HospitalInspections.org

Based on current hospital policy and procedure review, medical record review, the hospital's "Emergency Room On-Call Schedule," the hospital's "Medical Staff Roster," Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

Based on current hospital policy and procedure review, medical record review, the hospital's "Emergency Room On-Call Schedule," the hospital's "Medical Staff Roster," Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

1. The hospital's Dedicated Emergency Department's (DED) medical staff failed to ensure that when emergency department physicians notified on-call physicians who were on the staff, had privileges at the hospital and were available to provide further treatment necessary after the initial examination to stabilize an individual who presented to the hospital a second time with a limb threatening hand injury for 1 ( #8) of 24 sampled patients.
~ Cross refer to §489.24(j) Availability of On-Call Physicians, Tag A2404.

2. The hospital's DED's medical staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 24 sampled patients who presented to the hospital's DED with an EMC (Emergency Medical Condition) and were transferred to another facility. (Patient #8).

~ Cross refer to §489.24(a) and §489.24(c) Stabilizing Treatment Condition, Tag A2407.

3. The hospital inappropriately transferred an individual by failing to provide medical treatment that was within its capability and capacity to render care that minimized the risks to an individual's health who presented to the hospital's emergency department with a limb threatening injury for 1 (#8) of 24 sampled patients.

~ Cross refer to§ 489.24 (2) ( i) Appropriate Transfer , Tag A2409.

Based on current hospital policy and procedure review, medical record reviews, the hospital's "Emergency Room On-Call Schedule," review, and physician core privileges review, the hospital's "Medical Staff Roster", Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital's Dedicated Emergency Department's (DED) medical staff failed to ensure that when emergency department physicians notified on-call physicians who were on the staff, had privileges at the hospital and were available to provide further treatment necessary after the initial examination to stabilize an individual who presented to the hospital a second time with a limb threatening hand injury for 1 ( #8) of 24 sampled patients.
Findings included:

Review on 05/17/2017 of the hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act): Medical Screening, Stabilization, and Transfer" (Revision Date: 12/2015), Policy Number 509, revealed "Purpose and Applicable Law: 1. To provide a medical screening examination to any individual who comes to the Emergency Department and requires examination or treatment to determine if an emergency medical condition exists (42 USC 1395dd(a))...2. If an emergency medical condition exists, to stabilize the condition or provide for an appropriate transfer of the patient to another facility (42 USC 1395 dd (b))...III. Definitions: C. Emergency Medical Condition- means either (a) a condition that manifest itself by such acute and severe symptoms that in the absence of immediate medical attention could reasonably result in serious jeopardy of the health of the individual ...serious impairment to bodily functions, or serious dysfunction of any bodily organ or part." ... D. Appropriate Medical Screening Examination - means a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists ...IV. PROCEDURE: Patient Evaluations and Treatment: ...4. If it is determined that an Emergency Medical Condition exists ...a. Stabilize the patient by providing further medical examination and treatment within the capabilities of the Hospital ...List of On-Call Physicians ...The on-call specialist must provide reasonable on call services when called upon for a medical emergency condition and respond within a reasonable period of time when called to the emergency department."


Hospital A (Onslow Memorial Hospital), closed DED record review on 05/17/2017 for Patient #8, revealed a 49-year-old male presented ambulatory via POV (privately owned vehicle) to the hospital's DED on 04/30/2017 at 2000 (visit #1). Review of a triage registration form revealed the reason for visit was "Unknown bite on hand." Review of PIVOT Triage Assessment documentation by an RN at 2107, revealed a chief complaint of "Insect Bite" and a History of Present Illness of "Pt (patient) states about 3hrs (3 hours) PTA (prior to arrival) he felt a bite or sting, states he called EMS (emergency medical services) and they stated no snake or any bite. Pt state at first it felt like a bee sting but, then felt 'a fire going up my arm' that he has never felt with a bee sting. States EMS circled the swelling with a pen and now swelling is past that point. Left hand is swollen to wrist." Review of initial triage vital signs at 2108 revealed Blood Pressure (BP) 154/91, Pulse Rate (P) 93, Respiratory Rate (R) 15, Pulse Oximetry (SpO2) 96% on room air, and Temperature (T) 98.9° F (Fahrenheit). Pain was assessed using a numerical pain scale of 0 to 5 (0 no hurt, 5 hurts worst) with a reported pain level of 5. The patient was assessed as Awake, Alert, Appropriate. Respiratory Pattern Normal. The patient was assigned a priority of 3H (ESI level 1-5, 1 severe, 5 least severe). Review of Triage/ED Nursing Assessment documentation by an RN at 2150 revealed, "Triage - Skin Rash/Insect Bite/Abscess" and "HPI - Skin Problem" with Problem - tender/swollen area; Skin character - erythema, swelling, tenderness, warm. Occurred - this afternoon. Timing - worse. Quality of rash - painful. Skin temperature - warm. Notes - "Pt presents to ED with a swollen Rt. (right) hand. Pt states he was working in the yard today and may have gotten bitten by something. Pt states had has gotten more swollen and tender and the redness has moved out of the area that was originally marked. PMS (pulse, motor, sensation) intact." Overall pain level - 5. Initial Assessment - awake, alert, appropriate. Glasgow coma assessment - eye opening spontaneous, verbal response oriented, motor response obeys commands. Score 15 (normal). Skin - dry, pink, intact warm. Musculoskeletal - moves all extremities, pulse strong.

Review revealed the following medications and nursing procedures were administered by an RN as ordered by Physician's Assistant (PA) #1:
~ Saline lock established at 2121;
~ Pepcid 20 mg (milligrams) IV (intravenous) now given at 2156;
~ Benadryl 25 mg IV now given at 2157;
~ Solu-Medrol 125 mg IV now given at 2157; and
~ Boostrix (Diphtheria/Tetanus/Pertussis) Vaccine 0.5 mL (milliliter) IM (intramuscular) now, not given patient refused at
2200; and
~ Benadryl 25 mg IV now given at 2257.

Review of nursing documentation revealed:
~ At 2311 - Hourly rounding. No needs at this time. No questions at this time. At 0005 (05/01/17) - Vital signs reassessed - BP
124/75, T 97.4° F, P 79, R 14, and SpO2 95% on room air.
~ At 0010 - Discharge documentation: Condition at discharge unchanged, IV removed yes, Pain level 3 (decreased). DC
transport method: personal vehicle. Patient discharged via: ambulated. Discharge instructions given to patient.
Notes: "Pt verbalized understanding of D/C, F/U (follow-up) and prescription instructions. Pt ambulated to D/C
office with steady gait in NAD (no acute distress) at this time."

Record review revealed a MSE was performed on 04/30/2017 at 2117 by PA #1. MSE documentation revealed, "ED Skin Rash / Insect Bite / Abscs (abscess) - General Chief Complaint: Insect Bite Stated Complaint: Possible Spider Bite Notes: Patient is a 49-year-old male that comes [sic] emergency department for chief complaint of suspected insect bite or sting between his fourth and fifth digits of the right hand. Patient states that he was working with to swell [sic] (with soil) and he felt a sharp stinging sensation with burning pain shooting up his arm. He did not visualize any insect. He states EMS evaluated him shortly after and circled the area, he states that he began to have swelling of the hand and redness that was spreading almost immediately afterwards and has [sic] (as) a result came to the emergency department. Patient reports redness and swelling to the area was almost immediately after the contact. He is not up-to-date on his tetanus within 5 years. He denies and daily medications, medical history, or allergies. ...Review of Systems ...Musculoskeletal: See HPI Skin: See HPI ..." Review of Physical Exam revealed: General appearance: appears well, alert. In distress: None. Head: normocephalic, atraumatic. Eyes: normal. Pupils: PERRL (pupils equal round reactive to light). Pharynx: normal. Neck: normal, No: anterior cervical chain, posterior cervical chain. Respiratory status: no respiratory distress, no: labored. Chest status: Nontender. Breath sounds: normal, no: decreased air movement, stridor, wheezing. Chest palpation: Normal. Cardiovascular rhythm: Regular. Heart sounds: normal auscultation. Murmur: no. Abdominal inspection: normal. Distention: no distention. Bowel sounds: normal. Tenderness: nontender. Organomegaly: no organomegaly. Back: normal, nontender. Extremities: General upper extremity: other - right hand with [sic] (Note: refer to PA #1 interview regarding missing documentation of right hand assessment). General lower extremity: normal inspection, nontender, normal color, normal ROM (range of motion), normal temperature, normal weight bearing. No: Homan's sign. Neurology: grossly intact. Cognition: normal. Orientation: AAOX4 (alert and oriented to person, place, time, situation). Glasgow Coma Scale Total: 15 (normal). Speech: normal. Cranial nerves: normal. Cerebellar coordination: normal. Mother strength normal: LUE, RUE, LLE, RLE (all extremities). Additional motor exam normal: equal grip. Sensory: normal. Psychological: normal affect and mood. Skin temperature: warm. Skin moisture: dry. Skin color: normal. Review revealed "Re-evaluation: Patient refusing tetanus update, states that 'if he gets an infection with tetanus he will get treated afterwards.' Patient again refused when offered. No evidence of anaphylaxis on reevaluation patient's [sic]. Remains localized swelling. Examination consistent with local histamine inflammatory response from insect sting/bites, after multiple does of antihistamines swelling significantly reduced, and also given Solu-Medrol, will cover with antibiotic prophylaxis, continue medication s at home, patient satisfied with improvement, discussed return precautions, patient states understanding and agreement." Review of discharge revealed a clinical impression of "Swelling right hand." Discharge condition "Stable." Disposition: home, self-care. Review of additional instructions revealed, "Examination is consistent with local inflammatory/histamine reaction, most likely from an insect bite. Take the prednisone as prescribed, take the Benadryl and Pepcid for at least 3 days, take Bactrim antibiotic to completion. Return immediately if you develop any concerning worsening symptoms such as spreading redness, fever, worsening swelling, or any other concerning symptoms."

Review revealed no documentation of lab and/or radiology studies ordered by PA #1.

Review revealed the patient was discharged with the following prescriptions:
~ Diphenhydramine HCL (Benadryl) 25 mg PO (by mouth) Q6 (every 6 hours) #20 capsule;
~ Famotidine (Pepcid) 20 mg PO daily #14 tablet;
~ Prednisone (Deltasone) 10 mg PO ASDIR (as directed) PRN (as needed) #21 tablet; and
~ Sulfamethoxazole/Trimethoprim (Bactrim) 1 each PO BID (twice per day) # 10 tablet.

Review revealed "I was personally available for consultation in the Emergency Department and serving as supervising physician for the MLP (mid-level provider)." Electronically signed by Physician A on 05/03/17 at 2103.

Hospital A, closed DED record review on 05/17/2017 for Patient #8, revealed the patient returned to the hospital's DED on 05/01/2017 at 1057 (visit #2). Review of a triage registration form revealed the reason for visit was "Bite." Review of PIVOT Triage Assessment documentation by an RN at 1109, revealed a chief complaint of "Hand Swelling" and a History of Present Illness of "Pt ambulatory to er (emergency room) with c/o (complaints of) swelling to the right hand. States seen yesterday and was thought to be and insect bite. States only one puncture site was seen last night. States today he can see 2 puncture sites. States he now thinks it was a snake bite." The patient was assessed as Awake, Alert, Appropriate. Respiratory Pattern Normal. Skin color normal. Review of initial triage vital signs at 1111 revealed BP 157/98, P 103, R 20, SpO2 95% on room air, and T 98.4° F. Pain was assessed using a numerical pain scale of 0 to 5 (0 no hurt, 5 hurts worst) with a reported pain level of 5. The patient was assigned a priority of 3H. Review of Triage documentation by an RN at 1122 revealed, "Triage - Hand/Wrist Injury" and "HPI - Hand or Wrist Injury" with Occurred - yesterday. Timing - constant. Distal pulses present no. Sensations intact no. Capillary refill less than 3 seconds. Notes - "Pt seen here last night for unknown bite to right hand. States swelling and discomfort has gotten worse today." Overall pain level - 5. Review of ED Nursing assessment documentation by an RN at 1211, revealed initial Assessment - awake, alert, appropriate. Patient oriented to person, place, time, and events. Glasgow coma assessment - eye opening spontaneous, verbal response oriented, motor response obeys commands. Score 15 (normal). Musculoskeletal - moves all extremities.

Review of nursing documentation revealed:
~ At 1125 - Elevate right arm above your heart.
~ At 1129 - Immobilize right arm in arm sling.
~ At 1334 - Hourly rounding. Provider at bedside at this time.
~ At 1342 - Saline lock established.
~ At 1623 - Received patient at this time to room 10 with IV infusing.
~ At 1645 - Telemetry Monitor. Vital signs reassessed - BP 145/90, P 75, R 18, SpO2 98%.
~ At 1651 - "Pt resting in bed. Pt c/o 3/5 pain to right hand and forearm at this time. Pt on cardiac monitor. Wife at bedside.
Call bell within reach. Will continue to monitor."
~ At 1700 - Vital signs reassessed - BP 130/82, P 81, R 19, SpO2 94%, T 97.7° F.
~ At 1747 - X-ray at bedside.
~ At 1801 - Vital signs reassessed - BP 121/80, R 18, SpO2 94%.
~ At 1817 - Vital signs reassessed - BP 138/77, R 17, SpO2 97%, T 97.7° F.
~ At 1821 - "Pt Crofab (Snake antivenom) completed at this time. Pt c/o 4/5 pain to right hand at this time. Pt c/o rash to forearm at this time.
Provider notified and new orders to follow."
~ At 1835 - Report called to (name) Vitalink (critical care transport service) at this time.
~ At 1840 - Report called to (name) RN, at (Hospital B) at this time.
~ At 1847 - "Pt states pain is a 2/5 at this time ..."
~ At 1901 - Vital signs reassessed - BP 149/80, P 85, R 18, SpO2 98%.
~ At 2000 - Hourly rounding. No needs at this time. Transport here ambulated to bathroom. Pain level 3. Vital signs
reassessed - BP 141/85, P 65, R 18, SpO2 97% on RA, T 97.9° F.
~ At 2021 - Discharge documentation: Condition at discharge improved, IV removed no, Pain level 3. DC transport method:
Vitalink. Patient discharged via: stretcher. Discharge instructions given to: report to transferring facility prior
RN.

Review revealed the following medications and nursing procedures completed by an RN as ordered by the DED Physician and/or QMP (Qualified Medical Personnel):

~ At 1125 - Elevate right arm above heart.
~ At 1129 - Immobilize right arm in arm sling.
~ At 1220 - Boostrix (Diphtheria, Tetanus, Pertussis) Vaccine 0.5 mL given.
~ At 1342 - Saline lock established.
~ At 1606 - IVF Normal Saline 0.9% 1000 mL bolus given.
~ At 1604 - Morphine 4 mg IV now given.
~ At 1605 - CroFab Antivenin 4 vials IV Bag given.
~ At 1825 - Morphine 4 mg IV now given.
~ At 1826 - Benadryl 25 mg PO now given.

Review revealed an "ED Medical Screen (RME)" [rapid medical evaluation - performed at triage by QMP] was performed on 05/01/2017 at 1125 by FNP #1. RME documentation revealed, "General Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury ...Notes: 49-year-old male seen last night with a bite while he was reaching under pine-needles to get a daffodil bulb at 6:30 PM has increased swelling past the wrist that is not pain out of proportion but it is tense and a second puncture mark showed up between the fourth and fifth base of the fingers. Dr. (Physician C) looked at it ..." Laboratory diagnostic studies were ordered by FNP #1.

Review revealed an MSE was performed on 05/01/2017 at 1124 by PA #2. MSE documentation revealed, "Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury. Notes: Patient is a 49-year-old male who presents with right hand swelling, warmth, and pain that started yesterday. He sates he was workin [sic] on replanting his daffodils when he felt a sting between his fourth and fifth finger and then a burning sensation 'like gasoline' travel up his right arm. This occurred yesterday at 6:30 PM. He was seen here last night around 2100, only one puncture wound was visible, diagnosed with possible spider bite, sent home with arm in sling, on oral antibiotics and steroids. He presents today because the pain and swelling which was localized to his has now spread to his wrist and up his right arm. He states when he cleaned his hand this morning, he noticed a second puncture wound which made him suspicious of a snake bite. He did not see a snake ad has not seen any around his house. He is right handed. Denies any fever, chills, erythema, numbness, tingling, chest pain or SOB (shortness of breath). ...Review of Systems ...Musculoskeletal: See HPI Skin: See HPI ..." Review of Physical Exam revealed: Constitutional: Alert and oriented, well-appearing and in no acute distress. HENT: normocephalic, atraumatic. Oropharynx clear without edema, erythema, tonsillar exudate or malocclusion. Trachea midline. Uvula midline. Moist mucous membranes. EYES: Pupils equal round and reactive to light, EOM intact. Sclera anicteric, conjunctiva are normal. No entrapment. NECK: supple without lymphadenopathy. ROM intact. HEART: Regular rate and rhythm without murmurs. LUNGS: CTAB and equal. No wheezes, rales or rhonchi. GI: Normoactive bowel sounds. Nontender, non-distended. No organomegaly. No CVAT. BACK: nontender, no paraspinous spasm, 5+//5 strengths, DTRs 2+, SLR -. EXTREMITIES: Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis to forearm that is tender to palpation. Cap refill <3 seconds. NEURO: Cranial nerves grossly intact. Normal sensory/motor exams. PSYCH: Normal mood, normal affect. SKIN: Warm and dry. Normal turgor. No rashes or lesions noted.

Review revealed, "Re-evaluation: 05/01/2017 12:38 Patient seen and examined. Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis extends from PIP joints of fingers to wrist with mild edema and ecchymosis to forearm that is tender to palpation. Cap Refill <3 seconds and distal pulses intact. Mild warmth to the touch but no streaking or erythema noted at this time. Patient has no respiratory distress. Tetanus was updated, initial labs drawn - mild leukocytosis (11.9). ...13:38 I have consulted with Dr. (Physician B) per (company name) APC guidelines who examined patient [sic] bedside, confirms suspicion of snake bite. Discussing case with Dr. (Physician D) for further opinion on administration of anti-venom. ...14:00 Dr. (Physician B) discussed case and consulted with hand surgeon on-call who declined, saying he does not treat snake bites. ...14:18 Dr. (Physician B), attending physician confirmed to start anti-venom. Cro-Fab ordered at this time. Patient remains stable with no respiratory distress - ordered IV fluids and IV morphine for pain. ...16:07 Consulted Dr. (Physician E) - general surgeon on call who states he declines coming to evaluate patient due to wound in upper extremity. He feels the patient should be transferred. ...1700 Consulted and discussed case with Dr. [Physician F] (IM) and Dr. [Physician G] (surgery) at (Hospital B) who suggested consulting trauma surgery before accepting. ...17:28 Consulted and discussed case with Dr. (Physician H), trauma surgery, who accepted patient for transfer. Patient updated with plan. At this time, patient reports improvement of pressure and swelling to right fingers with ROM improving. He does report mild erythema noted to anterior surface of forearm but no increase in swelling or pain to same area. No respiratory distress or chest pain noted at this time. Speaking in full sentences, alert and oriented. Crofab is still infusing. Patient is stable for transfer." Review revealed a clinical impression of snake bite and cellulitis. Condition: Stable. Disposition: (Hospital B). Electronically signed by PA #2 on 05/11/2017 at 2204 and Physician B on 05/12/2017 at 0304.

The facility failed to ensure that their Medical Staff Bylaws and Rules and Regulations were followed as evidenced by failing to ensure that the on call physicians who were on call for duty on 5/1/2017, after the initial examination to provide treatment necessary to stabilize Patient #8 on 5/1/2017 (second ED visit), who had limb threatening hand injury.

Review revealed the following Lab and Radiology studies ordered by the DED Physician and/or QMP:
1. 1135 - Complete Blood Count with Differential - WBC 12.0 H (high) [reference range 4.0-10.5].
2. 1135 - Prothrombin Time (PT) / INR - PT 13.2 [reference range 11.4-15.4], INR (D) 0.97 Therapeutic Range (Thromboembolic
Disease) [reference range 2.0-3.0].
3. 1135 - Partial Thromboplastin Time (PTT) - 26.9 [reference range 23.5-35.8].
4. 1135 - Comprehensive Metabolic Panel - Glucose 136 H (high) [reference range 75-110].
5. 1125 - Blood Culture X2 - No growth in 5 days.
6. 1315 - Repeat PT/INR - PT 13.0 [reference range 11.4-15.4], INR (D) 0.96 Therapeutic Range (Thromboembolic Disease)
[reference range 2.0-3.0].
7. 1315 - Repeat PTT - 27.8 [reference range 23.5-35.8].
8. 1315 - Fibrinogen - 531 H (high) [reference range 209-497].
9. 1449 - Fibrin Degradation Products - less than 10 [reference range <10).
10. 1645 - Urinalysis - Ketones Trace H (high) [reference range Negative].
11. 1755 - Right Hand 3 View X-ray - IMPRESSION: Negative Study of the right hand. No radiographic evidence of acute
injury.


Review on 05/17/2017 of Hospital A's "Emergency Room On-Call Schedule" for May 1, 2017 (revised at 1036) revealed, Physician D was on-call for Orthopedics and Physician E was on-call for General Surgery.

Review of Physician D's Core Privileges that were granted 7/28/2016 revealed in part, "Core ...hand and wrist disorders, management of 6/30/2017 TO 7/28/2018 , Hand surgery 6/30/2016 TO 7/28/2018."

Review on 05/17/2017 of Hospital A's Medical Staff Roster (dated 05/16/2017 at 1121), revealed Physician D's staff category was "active" and privilege status was "active" and specialty was "Orthopedics" and his re-privilege/credential date was 07/28/2018. Further review revealed, Physician D's staff category was "Locum Tenens" and privilege status was "Temporary" and specialty was "Surgery" and his re-privilege/credential date was 07/04/2017.


Telephone interview on 05/18/2017 at 0909 with PA #1, revealed he was on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). He remembered the patient. He was the QMP who performed the patient's MSE. The patient presented with a possible insect or spider bite to his right hand. Upon initial assessment of the right hand he could not see any marks or bleeding. There were no wounds. After the hand was cleaned, he noticed a mark, "one" mark in the web between fingers. The area was warm and red with swelling present. It could have been an ant, insect, or spider. It did not occur to him to be a snake bite. It appeared to be a "localized inflammatory response" The patient was administered Solumedrol, Benadryl and Pepcid IV. The patient was offered a Tetanus shot but he refused. When reassessed, the patient's hand had improved. It was not as hot or swollen. After a second round of anti-histamines were given, there was "significant improvement" and "minimal redness" and did not look like cellulitis. The patient was prescribed antibiotics to cover for potential infection from the puncture mark on the hand. The patient was discharged. He had no fever or risk factors. The supervising DED physician on-duty was not consulted about the patient. There was no reason to admit the patient. If the patient's condition had worsened, he would have consulted the physician. If he had the same scenario and same presentation by another patient, he would not have changed his treatment plan and would have discharged the patient. Note: When asked to clarify his MSE documentation of the "Extremities: General upper extremity: other - right hand with (blank)" his response was: The hospital used dictation software for the providers to document their MSE in the medical record. The software must have failed to document his assessment. The software should have transcribed right hand with red mark in center of the webbing between the 4-5 digits, localized swelling around the dorsum of the hand with mild heat to the area extending up to the right wrist. Normal ROM. Normal Pulse. PA #1 was unaware his assessment of the right hand had not been completely documented. Further interview revealed the patient's symptoms were not systemic, there was no toxicity and vital signs were stable. If he had suspected a cat or snake bite he may have ordered an x-ray to see if there were any teeth left in the puncture site. If he had suspected a snake bite, or if the patient had diabetes, fever, or cellulitis he would have ordered PT/PTT/INR and CBC. It crossed his mind initially that it may have been a snake, but when he examined the right hand and only saw one mark, he stated he was not even thinking a snake bite. He stated he ruled out snake bite do to the patient's response to antihistamines. The patient was discharged in stable condition. The patient had an EMC on presentation; on discharge "not so much." He stated he would not change the treatment delivered based on the presentation. The next day he was made aware the patient had returned to the ED and was transferred to Hospital B on Crofab. He also stated he was made aware the patient had filed a complaint with the hospital within the last 48 hours. Interview confirmed he did not discuss the patient's care with the on-duty supervising DED physician.

Telephone interview on 05/18/2017 at 0928 with PA#2, revealed she was on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). She recalled the patient. She was the QMP who performed the patient's MSE. The patient presented with increased swelling and redness to his right hand. The swelling did not extend past the elbow. The patient had full range of motion of the elbow and shoulder. Patient reported that when he was cleaning his hand in the morning, he noticed a second puncture wound. The patient reported a burning sensation traveling up his arm more than before. Labs were ordered and Dr. (Physician B) the attending DED physician on-duty was consulted. There was the possibility the patient would need antivenin. Physician B contacted poison control and determined the dose of antivenin to be administered. Discussed case with Physician B, he talked to the hand surgeon on-call, Dr. (Physician D). Physician D declined to evaluate the patient because he did not treat snake bites. CroFab administration was pending blood results to ensure lab values were within normal limits. Physician B confirmed to start the antivenin. She consulted Dr. (Physician E), the on-call General Surgeon, who was in a case? He declined to come evaluate the patient because he did not treat wounds/snake bites in the upper extremities. He felt the patient should be transferred. PA #2 then called Hospital B and consulted with Dr. (Physician F) [Internal Medicine], and Dr. (Physician G) [Surgeon]. They suggested she consult Trauma Surgery. She consulted Dr. (Physician H), Trauma Surgeon, who accepted the patient for transfer to Hospital B. PA #2, stated she nor Physician B consulted Hospital A's hospitalist because Physician B said the Hospitalist did not admit and treat snake bites. The decision was made to transfer the patient by Physician B. She stated the hospital's on-call physicians had turned the case down. The patient had an EMC. The patient needed to be monitored while on CroFab and monitored for compartment syndrome. The patient's condition was improved upon transfer, swelling, redness, and pain had decreased after the CroFab had been initiated.

Telephone interview on 05/18/2017 at 1005 with Physician E, revealed he was the on-call General Surgeon when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). He was consulted by the ED providers, but was not requested to present to the ED. He declined to evaluate the patient because he "does not treat hands." He stated hand surgeons have a skill set. "I don't have the skill set, there was no point in evaluating the patient."

Telephone interview on 05/18/2017 at 1030 with Physician D, revealed he was the on-call Orthopedist when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). Physician B, spoke with him regarding the patient. The patient had presented to the ED 24 hours earlier and returned for a snake bite to the hand. The hand was swollen. There were questions for the need of antivenin and admission. He stated he was not a snake bite specialist or hand surgeon. The patient needed to be admitted to the hospitalist services not orthopedics. There was not an orthopedic issue at the time, it was more of a medical issue due to the venom. He was not requested to present to the ED.

Review on 05/18/2017 of Hospital A's current Medical Staff Bylaws, Rules and Regulations (dated March 31, 2016), revealed, "Article II ...2.2.2 Unassigned Call Service a. Unassigned Call Schedule: The Hospital is required to maintain a list of physicians or appropriate designees who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. Each Clinical Department shall provide the Emergency Department and the Medical Staff
Services Office with a list of physicians and other practitioners who are scheduled to take emergency call on a rotating basis. Emergency call shall be from 0800 to 0800 the following day. Authorized allied health practitioners privileged through the medical staff can respond as first responder consistent with their collaborative agreements. b. Response Time: It is the responsibility of the on-call physician/practitioner to respond in an appropriate time frame. The on-call physician should respond to calls from the Emergency Department within thirty (30) minutes. If the on-call physician does not respond to being called or paged, the appropriate department policy with regard to the chain of command will be followed. Failure to respond in a timely manner may result in referral to the Medical Executive Committee (MEC) for appropriate action. c. Substitute Coverage: It is the on-call physician's responsibility to arrange for coverage and notify the Emergency Department through the switchboard if he/she is unavailable to take call when assigned. Failure to notify the Emergency Department of alternate call coverage may result in referral to the MEC for appropriate action and the physician will be considered to still be on call.

Telephone interview on 05/18/2017 at 1040 with Pharmacy Director #1, revealed the hospital kept a stock of CroFab on-hand. There was a quantity kept in the ED and a back-up supply in the pharmacy. The hospital kept a sufficient supply for the initial dose and to get an additional dose the following day. If additional does were needed they would have to order them from the supplier or borrow from surrounding hospitals. CroFab was "a very expensive medication." The cost of an average does of 4 vials was $46,000. The administration of CroFab does not require any authorization or approval from the Pharmacy or Hospital administration. If there is the need and a physician's order the medication is administered regardless of insurance or payor source. In emergent type situations, CroFab is immediately accessible by staff for administration to the patient.

Telephone interview on 05/18/2017 at 1345 with Physician A, revealed she was an attending physician on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). She was available for consult by PA #1. She had no contact with Patient #8. She only co-signed the chart. PA #1 did not consult her regarding Patient #8. She generally does not read the ED charts she just electronically co-signs them.

Telephone interview on 05/18/2017 at 1410 with Physician B, revealed he was the attending physician on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (

Based on current hospital policy and procedure review, medical record review, the hospital's "Emergency Room On-Call Schedule," the hospital's "Medical Staff Roster," Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital's Dedicated Emergency Department's (DED) medical staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 24 sampled patients who presented to the hospital's DED with an EMC and were transferred to another facility. (Patient #8)

Findings included:

Review on 05/17/2017 of the hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act): Medical Screening, Stabilization, and Transfer" (Revision Date: 12/2015), revealed "Purpose and Applicable Law: 1. To provide a medical screening examination to any individual who comes to the Emergency Department and requires examination or treatment to determine if an emergency medical condition exists (42 USC 1395dd(a))...2. If an emergency medical condition exists, to stabilize the condition or provide for an appropriate transfer of the patient to another facility (42 USC 1395 dd (b))...III. Definitions: D. Appropriate Medical Screening Examination - means a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists or whether a woman is in labor. The medical screening examination must be uniform for all patients who present with similar complaints. The screening examination must be performed by qualified medical personnel as designated by the medical staff bylaws."

Hospital A, closed DED record review on 05/17/2017 for Patient #8, revealed the patient returned to the hospital's DED on 05/01/2017 at 1057 (visit #2). Review of a triage registration form revealed the reason for visit was "Bite." Review of PIVOT Triage Assessment documentation by an RN at 1109, revealed a chief complaint of "Hand Swelling" and a History of Present Illness of "Pt ambulatory to er (emergency room) with c/o (complaints of) swelling to the right hand. States seen yesterday and was thought to be and insect bite. States only one puncture site was seen last night. States today he can see 2 puncture sites. States he now thinks it was a snake bite." The patient was assessed as Awake, Alert, Appropriate. Respiratory Pattern Normal. Skin color normal. Review of initial triage vital signs at 1111 revealed BP 157/98, P 103, R 20, SpO2 95% on room air, and T 98.4° F. Pain was assessed using a numerical pain scale of 0 to 5 (0 no hurt, 5 hurts worst) with a reported pain level of 5. The patient was assigned a priority of 3H. Review of Triage documentation by an RN at 1122 revealed, "Triage - Hand/Wrist Injury" and "HPI - Hand or Wrist Injury" with Occurred - yesterday. Timing - constant. Distal pulses present no. Sensations intact no. Capillary refill less than 3 seconds. Notes - "Pt seen here last night for unknown bite to right hand. States swelling and discomfort has gotten worse today." Overall pain level - 5. Review of ED Nursing assessment documentation by an RN at 1211, revealed initial Assessment - awake, alert, appropriate. Patient oriented to person, place, time, and events. Glasgow coma assessment - eye opening spontaneous, verbal response oriented, motor response obeys commands. Score 15 (normal). Musculoskeletal - moves all extremities.

Review of nursing documentation revealed:
~ At 1125 - Elevate right arm above your heart.
~ At 1129 - Immobilize right arm in arm sling.
~ At 1334 - Hourly rounding. Provider at bedside at this time.
~ At 1342 - Saline lock established.
~ At 1623 - Received patient at this time to room 10 with IV infusing.
~ At 1645 - Telemetry Monitor. Vital signs reassessed - BP 145/90, P 75, R 18, SpO2 98%.
~ At 1651 - "Pt resting in bed. Pt c/o 3/5 pain to right hand and forearm at this time. Pt on cardiac monitor. Wife at bedside.
Call bell within reach. Will continue to monitor."
~ At 1700 - Vital signs reassessed - BP 130/82, P 81, R 19, SpO2 94%, T 97.7° F.
~ At 1747 - X-ray at bedside.
~ At 1801 - Vital signs reassessed - BP 121/80, R 18, SpO2 94%.
~ At 1817 - Vital signs reassessed - BP 138/77, R 17, SpO2 97%, T 97.7° F.
~ At 1821 - "Pt Crofab completed at this time. Pt c/o 4/5 pain to right hand at this time. Pt c/o rash to forearm at this time.
Provider notified and new orders to follow."
~ At 1835 - Report called to (name) Vitalink (critical care transport service) at this time.
~ At 1840 - Report called to (name) RN, at (Hospital B) at this time.
~ At 1847 - "Pt states pain is a 2/5 at this time ..."
~ At 1901 - Vital signs reassessed - BP 149/80, P 85, R 18, SpO2 98%.
~ At 2000 - Hourly rounding. No needs at this time. Transport here ambulated to bathroom. Pain level 3. Vital signs
reassessed - BP 141/85, P 65, R 18, SpO2 97% on RA, T 97.9° F.
~ At 2021 - Discharge documentation: Condition at discharge improved, IV removed no, Pain level 3. DC transport method:
Vitalink. Patient discharged via: stretcher. Discharge instructions given to: report to transferring facility prior
RN.

Review revealed the following medications and nursing procedures completed by an RN as ordered by the DED Physician and/or QMP:

~ At 1125 - Elevate right arm above heart.
~ At 1129 - Immobilize right arm in arm sling.
~ At 1220 - Boostrix (Diphtheria, Tetanus, Pertussis) Vaccine 0.5 mL given.
~ At 1342 - Saline lock established.
~ At 1606 - IVF Normal Saline 0.9% 1000 mL bolus given.
~ At 1604 - Morphine 4 mg IV now given.
~ At 1605 - CroFab Antivenin 4 vials IV Bag given.
~ At 1825 - Morphine 4 mg IV now given.
~ At 1826 - Benadryl 25 mg PO now given.

Review revealed an "ED Medical Screen (RME)" [rapid medical evaluation - performed at triage by QMP] was performed on 05/01/2017 at 1125 by FNP #1. RME documentation revealed, "General Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury ...Notes: 49-year-old male seen last night with a bite while he was reaching under pine-needles to get a daffodil bulb at 6:30 PM has increased swelling past the wrist that is not pain out of proportion but it is tense and a second puncture mark showed up between the fourth and fifth base of the fingers. Dr. (Physician C) looked at it ..." Laboratory diagnostic studies were ordered by FNP #1.

Review revealed an MSE was performed on 05/01/2017 at 1124 by PA #2. MSE documentation revealed, "Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury. Notes: Patient is a 49-year-old Caucasian male who presents with right hand swelling, warmth, and pain that started yesterday. He sates he was workin [sic] on replanting his daffodils when he felt a sting between his fourth and fifth finger and then a burning sensation 'like gasoline' travel up his right arm. This occurred yesterday at 6:30 PM. He was seen here last night around 2100, only one puncture wound was visible, diagnosed with possible spider bite, sent home with arm in sling, on oral antibiotics and steroids. He presents today because the pain and swelling which was localized to his has now spread to his wrist and up his right arm. He states when he cleaned his hand this morning, he noticed a second puncture wound which made him suspicious of a snake bite. He did not see a snake ad has not seen any around his house. He is right handed. Denies any fever, chills, erythema, numbness, tingling, chest pain or SOB (shortness of breath). ...Review of Systems ...Musculoskeletal: See HPI Skin: See HPI ..." Review of Physical Exam revealed: Constitutional: Alert and oriented, well-appearing and in no acute distress. HENT: normocephalic, atraumatic. Oropharynx clear without edema, erythema, tonsillar exudate or malocclusion. Trachea midline. Uvula midline. Moist mucous membranes. EYES: Pupils equal round and reactive to light, EOM intact. Sclera anicteric, conjunctiva are normal. No entrapment. NECK: supple without lymphadenopathy. ROM intact. HEART: Regular rate and rhythm without murmurs. LUNGS: CTAB and equal. No wheezes, rales or rhonchi. GI: Normoactive bowel sounds. Nontender, non-distended. No organomegaly. No CVAT. BACK: nontender, no paraspinous spasm, 5+//5 strengths, DTRs 2+, SLR -. EXTREMITIES: Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis to forearm that is tender to palpation. Cap refill <3 seconds. NEURO: Cranial nerves grossly intact. Normal sensory/motor exams. PSYCH: Normal mood, normal affect. SKIN: Warm and dry. Normal turgor. No rashes or lesions noted.

Review revealed, "Re-evaluation: 05/01/2017 12:38 Patient seen and examined. Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis extends from PIP joints of fingers to wrist with mild edema and ecchymosis to forearm that is tender to palpation. Cap Refill <3 seconds and distal pulses intact. Mild warmth to the touch but no streaking or erythema noted at this time. Patient has no respiratory distress. Tetanus was updated, initial labs drawn - mild leukocytosis (11.9). ...13:38 I have consulted with Dr. (Physician B) per (company name) APC guidelines who examined patient [sic] bedside, confirms suspicion of snake bite. Discussing case with Dr. (Physician D) for further opinion on administration of anti-venom. ...14:00 Dr. (Physician B) discussed case and consulted with hand surgeon on-call who declined, saying he does not treat snake bites. ...14:18 Dr. (Physician B), attending physician confirmed to start anti-venom. Cro-Fab ordered at this time. Patient remains stable with no respiratory distress - ordered IV fluids and IV morphine for pain. ...16:07 Consulted Dr. (Physician E) - general surgeon on call who states he declines coming to evaluate patient due to wound in upper extremity. He feels the patient should be transferred. ...1700 Consulted and discussed case with Dr. [Physician F] (IM) and Dr. [Physician G] (surgery) at (Hospital B) who suggested consulting trauma surgery before accepting. ...17:28 Consulted and discussed case with Dr. (Physician H), trauma surgery, who accepted patient for transfer. Patient updated with plan. At this time, patient reports improvement of pressure and swelling to right fingers with ROM improving. He does report mild erythema noted to anterior surface of forearm but no increase in swelling or pain to same area. No respiratory distress or chest pain noted at this time. Speaking in full sentences, alert and oriented. Crofab is still infusing. Patient is stable for transfer." Review revealed a clinical impression of snake bite and cellulitis. Condition: Stable. Disposition: (Hospital B). Electronically signed by PA #2 on 05/11/2017 at 2204 and Physician B on 05/12/2017 at 0304.

Review revealed the following Lab and Radiology studies ordered by the DED Physician and/or QMP:
1. 1135 - Complete Blood Count with Differential - WBC 12.0 H (high) [reference range 4.0-10.5].
2. 1135 - Prothrombin Time (PT) / INR - PT 13.2 [reference range 11.4-15.4], INR (D) 0.97 Therapeutic Range (Thromboembolic
Disease) [reference range 2.0-3.0].
3. 1135 - Partial Thromboplastin Time (PTT) - 26.9 [reference range 23.5-35.8].
4. 1135 - Comprehensive Metabolic Panel - Glucose 136 H (high) [reference range 75-110].
5. 1125 - Blood Culture X2 - No growth in 5 days.
6. 1315 - Repeat PT/INR - PT 13.0 [reference range 11.4-15.4], INR (D) 0.96 Therapeutic Range (Thromboembolic Disease)
[reference range 2.0-3.0].
7. 1315 - Repeat PTT - 27.8 [reference range 23.5-35.8].
8. 1315 - Fibrinogen - 531 H (high) [reference range 209-497].
9. 1449 - Fibrin Degradation Products - less than 10 [reference range <10).
10. 1645 - Urinalysis - Ketones Trace H (high) [reference range Negative].
11. 1755 - Right Hand 3 View X-ray - IMPRESSION: Negative Study of the right hand. No radiographic evidence of acute
injury.

Review of the "Patient Transfer Form (EMTALA)" dated 05/01/2017 certified by Physician B at 1800, revealed "[check mark in box] Stable. The patient has an emergency medical condition, but the condition is stable. No material deterioration is likely to result from: (1) a transfer to another facility, or (2) discharge with instructions for appropriate follow-up care. ...Patient-Specific Benefits of Transfer: Admission to manage snakebite injury. Patient-Specific Risks of Transfer: worsening swelling of hand, increased pain. ..." Review revealed the patient's vital signs prior to transport were reassessed at 2002 as T 97.9? F, P 65, R 18, BP 141/85, SpO2 97% on room air. The patient was transported by critical care personnel to another hospital (B) where he was admitted as inpatient and treated. The patient departed the DED at 2021.

Review on 05/17/2017 of Hospital A's "Emergency Room On-Call Schedule" for May 1, 2017 (revised at 1036) revealed, Physician D was on-call for Orthopedics and Physician E was on-call for General Surgery.

Review on 05/17/2017 of Hospital A's Medical Staff Roster (dated 05/16/2017 at 1121), revealed Physician D's staff category was "active" and privilege status was "active" and specialty was "Orthopedics" and his re-privilege/credential date was 07/28/2018. Further review revealed, Physician D's staff category was "Locum Tenens" and privilege status was "Temporary" and specialty was "Surgery" and his re-privilege/credential date was 07/04/2017.

Hospital B (Receiving Hospital), closed medical record review on 06/02/2017 for Patient #8, revealed the patient presented to the hospital via Vitalink ambulance on 05/01/2017 at 2147 and was direct admitted to an in-patient unit for observation with a diagnosis of snake bite envenomation right hand. Review of a "Surgical House Staff/Trauma Surgery History and Physical" dated 05/01/2017 at 2245, revealed "Chief Complaint: Snakebite RUE. History of Present Illness: ...49 y. o. Caucasian male with no pmhx (past medical history) who reports a snakebite to Right hand. Patient states he was gardening and reached his hand under a board and felt a burning sensation. He did not see the snake. He states he knows this was a snake due to the two puncture marks over his 4th/5th digits. States he had some immediate swelling and went to the ED and was subsequently sent home. He then returned to (Hospital A) ED today with increased swelling and received one dose of crofab with improvement. Per (Hospital A) records, general surgery did not feel they could take care of wound and he was sent to (Hospital B) for further care. ...He states the dose of crofab improved the swelling such that now he is able to move his hand without intense pain. He has full sensation and motor function to RUE. He received tetanus at (Hospital A). Right hand XRay [sic] at (Hospital A) was negative for any injury. ...Assessment: ...male with recent snakebite to RUE with increased swelling. Received Crofab at (Hospital A). Will monitor for signs, symptoms of compartment syndrome and give 2nd dose of crofab if needed. ...Plan: 1. Admit to floor 2. IVFs 3. Pain control ...6. Will monitor for s/s (signs and symptoms) of compartment syndrome. ..." Review of a "Trauma Services Discharge Summary" dated 05/02/2017 at 0936, revealed " ... Hospital Course: After full trauma work up, primary and secondary surveys completed, including labs, xrays [sic], and CT scans the above listed injuries were identified. The patient was admitted for continued care. Had no issues while in the hospital, no fevers or reaction to the crofab or the bite. Labs were normal, medically clear to be discharged. This discharge is inclusive of a negative tertiary evaluation. Tertiary survey was completed and was negative for additional injuries. Disposition: The patient will be discharged to Home in Stable condition." Review revealed a discharge diagnosis of "Snake Bite." The patient was discharged on 05/02/2017 at 1046.

Telephone interview on 05/18/2017 at 0909 with PA #1, revealed he was on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). He remembered the patient. He was the QMP who performed the patient's MSE. The patient presented with a possible insect or spider bite to his right hand. Upon initial assessment of the right hand he could not see any marks or bleeding. There were no wounds. After the hand was cleaned, he noticed a mark, "one" mark in the web between fingers. The area was warm and red with swelling present. It could have been an ant, insect, or spider. It did not occur to him to be a snake bite. It appeared to be a "localized inflammatory response" The patient was administered Solumedrol, Benadryl and Pepcid IV. The patient was offered a Tetanus shot but he refused. When reassessed, the patient's hand had improved. It was not as hot or swollen. After a second round of anti-histamines were given, there was "significant improvement" and "minimal redness" and did not look like cellulitis. The patient was prescribed antibiotics to cover for potential infection from the puncture mark on the hand. The patient was discharged. He had no fever or risk factors. The supervising DED physician on-duty was not consulted about the patient. There was no reason to admit the patient. If the patient's condition had worsened, he would have consulted the physician. If he had the same scenario and same presentation by another patient, he would not have changed his treatment plan and would have discharged the patient. Note: When asked to clarify his MSE documentation of the "Extremities: General upper extremity: other - right hand with (blank)" his response was: The hospital used dictation software for the providers to document their MSE in the medical record. The software must have failed to document his assessment. The software should have transcribed right hand with red mark in center of the webbing between the 4-5 digits, localized swelling around the dorsum of the hand with mild heat to the area extending up to the right wrist. Normal ROM. Normal Pulse. PA #1 was unaware his assessment of the right hand had not been completely documented. Further interview revealed the patient's symptoms were not systemic, there was no toxicity and vital signs were stable. If he had suspected a cat or snake bite he may have ordered an x-ray to see if there were any teeth left in the puncture site. If he had suspected a snake bite, or if the patient had diabetes, fever, or cellulitis he would have ordered PT/PTT/INR and CBC. It crossed his mind initially that it may have been a snake, but when he examined the right hand and only saw one mark, he stated he was not even thinking a snake bite. He stated he ruled out snake bite do to the patient's response to antihistamines. The patient was discharged in stable condition. The patient had an EMC on presentation; on discharge "not so much." He stated he would not change the treatment delivered based on the presentation. The next day he was made aware the patient had returned to the ED and was transferred to Hospital B on Crofab. He also stated he was made aware the patient had filed a complaint with the hospital within the last 48 hours. Interview confirmed he did not discuss the patient's care with the on-duty supervising DED physician.

Telephone interview on 05/18/2017 at 0928 with PA#2, revealed she was on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). She recalled the patient. She was the QMP who performed the patient's MSE. The patient presented with increased swelling and redness to his right hand. The swelling did not extend past the elbow. The patient had full range of motion of the elbow and shoulder. Patient reported that when he was cleaning his hand in the morning, he noticed a second puncture wound. The patient reported a burning sensation traveling up his arm more than before. Labs were ordered and Dr. (Physician B) the attending DED physician on-duty was consulted. There was the possibility the patient would need antivenin. Physician B contacted poison control and determined the dose of antivenin to be administered. Discussed case with Physician B, he talked to the hand surgeon on-call, Dr. (Physician D). Physician D declined to evaluate the patient because he did not treat snake bites. CroFab administration was pending blood results to ensure lab values were within normal limits. Physician B confirmed to start the antivenin. She consulted Dr. (Physician E), the on-call General Surgeon, who was in a case? He declined to come evaluate the patient because he did not treat wounds/snake bites in the upper extremities. He felt the patient should be transferred. PA #2 then called Hospital B and consulted with Dr. (Physician F) [Internal Medicine], and Dr. (Physician G) [Surgeon]. They suggested she consult Trauma Surgery. She consulted Dr. (Physician H), Trauma Surgeon, who accepted the patient for transfer to Hospital B. PA #2, stated she nor Physician B consulted Hospital A's hospitalist because Physician B said the Hospitalist did not admit and treat snake bites. The decision was made to transfer the patient by Physician B. She stated the hospital's on-call physicians had turned the case down. The patient had an EMC. The patient needed to be monitored while on CroFab and monitored for compartment syndrome. The patient's condition was improved upon transfer, swelling, redness, and pain had decreased after the CroFab had been initiated.

Telephone interview on 05/18/2017 at 1005 with Physician E, revealed he was the on-call General Surgeon when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). He was consulted by the ED providers, but was not requested to present to the ED. He declined to evaluate the patient because he "does not treat hands." He stated hand surgeons have a skill set. "I don't have the skill set, there was no point in evaluating the patient."

Telephone interview on 05/18/2017 at 1030 with Physician D, revealed he was the on-call Orthopedist when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). Physician B, spoke with him regarding the patient. The patient had presented to the ED 24 hours earlier and returned for a snake bite to the hand. The hand was swollen. There were questions for the need of antivenin and admission. He stated he was not a snake bite specialist or hand surgeon. The patient needed to be admitted to the hospitalist services not orthopedics. There was not an orthopedic issue at the time, it was more of a medical issue due to the venom. He was not requested to present to the ED.

Review on 05/18/2017 of Hospital A's current Medical Staff Bylaws, Rules and Regulations (dated March 31, 2016), revealed, "Article II ...2.2.2 Unassigned Call Service a. Unassigned Call Schedule: The Hospital is required to maintain a list of physicians or appropriate designees who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. Each Clinical Department shall provide the Emergency Department and the Medical Staff
Services Office with a list of physicians and other practitioners who are scheduled to take emergency call on a rotating basis. Emergency call shall be from 0800 to 0800 the following day. Authorized allied health practitioners privileged through the medical staff can respond as first responder consistent with their collaborative agreements. b. Response Time: It is the responsibility of the on-call physician/practitioner to respond in an appropriate time frame. The on-call physician should respond to calls from the Emergency Department within thirty (30) minutes. If the on-call physician does not respond to being called or paged, the appropriate department policy with regard to the chain of command will be followed. Failure to respond in a timely manner may result in referral to the Medical Executive Committee (MEC) for appropriate action. c. Substitute Coverage: It is the on-call physician's responsibility to arrange for coverage and notify the Emergency Department through the switchboard if he/she is unavailable to take call when assigned. Failure to notify the Emergency Department of alternate call coverage may result in referral to the MEC for appropriate action and the physician will be considered to still be on call.

Telephone interview on 05/18/2017 at 1040 with Pharmacy Director #1, revealed the hospital kept a stock of CroFab on-hand. There was a quantity kept in the ED and a back-up supply in the pharmacy. The hospital kept a sufficient supply for the initial dose and to get an additional dose the following day. If additional does were needed they would have to order them from the supplier or borrow from surrounding hospitals. CroFab was "a very expensive medication." The cost of an average does of 4 vials was $46,000. The administration of CroFab does not require any authorization or approval from the Pharmacy or Hospital administration. If there is the need and a physician's order the medication is administered regardless of insurance or payor source. In emergent type situations, CroFab is immediately accessible by staff for administration to the patient.

Telephone interview on 05/18/2017 at 1345 with Physician A, revealed she was an attending physician on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). She was available for consult by PA #1. She had no contact with Patient #8. She only co-signed the chart. PA #1 did not consult her regarding Patient #8. She generally does not read the ED charts she just electronically co-signs them.

Telephone interview on 05/18/2017 at 1410 with Physician B, revealed he was the attending physician on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). He received report from the PA (PA #2) and evaluated the patient. The patient had old ink drawn on his right hand that delineated swelling above the wrist. The patient now had swelling from his wrist to his elbow. There were two visible puncture marks on the dorsal of the hand at the 4th-5th web space, distal to the knuckle. When you only have one puncture mark the question is, is it a snake bite vs. spider bite? The patient reported after he cleaned up his hand, he saw little marks and the second puncture mark and returned to the ED. Knowing CroFab cost "thousands of dollars" and that the patient had no insurance, he performed an internet search to find out the value of administering CroFab twenty hours after an initial snakebite. He was unable to find any information. Dr. (Physician D) was on-call for Orthopedics. Physician D was consulted and stated he did not do snake bites and declined the evaluation. The PA called Dr. (Physician E) the on-call General Surgeon who stated he did not do upper extremities/hands and had never given CroFab; and declined to evaluate the patient. Physician E recommended the patient be admitted to medical for monitoring. Physician B stated he knew Hospital A's hospitalist did not admit and take care of snake bites. He attempted to call Dr. (Physician C), who had experience with snakebites, but was not on-call and was in New York; prior to calling Physician E. Based on his experience he believed the patient had been bitten by a cotton mouth or copperhead snake. .

Interview on 05/18/2017 at 1020 with the CEO of Hospital A, revealed Physician E was a Locums Tenens physician with temporary privileges signed on 03/26/2017.

In summary, patient #8 presented to the hospital on 05/01/2017 the patient returned to the hospital (11 hours later) with increased pain, swelling, redness, and warmth with distal pulses and sensation diminished. The patient informed the hospital staff there were "now" two puncture sites visible and he was concerned that he was bitten by a snake. The patient's arm was elevated and he was given a sling along with a hand consultation done by physician who stated he did not take care of snake bites. The patient was administered a snake antivenom and a general surgeon consult was done who also stated he did not take care of wounds to the hands and suggested a patient transfer. The patient was transported by critical care personnel to another hospital (B) where he was admitted as inpatient and treated. The review revealed concerns that the patient was not stabilized prior to transfer during the second DED visit to Hospital A on 05/01/2017 as evidenced by the hand surgeon refusing to accept the patient on their service or manage the patient in conjunction with an accepting medical team.

Based on review of medical records, policies and procedures, medical staff rosters, Emergency Room Call Schedules, and interviews the hospital inappropriately transferred and individual by failing to provide medical treatment that was within its capability and capacity to render care that minimized the risks to an individual's health who presented to the hospital's emergency department with a limb threatening injury for 1 (#8) of 24 sampled patients.

Findings Included:

Review of the facility's policy and procedure titled "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER. POLICY #509, effective August 6, 1999, last revision date 12/12, revealed in part, "G. Other EMTALA Provisions ...An improper transfer includes the following "D. Refusal of an on call physician to respond to a request from the emergency department for evaluation of a person believed to have an emergency medical condition ...or to provide stabilizing treatment to a patient with an emergency medical condition, when refusal cause the transfer of the patient to another hospital to receive stabilizing treatment."

Review of Patient #8's "Patient Transfer Form (EMTALA)" dated 05/01/2017 certified by Physician B at 1800, revealed "[check mark in box] Stable. The patient has an emergency medical condition, but the condition is stable. No material deterioration is likely to result from: (1) a transfer to another facility, or (2) discharge with instructions for appropriate follow-up care. ...Patient-Specific Benefits of Transfer: Admission to manage snakebite injury. Patient-Specific Risks of Transfer: worsening swelling of hand, increased pain. ..." Review revealed the patient's vital signs prior to transport were reassessed at 2002 as T 97.9? F, P 65, R 18, BP 141/85, SpO2 97% on room air. The patient was transported by critical care personnel to another hospital (B) where he was admitted as inpatient and treated. The patient departed the DED at 2021.

Review on 05/17/2017 of Hospital A's "Emergency Room On-Call Schedule" for May 1, 2017 (revised at 1036) revealed, Physician D was on-call for Orthopedics and Physician E was on-call for General Surgery.

Review on 05/17/2017 of Hospital A's Medical Staff Roster (dated 05/16/2017 at 1121), revealed Physician D's staff category was "active" and privilege status was "active" and specialty was "Orthopedics" and his re-privilege/credential date was 07/28/2018. Further review revealed, Physician D's staff category was "Locum Tenens" and privilege status was "Temporary" and specialty was "Surgery" and his re-privilege/credential date was 07/04/2017.

Hospital B (Receiving Hospital), closed medical record review on 06/02/2017 for Patient #8, revealed the patient presented to the hospital via Vitalink ambulance on 05/01/2017 at 2147 and was direct admitted to an in-patient unit for observation with a diagnosis of snake bite envenomation right hand. Review of a "Surgical House Staff/Trauma Surgery History and Physical" dated 05/01/2017 at 2245, revealed "Chief Complaint: Snakebite RUE. History of Present Illness: ...49 y. o. male with no pmhx (past medical history) who reports a snakebite to Right hand. Patient states he was gardening and reached his hand under a board and felt a burning sensation. He did not see the snake. He states he knows this was a snake due to the two puncture marks over his 4th/5th digits. States he had some immediate swelling and went to the ED and was subsequently sent home. He then returned to (Hospital A) ED today with increased swelling and received one dose of crofab with improvement. Per (Hospital A) records, general surgery did not feel they could take care of wound and he was sent to (Hospital B) for further care. ...He states the dose of crofab improved the swelling such that now he is able to move his hand without intense pain. He has full sensation and motor function to RUE. He received tetanus at (Hospital A). Right hand XRay [sic] at (Hospital A) was negative for any injury. ...Assessment: ...male with recent snakebite to RUE with increased swelling. Received Crofab at (Hospital A). Will monitor for signs, symptoms of compartment syndrome and give 2nd dose of crofab if needed. ...Plan: 1. Admit to floor 2. IVFs 3. Pain control ...6. Will monitor for s/s (signs and symptoms) of compartment syndrome. ..." Review of a "Trauma Services Discharge Summary" dated 05/02/2017 at 0936, revealed " ... Hospital Course: After full trauma work up, primary and secondary surveys completed, including labs, xrays [sic], and CT scans the above listed injuries were identified. The patient was admitted for continued care. Had no issues while in the hospital, no fevers or reaction to the crofab or the bite. Labs were normal, medically clear to be discharged. This discharge is inclusive of a negative tertiary evaluation. Tertiary survey was completed and was negative for additional injuries. Disposition: The patient will be discharged to Home in Stable condition." Review revealed a discharge diagnosis of "Snake Bite." The patient was discharged on 05/02/2017 at 1046.

A telephone interview was conducted with Physician B on 5/18/2017 at 1410. Physician B stated he did have an issue with General Surgery. He thought the patient should have been taken care of at Hospital A and not transferred. He felt any General Surgeon should be able to treat a snakebite and that generally, Orthopedics do not. Given the hospital's resources, if a Surgeon was not comfortable treating a snakebite they should tell someone and not be staffing the ED. Physician B stated no hospitalist at Hospital A were consulted. Historically General Surgery has taken care of snakebites at the hospital and if needed a referral is made to Orthopedics.


The facility failed to ensure that their own policies and procedures were followed as evidenced by the on call physician declining/refusing to come to the emergency department when notified by the emergency department physician that further evaluation and treatment was needed for patient #8 on 5/1/2017, when it was determined the patient had an emergency medical condition. As this resulted in an inappropriate/improper transfer of patient #8 on 5/1/2017.