrome, indicates there is inflammation throughout the whole body caused by an infection- is criteria used to indicate the severity of sepsis and septic shock. It is used to guide clinical decision making for the patient), was met with heart rate "greater than 90" and "suspected infection" based on Patient 1's presenting symptoms.

Patient 1's "stated weight" was 150 pounds or 68.03kg (kilograms- a metric unit of measurement). There was no evidence in the medical record an actual weight from a scale was obtained and documented.

A review of a document titled, "Medical Decision Making", dated 7/28/23 at 5:26 a.m., "CT"( a medical technique used to obtain detailed images of the bodies internal organs) results, "SMV thrombus (the formation of a blood clot in the superior mesenteric vein- a vein that helps carries blood from the intestines to the liver) with likely infarcted jejunum, (narrowing or blockage of one or more arteries that supply blood to the small intestine) likely more bowel at risk." The document continued, "Heparin (medication used to prevent harmful clots) ... ordered .... Rocephin and Flagyl (antibiotics used to stop the growth of bacteria) ordered for intra-abdominal coverage." During a further review of the same document indicated "there is/was a high probability of imminent or life-threatening deterioration in the patient's condition due to cardiopulmonary, [heart and lungs], GI [gastro-intestinal, stomach and gut] comprise without immediate intervention." The document also indicated, "No IR (Interventional Radiology- a surgical procedure to treat conditions like clots) at [Hospital Name] until 8 am".

During a review of the document, "Laboratory Results", dated 7/28/23 at 5:26 a.m., the following was noted:

WBC: 16.6 k/uL (per cubic milliliter- unit of measure), white blood cells- normal range is 4.5 to 11.00, part of the immune system to fight infections, which is elevated indicating a potential infection);

Anion Gap: 23 mEq/L (milliequivalents per liter- unit of measure, Normal range 4mEq/L-12mEq/L a measurement of the acid base balance of blood, levels increase during severe infection)

Glucose: 154 mg/dL (milligrams per deciliter- unit of measure, normal range 125mg/dL or lower, sugar found in blood, when fighting infection, the body responds by increasing the glucose);

Total Bilirubin: 1.9 mg/dL (Normal range 1.2, tells how well the liver is working);

Lactic Acid: 2.3 mg/dL (greater than 2mg/dL indicates there is not sufficient oxygen at the cellular level, high levels are common in sepsis or severe shock)
Repeat Lactic acid results at 11:41 a.m.: 9.2 with a note, "Critical value called to and read back by RN 2 in ED at [12:40 p.m.] 7/28/23."

During a review of a document titled, "Hemodynamics and Vitals", dated 7/28/23 from 3:13 a.m. through 2:25 p.m., revealed Patient 1's systolic blood pressure (measures the pressure in millimeters of mercury [mmHg- a unit of measure] in the arteries when the heart beats) was as high as 158 and as low as 56. Patient 1's diastolic blood pressure (measures the pressure in mmHg in the arteries when your heart relaxes between beats) was as high as 104 and as low as 38. Patient 1's pulse was as low as 58 bpm and as high as 140 bpm. Patient 1's respiratory rate was as low as 15 bpm and as high as 29 bpm.

A review of Patient 1's "Medication Administration" document, dated 7/28/2023 at 3:42 a.m., indicated the physician ordered one liter (L, unit of measurement) of normal saline (NS, a solution mixed with salt and water) intravenously (IV, within a vein) immediately to infuse at 200 mL/hour for Patient 1. At 5:25 a.m., the physician ordered "Lactated Ringers (LR a solution used for replacing fluids and electrolytes in a person with low blood pressure) 1L IV (one time) STAT (to be given immediately) infuse over 65 minutes." At 1:36, p.m., the physician ordered an additional liter of "Lactated Ringers 1,000 mL IV x 1 STAT infuse over 65 minutes."

During a review of a document titled "Intake and Output," dated 7/28/23, Patient 1's total intake (IV or oral fluid intake) was 3262.2 mL. The total documented output (urine) was 0. There was no evidence Patient 1's physician was notified of the lack of urinary output for 12 hours.

A review of Patient 1's medical record note titled, "Respiratory", dated 7/28/23 at 1:49 p.m., noted, "Bi-Level Positive Airway Pressure (BIPAP) "BIPAP per protocol" ...(Used to support breathing through a face mask). The document further indicated at 2:00 p.m., "transferred airway care management to EMS transport team without complications." The note continues, "At 2:11 p.m., "unable to obtain ABG (Arterial Blood Gas- measures how much oxygen, carbon dioxide and the pH, level of acidity or basicity, is in the blood) at this time, transport here to pick up patient."

A review of a document titled, "Patient Care Report" (ambulance transport note), dated 7/28/23 at 2:41 p.m., approximately 13 hours after presenting to the ED, indicated the following:

"Dispatched to ... [name of facility] for a 52 YOM [year old male] who presented to the ED with generalized, worsening abdominal pain x 3 days, CT revealed full occlusion of superior messentric [sic] artery. While in ED patient had multiple episodes of hypotension (low blood pressure), which were treated with a total of 3L NS (normal saline). Patient then became dyspneic (shortness of breath) and was placed on Bipap for ventilator support.".
"Arrived to find patient hypotensive ...pale/cool/diaphoretic, on Bipap ... 9/10 abdominal pain (a numeric scale used to determine a patient's level of pain with 0 being no pain and 10 being worst pain ever) not relieved by pain meds ... ST [rapid heart rate] on monitor ...".

"Enroute to receiving facility patient began to decompensate requiring Levophed (IV medication used to treat life threatening low blood pressure, maybe referred to as a 'pressor') and CPAP (CPAP provides a positive pressure of air through a mask and into the airway which helps keep the airway open) to be started".

A review of a document titled, "Patient Care Report" (ambulance transport note), dated 7/28/23 at 2:41 p.m., included the following vital signs during transport:
2:51 p.m.: 65/31 (BP), 125 pulse, pain- 9/10
2:54 p.m.: 75/59 (BP), 124 pulse, pain- 9/10
3:03 p.m.: 86/63 (BP), heart rate not documented, pain- 9/10
3:05p.m.: 76/51 (BP), 133 pulse, pain- 9/10
3:07p.m.: 81/56 (BP), 131 pulse, pain- 9/10

During a review of a document from the receiving hospital titled, "Final Report", dated 7/28/24 at 3:40 p.m., the document indicated the following:

Patient 1 arrived at the receiving facility complaining of 8/10 abdominal pain and Patient 1 was started on "Levophed and CPAP shortly before arrival". Upon arrival at the receiving hospital, Patient 1's vital signs were documented as blood pressure of 117/97, pulse 125 and respiratory rate of 25, SPO2 97%.

During a review of the same document under "Procedures" the following was documented:
"Given the patient's presentation with abdominal pain, there is/was a high probability of imminent or life-threatening deterioration (becoming progressively worse) in patients condition due to cardiovascular, metabolic comprise (failure of the heart and other internal organs) without immediate intervention." Further review of the document dated 7/28/24 at 3:19 p.m., included, "Direct Laryngoscopy/Intubation was performed for airway protection (placement of a flexible plastic tube into the windpipe to maintain an open airway). Further review indicated a "Central Venous Catheter (a thin flexible catheter that is inserted into a large, central vein usually below the collar bone to give intravenous fluids, blood, and drugs) was placed for "emergent access for fluid and drug administration".

Patient 1's weight was documented as 256.96lbs. or 116.5kg. This was 106.96 lb greater than Patient 1's stated weight of 150 lbs at the previous ED.

Review of the same document under "Laboratory Results", at 3:33 p.m. the following abnormal laboratory results were documented:
WBC: 29.2 k/uL, increasing WBC indicated infection;

CO2: 10 mmol/L (millimoles/ Liter- unit of measure- normal range is 22-29 mmol/L (regulates breathing, when low may indicate acidosis, acidic blood);

Anion Gap: 31 mEq/L, levels increase during severe infection;

Glucose: 396 mg/dL, levels increase with severe infection;

Creatinine: 2.85mg/dl (normal range 0.7 -1.3mg/dl- may indicate an acute kidney injury);

Lactic Acid: 16.1 mg/dL, levels increase with severe infection;

Troponin: 101 mg/mL (normal range 0-0.04mg/ml, elevation is an indicator of heart damage related to shock).

The document revealed a second, "CT Angio Abdomen and Pelvis" was performed at 5:33 p.m., and indicated the following, "Patient has known thrombus (blood clot) within the jejunal veins (carry blood to large arteries in the intestines) and thrombosis (blood clot) of entire superior mesenteric vein to its confluence with the splenic vein with thrombus now also extending into the proximal portal vein (more clotting and loss of blood flow) ... Increasing length of involvement of jejunal loops (intestine) as well as also extending towards the proximal ileal loop (intestine) ... The terminal ileum (intestine) is now collapsed" and, "worsening mesenteric fat stranding and edema (swelling) and free fluid in the central mesentery suggesting venous congestion as well as increasing free fluid around the liver and spleen and right lower quadrant."

During a concurrent interview and document review on 4/23/24 at 2:30 p.m., with the Quality Safety Program Manager 2 (QSPM 2), the QSPM 2 indicated their role included collecting and monitoring sepsis data for the hospital. During a review of Patient 1's medical record, the QSPM 2 indicated Patient 1 "did not rule in (meet criteria for interventions) for severe sepsis [from the hours of] 3:00 a.m. -7:00 a.m.," and stated at 10:00 a.m. Patient 1 now ruled in for sepsis meeting "two SIRS [criteria] with organ failure, pulse and respiratory rate". The QSPM 2, acknowledged the repeated lactic acid laboratory value, "indicates severe sepsis". The QSPM 2 stated Patient 1, "should have had two large bore IV's as well as blood cultures" as both were part of the facility's [sepsis] protocol. The QSPM 2 acknowledged no urine output was recorded and indicated urine output needed to be monitored for fluid resuscitation (fluids given IV to restore or replace fluid depleted during illness such as sepsis/shock). The QSPM 2 stated "The sepsis protocol was not followed" and Patient 1 "was not stable for transfer."

During a phone interview on 4/24/24 at 3:15 p.m., with Emergency Department Registered Nurse (EDRN) 1, EDRN 1 stated they were Patient 1's primary nurse. EDRN1 stated "[Patient 1] was stable at the time of transfer." EDRN 1 further indicated when he assumed care of Patient 1, Patient 1 had already been in the ED for 4 hours. EDRN 1 stated he was not aware if Patient 1 had a large bore IV or any urinary output as facility policy requires. EDRN1 recalled IR [Interventional Radiology] at the facility had refused Patient 1, so he [EDRN 1] kept asking the physicians, "what are we going to do."

During the same phone interview on 4/24/24 at 3:15 p.m., with EDRN1, he indicated he believed it was up to the physician to follow the sepsis protocol, but he would have advised the physician of the changing vital signs. When asked if EDRN 1 did advise the physician of the changing vital signs, EDRN1 stated "I should have charted more; I don't remember specifically telling the physician about the changing vital signs." EDRN1 stated he did not check a manual blood pressure or calculate a mean (mean arterial pressure- used to check if there is enough blood circulating to major organs i.e., heart, and brain) and stated, "the mean was always stable based on the cardiac monitor."

EDRN 1 stated he did not remember if he hung more than 1 liter of IV fluids and indicated fluids administered would be based on an actual weight (scale) and not a stated weight (what a patient stated they weigh). EDRN 1 stated Patient 1 was "on a weight bed." (bed with a scale). EDRN 1 acknowledged he had been trained on the Sepsis protocol and was aware of placing two large bore IV's as well as the recommendation for placing a central line and intubating patient along with adequate fluid resuscitation.

During an interview on 4/24/24 at 1:55 p.m., with Emergency Department Medical Doctor (EDMD) 1, EDMD 1 states, "sepsis was not the issue, primary problem was a dying bowel." EDMD 1 further stated "same issues as in the past, occasional IR at (name of facility). EDMD 1 stated, Patient 1 "started crashing between 11:30 a.m. -12:00 p.m ... should have had additional fluids and 2nd line [IV access] ... could have inserted a central line as well as hung [administered] pressors (medication to increase the blood pressure)". The EDMD 1 did not recall ordering pressors prior to signing Patient 1 out to EDMD 2 at around 2:00 pm.

During an interview on 4/24/24 at 4:00 p.m. with EDMD 2, the EDMD 2 indicated Patient 1 should have been treated for sepsis and stated, "You treat no matter the cause when criteria [sepsis/ SIRS] is met." EDMD 2 stated, Patient 1 "should have had fluids administered at 30ml/kg per hour as well as urine output monitored, and blood cultures done." EDMD 2 also stated "Pressors should have been hung prior to transfer as [Patient 1] was not stable for transfer." EDMD 2 stated they, "Saw [Patient 1] as he was being loaded on gurney for transfer."

Patient weight is used to calculate medications and to determine how much IV fluids are needed to provide a fluid resuscitation to treat shock and low blood pressure. Patient 1's stated weight of 150 lbs or 68.03 kg at the previous ED would have required: 68.03 kg x 30ml/hour for 12 hours would be approximately 24,490 ml of IV fluids. The actual intake documented for Patient 1 from the ED was 3262.2 mL, a 21,227.8 mL deficit and no urine output noted.

The Patient 1's actual weight per scale at receiving facility was documented as 256.96lbs. or 116.8kg, 106.96 lb greater than the initial 150lbs. The weight-based fluid resuscitation for Patient 1's actual weight would have required: 116.8kg x 30ml/hours for 12 hours would be approximately 42,048 ml of IV fluids.

During an interview on 4/24/24 at 3:15 p.m., with the Emergency Department Chief (EDC), the EDC stated if Patient 1 had "earlier intervention it could have improved his outcome." The EDC further indicated Patient 1 should have had an additional IV inserted for fluids could use "ideal body weight but fluids nor antibiotics would change a dying bowel." EDC indicated Patient 1's "probably met SIRS criteria but had [a] dying bowel [that] needs to go to [the] OR [operating room]."

A review of the facility policy titled, "Severe Sepsis/Septic Shock Guidelines", dated 1/26/22, explained, "To provide the physician with a guideline for treating the adult patient (18 years old or greater or as stated in the individual facilities guidelines) who screens positive for severe sepsis and /or septic shock as defined by the Surviving Sepsis Campaign and the CMS SEP-1 Measure definition ..." The policy directed the following for clinical management:
" 1. All adult patients who enter through the emergency department (ED) will have a screening for sepsis within 30 minutes of entering the facility ...
3. Patients who screen negative upon arrival in the ED will be re-screened between one-two hours after initial screening ...
4. Patients who meet severe sepsis or septic shock shall have the Resuscitation bundle and/or the septic shock bundle initiated as outlined below.
5. For initial fluid resuscitation, please start with 2 large bore peripheral IV's
6. It is recommended that patients who require ongoing volume resuscitation or any vasopressor agents have a central line placed ...
7. For adults with septic shock, we suggest starting vasopressors peripherally (in the arms) to restore...[blood] pressure rather than delaying initiation until central venous access is secured ...
9. Initial lactate greater >2 is to be repeated within 6 hours.
10. Patients who have severe sepsis or septic shock with elevated lactates greater than 4 will have lactate measurements repeated after 30ml/kg fluids completed ...
B. Initial Resuscitation Bundle for the Adult ...Two sets of blood cultures (test for organisms in the blood) ... 5. Initiate fluid challenge ...
7. During the first 6 hours of resuscitation the goals of fluid resuscitation should include all of the following as part of the treatment protocol:
a. MAP (mean arterial pressure, blood pressure) greater than or equal to 65mmHg
b. Urine output greater than 0.5ml/kg/hour
c. HR< 110 bpm
d. A trend toward normalization of lactate level".

A review of the facility policy titled, "Emergency Medical Treatment and Active Labor ACT (EMTALA) Corporate Policy", effective 9/25/2018, directed, "Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at Dedicated Emergency Departments (DED)" ... The policy further describes, "to stabilize the emergency condition or to transfer the individual appropriately and in conformity with legal and regulatory requirements." Section M of the policy defines, "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." ...

Section E of the same policy titled, "Emergency Medical Treatment and Active Labor Act
(EMTALA) indicates "if the individual has an Emergency Medical Condition, the individual is to be treated in the DED until the condition is stabilized or the individual can be appropriately transferred." The policy further states: "The hospital will not transfer an individual with an unstablized emergency medical condition. The hospital must provide additional examination and treatment as maybe required to stabilize the emergency medical condition." ... The hospital provides medical treatment within its capacity to minimize the risks to the individual's health."

2. During a review of Patient 11's electronic medical record (EMR) note titled "Emergency Documentation - [MD]", dated 3/11/2024 at 12:13 a.m., Patient 11 was brought into the facility's ED by ambulance. Patient 11 complained of multiple episodes of vomiting, diarrhea, nausea, dizziness, along with two episodes of fainting within the past hour. The note further indicated Patient 11's lab results included a hemoglobin (protein containing iron that transports oxygen in the red blood cells) of 10 grams/deciliter (g/dl, unit of measurement with 14 to 18 g/dl as the normal range in males) and a hematocrit (percentage by volume of red cells in the blood) of 29.3 (normal percentage in males is 40-54%).

A review of Patient 11's EMR note titled "Medication Administration" dated 3/11/2024 indicated Patient 11 received one liter of NS at 12:33 a.m. and another liter of NS at 1:09 a.m.
A review of Patient 11's EMR note titled "Orders ", dated 3/11/2024, indicated the physician ordered a chest x-ray at 1:05 a.m. for Patient 11 due to shortness of breath, which was completed at 1:59 a.m. and a computed tomography scan (CT scan, series of x-ray pictures for imaging) of Patient 11's chest at 2:02 a.m., which was completed at 2:26 a.m.

A review of Patient 11's EMR note titled "Emergency Documentation - [MD]", dated 3/11/2024, indicated Patient 11's chest x-ray showed a right plural effusion (buildup of too much fluid around the lungs), and Patient 11's chest CT scan showed a large right plural effusion.

The note further indicated the physician performed a thoracentesis (procedure to remove fluid or air around the lung) on Patient 11 but needed to stop due to frank (bright) red blood collected at the site.

During a concurrent record review and interview with Emergency Department Registered Nurse (EDRN) 3 on 4/23/2024 at 5:30 p.m.; Patient 11's EMR note titled "Emergency Documentation - [MD]", dated 3/11/2024, the note indicated the physician placed a chest tube (a flexible plastic tube inserted into the chest cavity to drain fluid or blood) into Patient 11's right chest site and two liters of blood were collected. The EDRN 3 stated Patient 11 " ...looked pale." The EDRN 3 further stated Patient 11 complained of being dizzy when positioning for the procedure.

During a concurrent record review of Patient 11's EMR note titled, "Orders", dated 3/11/2024 and interview with Quality Safety Program Manager (QSPM) 2 on 4/24/2024 at 10:10 a.m., the note indicated two units of uncrossed matched (lifesaving universal blood given to patients of unknown blood types) packed red blood cells (PRBCs, blood products transfused to prevent tissue lack of oxygen) were ordered for transfusion immediately with the indication of acute hemorrhage/hemodynamic (how the blood flows through the vessels) instability. The first unit was ordered at 3:48 a.m., and the second unit was ordered at 4:39 a.m. QSPM 2 verified Patient 11 was ordered two units of blood which were to be transfused immediately.

During a concurrent record review of Patient 11's EMR note titled, "General Information", dated 3/11/2024 and interview with QSPM 2 on 4/24/2024 at 10:20 a.m., QSPM 2 indicated the first unit of blood was started at 5:00 a.m. and finished at 6:00 a.m. There was no documentation of the second unit. QSPM 2 verified Patient 11's first unit of blood transfusion lasted 60 minutes and the second unit was not transfused.

During a concurrent record review of Patient 11's EMR note titled, "Emergency Documentation - [MD]", dated 3/11/2024 and interview with Registered Nurse Informatics (RNI) on 4/24/2023 at 1:15 p.m., the note indicated Patient 11 had a total of three liters of blood loss. The note further indicated Patient 11 only received one unit of blood. The RNI confirmed one liter was drained during the thoracentesis procedure and the other two liters were drained with the chest tube insertion, which resulted in a total of three liters of blood loss. RNI further verified only one unit of blood was transfused into Patient 11.

During a concurrent record review of Patient 11's EMR titled, "Emergency Documentation - [MD]", dated 3/11/2024 and interview with Emergency Department Chief (EDC) on 4/24/2024 at 3:30 p.m., the note indicated the physician ordered two units of uncross-matched PRBCs "now." The note further indicated Patient 11's diagnosis was hemothorax (a serious condition in which blood collects in your lungs and rib cage) and hemorrhagic shock. The EDC acknowledged Patient 11's diagnosis, that "now" was expected to be done immediately, and Patient 11 should have received the two units of PRBCs as ordered.

A review of Patient 11's EMR note titled "Emergency Documentation - [MD]" dated 3/11/2024 indicated Patient 11 was classified as a critical patient due to Patient 11's low blood pressure. The note further indicated "There is/was a high probability of imminent or life-threatening deterioration in the patient's condition due to pulmonary and cardiovascular compromise without immediate intervention. During the course of the patient's stay, serial re-evaluations of their hemodynamic and clinical status were performed because of the recognized potential threat to life or limb in this condition."

A review of Patient 11's EMR note titled "Hemodynamics and Vitals" dated 3/11/2024 indicated the following:
At 12:05 a.m., blood pressure (BP) = 130/71
At 12:35 a.m., BP= 107/54
At 1:00 a.m., BP= 81/42
At 1:30 a.m., BP= 98/61
At 2:20 a.m., BP= 11/51
At 2:30 a.m., BP= 102/48
At 3:00 a.m., BP= 92/48
At 3:30 a.m., BP= 78/44
At 3:45 a.m., BP= 82/52
At 4:00 a.m., BP= 88/56
At 5:15 a.m., BP= 98/48
At 5:30 a.m., BP= 96/51
At 5:45 a.m., BP= 94/44
At 6:00 a.m., BP= 96/51

A review of Patient 11's ambulance report titled "Patient Care Report", dated 3/11/2024, indicated Patient 11 was placed in the ambulance at 6:12 a.m. to be transferred to another hospital for care. At 6:29 a.m., Patient 11's BP dropped to 74/36, Patient 11's feet were raised, and two L (liters) of NS (normal saline) was given immediately IV. At 6:38 a.m., the ambulance arrived at the accepting facility with the receiving trauma team.

A review of Patient 11's EMR note titled, "Final Report", dated 3/11/2024, indicated Patient 11 arrived at the accepting facility at 6:38 a.m. and received two units of PRBCs utilizing the Massive Transfusion Protocol (MTP). The note further indicated Patient 11 met trauma activation criteria (mobilization of medical professionals to coordinate care for a patient with traumatic injury) upon arrival and "required immediate and multiple repeat bedside examinations", and, "I stopped seeing other patients in order to care for this patient and prevent decompensation, system failure, and/or death." The note indicated Patient 11's diagnosis was massive right hemothorax and hemorrhagic shock.

During an interview with Emergency Department Registered Nurse (EDRN) 4 on 4/25/2024 at 11:20 a.m., EDRN 4 stated an order for uncrossed matched blood to be transfused "now" means immediately have another nurse go to the lab to get the blood and transfuse all of the blood quickly. EDRN 4 further stated the blood should be transfused within 15 minutes per unit of blood.

During an interview with Emergency Department Registered Nurse (EDRN) 5 on 4/25/2024 at 12:10 p.m., EDRN 5 stated a MTP is ordered if a patient is actively bleeding in the ED such as if a patient had lost three liters of blood. EDRN 5 further stated the nurse should verify the MTP order with the physician and use the rapid transfusing equipment for the blood products.

A review of the facility's policy titled "Massive Transfusion Protocol," last revised 3/24/2021, indicated a massive transfusion protocol (MTP) was "established to provide a standard for emergency provision of blood and blood components for patients with unexpected severe hemorrhage .... In an emergency situation and when requested by a physician, blood may be released without a crossmatch or even when a recipient's blood group and type are known." The policy further indicated uncrossed matched PRBCs are available within 10 minutes from the phone call to the lab."

A review of the facility's policy titled "Blood Products Management, last revised 3/24/2021, indicated blood transfusions utilizing the MTP are administrated per "physician direction."

A review of the facility policy titled, "Emergency Medical Treatment and Active Labor ACT (EMTALA) Corporate Policy", effective 9/25/2018, directed, "Emergency Medical Screening and stabilizing treatment will be provided to all individuals presenting at Dedicated Emergency Departments (DED)" ... The policy further describes, "to stabilize the emergency condition or to transfer the individual appropriately and in conformity with legal and regulatory requirements." Section M of the policy defines, "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." ...

Section E of the same policy titled, "Emergency Medical Treatment and Active Labor Act
(EMTALA) indicates, "if the individual has an Emergency Medical Condition, the individual is to be treated in the DED until the condition is stabilized or the individual can be appropriately transferred." The policy further states: "The hospital will not transfer an individual with an unstablized emergency medical condition. The hospital must provide additional examination and treatment as maybe required to stabilize the emergency medical condition." ... The hospital provides medical treatment within its capacity to minimize the risks to the individual's health."