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Based on review of hospital policy and procedure, medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

The findings include:

1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 18 sampled DED patients (Patient #3) who presented to the hospital for evaluation and treatment who was transferred; and 2 of 5 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home without receiving an appropriate medical screening examination by qualified medical personnel (Patient #8 and Patient #9).

~ Cross refer to §489.24(a) and §489.24(c) Medical Screening Examination - Tag A 2406.

2. The hospital's Dedicated Emergency Department (DED) staff failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 1 of 18 sampled DED patients, (Patient # 3) who presented to the hospital for evaluation and treatment and transferred; and 2 of 5 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #8 and Patient #9).

~ Cross refer to §489.24(d)(1-3) Stabilizing Treatment, Tag A 2407.

3. The hospital's Dedicated Emergency Department (DED) failed to ensure an appropriate transfer by not providing further care and treatment within the capability and capacity of the hospital for 1 of 6 sampled DED patients that were transferred with an emergency medical condition (Patient #3).

~ Cross refer to §489.24(e)(1)-(2) Appropriate Transfer, Tag A 2409.

Based on policy review, medical record reviews, Physician Credentialing file review, and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 18 sampled DED patients (Patient #3) who presented to the hospital for evaluation and treatment who was transferred; and 2 of 5 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home without receiving an appropriate medical screening examination by qualified medical personnel (Patient #8 and Patient #9).
The findings include:

Review of hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", effective October 1, 2017 revealed "..B. Medical Screening Examination: 1. Any individual who presents to XYZ Medical Center (Hospital A-Southeastern Regional Medical Center) seeking emergency care shall undergo a medical screening examination to determine whether that the individual is experiencing an emergency medical condition.. Generally, an "emergency medical condition" is one manifesting such symptoms (including severe pain, psychiatric disturbances, and or other symptoms of substance abuse) that the absence of immediate medical attention is likely to cause serious dysfunction or serious jeopardy to the health of the individual... 4. The exam shall include those ancillary services routinely available to, although not located in Emergency Services.. including on-call physicians...".

Review of hospital policy "Qualified Medical Professionals for EMTALA Screening", effective January, 2018 revealed "....III. All individuals presenting to the XYZ (Hospital A) dedicated emergency department (as defined by law) for examination or treatment shall be given an appropriate medical screening examination (MSE) by qualified medical personnel (QMP) to determine if an emergency medical condition exists. QMP include physicians, physician assistants, nurse practitioners, and midwives (for labor and delivery patients only). Additionally, a registered nurse (RN) may conduct the MSE, as long as the nurse is acting within the scope of his/her license...."

1. Closed medical record review revealed Patient #3, a 96 year old male, presented to the facility's DED on 10/15/2018 at 1912 with an arrival complaint of diarrhea, nausea and vomiting. Record review revealed at 1932 vital signs at triage were BP 137/66; Pulse 90; Respirations 17; Temperature 98.6 F. Record review revealed ED Notes at 1940 "Pt arrives in the ED via EMS (emergency medical services). Pt states "I can't keep my bowels from running." EMS reports hx (history) of dementia and states that the pt has had nausea, vomiting and diarrhea x 2 days with no relief. EMS gave 4mg Zofran in route ..." Review of ED notes revealed at 2013 "Pt taken to room 23 for diaper change per pt. But no bowel movement at this time." Review revealed MSE initiated at 2054 by Resident #1. Record review revealed at 2054 Lab Ordered: Urinalysis, Lactic Acid and Sepsis Screen, B-Type Natriuretic Peptide, Troponin Ghost Panel, Lipase, Comprehensive Metabolic Panel, CBC and Auto Differential. Also ordered was CT Stone Chaser (CAT scan to rule out kidney stone). Review of ED Notes revealed at 2111 "Pt gone to medical imaging at this time." Review revealed at 2144 Labs resulted with abnormal results: WBC 14.5 [ref range: 4.8-10.8]; Hemoglobin 11.7 [ref range: 14.0-18.0] and Hematocrit 38.4% [ref range: 42.0-52.0]. Review of ED Notes revealed at 2145 "Pt returned from medical imaging. Pt is resting quietly in bed ... and denies needs at this time." Review of CT Stone Chase results revealed IMPRESSION: 1. Suspected grade 2 splenic laceration. Suggest clinical correlation with a history of recent fall. 2. The gastric lumen I markedly distended. This is coupled with mild proximal small bowel dilation. Partial small bowel obstruction versus ileus/gastroparesis, cannot be entirely excluded ..." Review of record revealed disposition set to "Transfer to Another Facility" at 2338. Review of vital signs at 0053 on 10/16/2018 revealed BP 127/98; Pulse 106 and pain score of 0 on 1-10 scale with 0 being no pain. Review revealed at 0255 patient was transferred out of the facility to Hospital B.

Review of ED Provider Notes on 10/16/2018 at 0213 revealed "History of Present Illness" revealed "Patient presents to the emergency department from long-term facility for evaluation of nausea, vomiting and diarrhea. Patient states he has had the symptoms for 1 day. History is limited due to patient's baseline dementia, though he does deny blood or yellow vomit. He denies any fevers, falls. [Sic] ... ED COURSE AND TREATMENT: Patient's condition remained stable during Emergency Department evaluation." Further review of ED Provider Notes at 2231 revealed "Discussed case with Surgeon #1 requests patient to higher level of care due to splenic laceration as he does not have trauma service ...CONDITION ON DISCHARGE: Stable ..."

Review of Hospital B medical record for Patient #3 revealed Chief Complaint Transferred from Hospital A for partial small bowel obstruction. History is taken from the son over the phone and also from the history of present illness note from ED ... He was evaluated by surgery who had initially accepted the patient and then in the ED recommended that patient be transferred to medical services. (Named hospitalist service) consulted for admission for partial small bowel obstruction and splenic laceration ....Assessment and Plan: Partial small bowel obstruction ... grade II splenic laceration, may be related to fall 1 month ago ...Surgery does not recommend any surgical intervention as it is conservative management only ..." Review revealed the patient was monitored during hospital stay with no surgery intervention needed and discharged back to long-term facility on 10/22/2018.



Interview with Resident #1 on 11/07/2018 at 1100 revealed he conducted the MSE on Patient #3. Interview revealed due to the CT scan findings the patient needed to be admitted so he consulted on-call surgery. Interview revealed he contacted Surgeon #1 and Surgeon #1 would not admit the patient and said to transfer the patient due to his splenic laceration.

Interview with Surgeon #1 on 11/07/2018 at 1330 revealed he suggested to transfer the patient due to the "possibility" of needing interventional radiology procedures which Hospital A does not have. Interview revealed he could perform a splenectomy but believes the care for Patient #3 was beyond the capabilities of the hospital. Interview revealed "a 96 year old patient should go to a trauma center." Interview revealed he would transfer out basic falls due to being traumatic in nature. Review of Surgeon #1 credentialing file revealed "Department: Surgery; Specialty: General Surgery Appointment Date 06/25/2018-06/24/2020." Review of approved delineation of privileges revealed "Abdomen Spleen- splenectomy (open and laparoscopic) and Abdomen: Spleen Splenorrhaphy."

Interview with Surgeon #2 on 11/07/2018 at 1555 revealed grade II splenic injuries are treated without surgical intervention unless the injury begins to actively bleed. Interview revealed if the spleen bleeds he would treat depending upon the severity of blood loss. Interview revealed he recently cared for a patient (Patient #23) with a grade II splenic injury and they managed the patient at Hospital A by monitoring the hemoglobin and hematocrit for signs of bleeding. Interview confirmed Hospital A has the capability to care for a patient with a grade II splenic laceration.

The facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department to include ancillary services (Surgeon #1 on call 10/5/2018) to determine whether or not an emergency medical condition existed for patient #3 when he presented to the ED on 10/15/2018.

2. Closed medical record review of Patient #8 revealed a 24 year old female gravida 2 (number of pregnancies); Para 1 (pregnancies carried beyond 20 weeks) who presented to Labor and Delivery on 10/23/2018 at 1205 with a complaint of a headache. Record review revealed Patient #8 was sent to Labor and Delivery from her OB (obstetrics) physician office for labs and monitoring to rule out pre-eclampsia (pregnancy complication characterized by high blood pressure and signs of damage to another organ system) due to worsened headache and scotoma (a break or interruption in visual field) in the right eye. Record review revealed patient denied leakage of fluids, vaginal bleeding, and contractions absent. Record review revealed orders placed by CNMW (certified nurse mid-wife) #1 at 1206 for vital signs, monitor fetal heart tones, external uterine contraction monitoring, notify physician- patient condition change, activity-bed rest with bathroom privileges, diet NPO (nothing by mouth), if non-reassuring FHR-consider fetal fibronectin test, cervical check. Record review revealed orders placed by CNMW#1 at 1209 for CBC (complete blood count) and differential, uric acid, comprehensive metabolic panel, protein urine, and creatinine urine. Record review revealed patient's vital signs obtained at 1216 were BP (blood pressure)-146/90, heart rate-70, temperature-98.1F (Fahrenheit) oral. Review of the pain score obtained at 1217 revealed "Pain Score: 1 (pt has a HA)." Record review revealed patient was placed on an external uterine contraction monitor at 1217 with a fetal heart rate baseline of 150. Record review revealed Fioricet one tablet ordered at 1225 by Patient #8's OB physician that sent her to Labor and Delivery for evaluation. Record review revealed Fioricet (Medication used to treat tension headaches) one tablet was administered by RN#2 at 1244. Review of the Nursing note dated 10/23/2018 at 1319 revealed "Named CNM called made aware of recent lab values and BP. Orders to continue to monitor pt, provider in a meeting will give further orders once meeting is over." Review of the nursing note dated 10/23/2018 at 1405 revealed "Named, CNM called back to unit with orders to call MD on call and update provider with pt info and follow MD orders from there." Review of the nursing note dated 10/23/2018 at 1408 revealed "Named Dr. called made aware of pt most recent BP and Lab values. Provider reviewed pt chart. Orders to d/c pt home. Keep next office apt." Review of the Progress Note dated 10/23/2018 at 1412 revealed "Reviewed patient's labs and BP's. Labs are stable from last week ...Patient rates headache 1/10 prior to medication and denies scotomata. Based on this, she has gestational hypertension. Pre-eclampsia (when a pt. has elevated blood pressure & Protein in the urine during pregnancy) precautions reviewed ..." Review of the nursing note dated 10/23/2018 at 1423 revealed "AVS d/c information given to pt. Instructed s/s of when to return to hospital. Pre-term labor precautions explained to pt. Routine undelivered instructions given to pt. Kick count explained. Instructed to keep next scheduled office apt ...Pt verbalizes understanding of AVS with no questions or concerns voiced." Record review revealed Patient #8 was discharged on 10/23/2018 at 1425.

Interview on 11/08/2018 at 1107 with RN#2 revealed she was the nurse that provided care for Patient #8 on 10/23/2018. Interview revealed the day Patient #8 came into Labor and Delivery, CNM #1 was in a meeting offsite at the clinic. Interview revealed MD #2 called the unit inquiring about another patient and RN#2 made her aware of Patient #8's status. Interview revealed RN #2 received a verbal order from MD #2 to discharge the patient home. Interview revealed it is standard process for the RN to "handle" non-labor complaints without the CNM or MD physically assessing the patient. Interview revealed RN #2 was unsure if the CNM or MD physically assessed Patient #8 on 10/23/2018.

Interview on 11/08/2018 at 1211 with MD #2 revealed she was the MD on call on 10/23/2018 when Patient #8 was sent to Labor and Delivery. Interview revealed she had seen Patient #8 in the clinic the week before and was familiar with her. Interview revealed after review of the chart she was unsure if the patient had been seen by herself or the CNM. Interview revealed the MD or CNM typically physically sees and assesses the patients.

Interview on 11/08/2018 at 1235 with CNM #1 revealed she was at a luncheon on the unit the day Patient #8 was sent to Labor and Delivery for evaluation. Interview revealed she did not physically see or assess Patient #8 that day. Interview revealed Patient #8 came from the clinic so she would have already been seen by a provider prior to arriving to the labor and delivery unit.

3. Closed medical record review of Patient #9, a 29 year old female, who presented to the facility's Labor and Delivery (L&D) unit on 11/06/2018 at 0331 after sustaining a fall while at work. Review revealed the patient's due date was 11/14/2018. Review revealed Nursing Note on 11/06/2018 at 0405 "MD #1 notified of patient's arrival, hx (history). Fhr (fetal heart rate) tracing with minimal variability and no accels, irregular contractions, and the patient fell at 0100 in the ER on her hands and knees and did not hit her belly. Received orders to hydrate with juice for NST and may discharge home once FHR is reactive." Review revealed no documentation or assessment by a QMP prior to patient discharge. Review revealed Patient #9 was discharged home at 0450.

Interview with MD #1 on 11/07/2018 at 1605 revealed he was on call on 11/05/2018 for 24 hours. Interview revealed he did not come see the patient. Interview revealed there was a midwife on call. Interview revealed he may or may not come in to see a patient depending upon the situation. Interview revealed he thought the midwife had evaluated the patient in L&D.

Interview with RN #1 on 11/07/2018 at 1615 revealed she cared for Patient #9 on 11/06/2018. Interview revealed Patient #9 was an employee in the hospital when the fall occurred. Interview revealed she was not experiencing any abdominal pain. Interview revealed the nurse midwife nor the physician came to see the patient. Interview revealed the patient was monitored and sent home as per physician order. Interview confirmed QMPs do not come in to evaluate all patients who present with non-labor complaints.

The facility failed to ensure that appropriate medical screening examinations were provided for Patient #8 and Patient #9 by Qualified medical personnel.

Based on policy review, medical record reviews, credentialing reviews, on-call schedules reviews, and staff interviews, the hospital's Dedicated Emergency Department (DED) staff failed to provide within the capabilities of the staff and facilities available at the hospital further medical examination and treatment as required to stabilize a patient's Emergency Medical Condition (EMC) for 1 of 18 sampled DED patients, (Patient # 3) who presented to the hospital for evaluation and treatment and transferred; and 2 of 5 DED obstetrical patients who presented to the hospital for evaluation and treatment and was discharged home (Patient #8 and Patient #9).

The findings include:

Review of hospital policy "Emergency Medical Treatment and Active Labor Act (EMTALA)", effective October 1, 2017 revealed "...D. Stabilization: 1. Any individual experiencing an emergency medical condition must be stabilized prior to transfer or discharge, except as set forth below. 2."Stabilization" is achieved when no medical deterioration is likely to result from the transfer or discharge of the individual..."

Review of hospital policy "Qualified Medical Professionals for EMTALA Screening", effective January, 2018 revealed "....III. All individuals presenting to the XYZ (Hospital A) dedicated emergency department (as defined by law) for examination or treatment shall be given an appropriate medical screening examination (MSE) by qualified medical personnel (QMP) to determine if an emergency medical condition exists. QMP include physicians, physician assistants, nurse practitioners, and midwives (for labor and delivery patients only). Additionally, a registered nurse (RN) may conduct the MSE, as long as the nurse is acting within the scope of his/her license...."

1. Closed medical record review revealed Patient #3, a 96 year old male, presented to the facility's DED on 10/15/2018 at 1912 with an arrival complaint of diarrhea, nausea and vomiting. Record review revealed at 1932 vital signs at triage were BP 137/66; Pulse 90; Respirations 17; Temperature 98.6 F. Record review revealed ED Notes at 1940 "Pt arrives in the ED via EMS (emergency medical services). Pt states "I can't keep my bowels from running." EMS reports hx (history) of dementia and states that the pt has had nausea, vomiting and diarrhea x 2 days with no relief. EMS gave 4mg Zofran in route ..." Review of ED notes revealed at 2013 "Pt taken to room 23 for diaper change per pt. But no bowel movement at this time." Review revealed MSE initiated at 2054 by Resident #1. Record review revealed at 2054 Lab Ordered: Lab Ordered: Urinalysis, Lactic Acid and Sepsis Screen, B-Type Natriuretic Peptide, Troponin Ghost Panel, Lipase, Comprehensive Metabolic Panel, CBC and Auto Differential. Also ordered was CT Stone Chaser (CAT scan to rule out kidney stone). Review of ED Notes revealed at 2111 "Pt gone to medical imaging at this time." Review revealed at 2144 Labs resulted with abnormal results: WBC 14.5 [ref range: 4.8-10.8]; Hemoglobin 11.7 [ref range: 14.0-18.0] and Hematocrit 38.4% [ref range: 42.0-52.0]. Review of ED Notes revealed at 2145 "Pt returned from medical imaging. Pt is resting quietly in bed ... and denies needs at this time." Review of CT Stone Chase results revealed IMPRESSION: 1. Suspected grade 2 splenic laceration. Suggest clinical correlation with a history of recent fall. 2. The gastric lumen I markedly distended. This is coupled with mild proximal small bowel dilation. Partial small bowel obstruction versus ileus/gastroparesis, cannot be entirely excluded ..." Review of record revealed disposition set to "Transfer to Another Facility" at 2338. Review of vital signs at 0053 on 10/16/2018 revealed BP 127/98; Pulse 106 and pain score of 0 on 1-10 scale with 0 being no pain. Review revealed at 0255 patient was transferred out of the facility to Hospital B.

Review of ED Provider Notes on 10/16/2018 at 0213 revealed "History of Present Illness" revealed "Patient presents to the emergency department from long-term facility for evaluation of nausea, vomiting and diarrhea. Patient states he has had the symptoms for 1 day. History is limited due to patient's baseline dementia, though he does deny blood or yellow vomit. He denies any fevers, falls. [Sic] ... ED COURSE AND TREATMENT: Patient's condition remained stable during Emergency Department evaluation." Further review of ED Provider Notes at 2231 revealed "Discussed case with Surgeon #1 requests patient to higher level of care due to splenic laceration as he does not have trauma service ...CONDITION ON DISCHARGE: Stable ..."

Review of Hospital B medical record for Patient #3 revealed Chief Complaint Transferred from Hospital A for partial small bowel obstruction. History is taken from the son over the phone and also from the history of present illness note from ED ... He was evaluated by surgery who had initially accepted the patient and then in the ED recommended that patient be transferred to medical services. (Named hospitalist service) consulted for admission for partial small bowel obstruction and splenic laceration ....Assessment and Plan: Partial small bowel obstruction ... grade II splenic laceration, may be related to fall 1 month ago ...Surgery does not recommends any surgical intervention as it is conservative management only ..." Review revealed the patient was monitored during hospital stay with no surgery intervention needed and discharged back to long-term facility on 10/22/2018.

Interview with Resident #1 on 11/07/2018 at 1100 revealed he conducted the MSE on Patient #3. Interview revealed due to the CT scan findings the patient needed to be admitted so he consulted on-call surgery. Interview revealed he contacted Surgeon #1 and Surgeon #1 would not admit the patient and said to transfer the patient due to splenic laceration.
Interview with Surgeon #1 on 11/07/2018 at 1330 revealed he suggested to transfer the patient due to the "possibility" of needing interventional radiology procedures which Hospital A does not have. Interview revealed he could perform a splenectomy but believes the care for Patient #3 was beyond the capabilities of the hospital. Interview revealed "a 96 year old patient should go to a trauma center." Interview revealed he would transfer out basic falls due to being traumatic in nature. A review of the facility's on-call schedule verified that Surgeon #1 was on call when patient #3 presented to the ED on 10/15/2018.

Review of Surgeon #1 credential file revealed "Department: Surgery; Specialty: General Surgery Appointment Date 06/25/2018-06/24/2020." Review of approved delineation of privileges revealed "Abdomen Spleen- splenectomy (open and laparoscopic) and Abdomen: Spleen Splenorrhaphy."

Interview with Surgeon #2 on 11/07/2018 at 1555 revealed grade II splenic injuries are treated without surgical intervention unless the injury begins to actively bleed. Interview revealed if the spleen bleeds he would treat depending upon the severity of blood loss. Interview revealed he recently cared for a patient (Patient #23) with a grade II splenic injury and they managed the patient at Hospital A by monitoring the hemoglobin and hematocrit for signs of bleeding. Interview confirmed Hospital A has the capability to care for a patient with a grade II splenic laceration.

The facility failed to ensure that stabilizing treatment was provided that was within the capability of the staff (on-call surgeon #1) and facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for patient #3 on 10/15/2018.

2. Closed medical record review of Patient #8 revealed a 24 year old female gravida 2 (number of pregnancies); Para 1 (pregnancies carried beyond 20 weeks) who presented to Labor and Delivery on 10/23/2018 at 1205 with a complaint of a headache. Record review revealed Patient #8 was sent to Labor and Delivery from her OB (obstetrics) physician office for labs and monitoring to rule out pre-eclampsia (pregnancy complication characterized by high blood pressure and signs of damage to another organ system) due to worsened headache and scotoma (a break or interruption in visual field) in the right eye. Record review revealed patient denied leakage of fluids, vaginal bleeding, and contractions absent. Record review revealed orders placed by CNMW (certified nurse mid-wife) #1 at 1206 for vital signs, monitor fetal heart tones, external uterine contraction monitoring, notify physician- patient condition change, activity-bed rest with bathroom privileges, diet NPO (nothing by mouth), if non-reassuring FHR-consider fetal fibronectin test, cervical check. Record review revealed orders placed by CNMW#1 at 1209 for CBC (complete blood count) and differential, uric acid, comprehensive metabolic panel, protein urine, and creatinine urine. Record review revealed patient's vital signs obtained at 1216 were BP (blood pressure)-146/90, heart rate-70, temperature-98.1F oral. Review of the pain score obtained at 1217 revealed "Pain Score: 1 (pt has a HA)." Record review revealed patient was placed on an external uterine contraction monitor at 1217 with a fetal heart rate baseline of 150. Record review revealed Fioricet one tablet ordered at 1225 by Patient #8's OB physician that sent her to Labor and Delivery for evaluation. Record review revealed Fioricet one tablet was administered by RN#2 at 1244. Review of the Nursing note dated 10/23/2018 at 1319 revealed "Named CNM called made aware of recent lab values and BP. Orders to continue to monitor pt, provider in a meeting will give further orders once meeting is over." Review of the nursing note dated 10/23/2018 at 1405 revealed "Named, CNM called back to unit with orders to call MD on call and update provider with pt info and follow MD orders from there." Review of the nursing note dated 10/23/2018 at 1408 revealed "Named Dr. called made aware of pt most recent BP and Lab values. Provider reviewed pt chart. Orders to d/c pt home. Keep next office apt." Review of the Progress Note dated 10/23/2018 at 1412 revealed "Reviewed patient's labs and BP's. Labs are stable from last week ...Patient rates headache 1/10 prior to medication and denies scotomata. Based on this, she has gestational hypertension. Pre-eclampsia precautions reviewed ..." Review of the nursing note dated 10/23/2018 at 1423 revealed "AVS d/c information given to pt. Instructed s/s of when to return to hospital. Pre-term labor precautions explained to pt. Routine undelivered instructions given to pt. Kick count explained. Instructed to keep next scheduled office apt ...Pt verbalizes understanding of AVS with no questions or concerns voiced." Record review revealed Patient #8 was discharged on 10/23/2018 at 1425.

Interview on 11/08/2018 at 1107 with RN#2 revealed she was the nurse that provided care for Patient #8 on 10/23/2018. Interview revealed the day Patient #8 came into Labor and Delivery, CNM #1 was in a meeting offsite at the clinic. Interview revealed MD #2 called the unit inquiring about another patient and RN#2 made her aware of Patient #8's status. Interview revealed RN #2 received a verbal order from MD #2 to discharge the patient home. Interview revealed it is standard process for the RN to "handle" non-labor complaints without the CNM or MD physically assessing the patient. Interview revealed RN #2 was unsure if the CNM or MD physically assessed Patient #8 on 10/23/2018.

Interview on 11/08/2018 at 1211 with MD #2 revealed she was the MD on call on 10/23/2018 when Patient #8 was sent to Labor and Delivery. Interview revealed she had seen Patient #8 in the clinic the week before and was familiar with her. Interview revealed after review of the chart she was unsure if the patient had been seen by herself or the CNM. Interview revealed the MD or CNM typically physically see and assess the patients.

Interview on 11/08/2018 at 1235 with CNM #1 revealed she was at a luncheon on the unit the day Patient #8 was sent to Labor and Delivery for evaluation. Interview revealed she did not physically see or assess Patient #8 that day. Interview revealed Patient #8 came from the clinic so she would have already been seen by a provider prior to arriving to the labor and delivery unit.

3. Closed medical record review of Patient #9, a 29 year old female, who presented to the facility's Labor and Delivery (L&D) unit on 11/06/2018 at 0331 after sustaining a fall while at work. Review revealed the patient's due date was 11/14/2018. Review revealed Nursing Note on 11/06/2018 at 405 "MD #1 notified of patient's arrival, hx. Fhr tracing with minimal variability and no accels, irregular contractions, and the patient fell at 0100 in the ER on her hands and knees and did not hit her belly. Received orders to hydrate with juice for NST and may discharge home once FHR is reactive." Review revealed no documentation or assessment by QMP prior to patient discharge. Review revealed Patient #9 was discharged home at 0450.

Interview with MD #1 on 11/07/2018 at 1605 revealed he was on call on 11/05/2018 for 24 hours. Interview revealed he did not come see the patient. Interview revealed there was a midwife on call. Interview revealed he may or may not come in to see a patient depending upon the situation. Interview revealed he thought the midwife had evaluated the patient in L&D.

Interview with RN #1 on 11/07/2018 at 1615 revealed she cared for Patient #9 on 11/06/2018. Interview revealed Patient #9 was an employee in the hospital when the fall occurred. Interview revealed she was not experiencing any abdominal pain. Interview revealed the nurse midwife nor the physician came to see the patient. Interview revealed the patient was monitored and sent home as per physician order. Interview confirmed QMPs do not come in to evaluate all patients who present with non-labor complaints.


The facility failed to ensure that their policy was followed as evidenced by failing to provide stabilizing treatment as required prior to discharging Patient #8 , and Patient 9 , who were experiencing emergency medical conditions.

Based on medical record reviews and staff interviews, the hospital's Dedicated Emergency Department (DED) failed to ensure an appropriate transfer by not providing further care and treatment within the capability and capacity of the hospital for 1of 6 sampled DED patients that were transferred with an emergency medical condition (Patient #3).
The findings include:

Closed medical record review revealed Patient #3, a 96 year old male, presented to the facility's DED on 10/15/2018 at 1912 with an arrival complaint of diarrhea, nausea and vomiting. Record review revealed at 1932 vital signs at triage were BP 137/66; Pulse 90; Respirations 17; Temperature 98.6 F. Record review revealed ED Notes at 1940 "Pt arrives in the ED via EMS (emergency medical services). Pt states "I can't keep my bowels from running." EMS reports hx (history) of dementia and states that the pt has had nausea, vomiting and diarrhea x 2 days with no relief. EMS gave 4mg Zofran in route ..." Review of ED notes revealed at 2013 "Pt taken to room 23 for diaper change per pt. But no bowel movement at this time." Review revealed MSE initiated at 2054 by Resident #1. Record review revealed at 2054 Lab Ordered: Urinalysis, Lactic Acid and Sepsis Screen, B-Type Natriuretic Peptide, Troponin Ghost Panel, Lipase, Comprehensive Metabolic Panel, CBC and Auto Differential. Also ordered was CT Stone Chaser (CAT scan to rule out kidney stone). Review of ED Notes revealed at 2111 "Pt gone to medical imaging at this time." Review revealed at 2144 Labs resulted with abnormal results: WBC 14.5 [ref range: 4.8-10.8]; Hemoglobin 11.7 [ref range: 14.0-18.0] and Hematocrit 38.4% [ref range: 42.0-52.0]. Review of ED Notes revealed at 2145 "Pt returned from medical imaging. Pt is resting quietly in bed ... and denies needs at this time." Review of CT Stone Chase results revealed IMPRESSION: 1. Suspected grade 2 splenic laceration. Suggest clinical correlation with a history of recent fall. 2. The gastric lumen I markedly distended. This is coupled with mild proximal small bowel dilation. Partial small bowel obstruction versus ileus/gastroparesis, cannot be entirely excluded ..." Review of record revealed disposition set to "Transfer to Another Facility" at 2338. Review of vital signs at 0053 on 10/16/2018 revealed BP 127/98; Pulse 106 and pain score of 0 on 1-10 scale with 0 being no pain. Review revealed at 0255 patient was transferred out of the facility to Hospital B.

Review of ED Provider Notes on 10/16/2018 at 0213 revealed "History of Present Illness" revealed "Patient presents to the emergency department from long-term facility for evaluation of nausea, vomiting and diarrhea. Patient states he has had the symptoms for 1 day. History is limited due to patient's baseline dementia, though he does deny blood or yellow vomit. He denies any fevers, falls. [Sic] ... ED COURSE AND TREATMENT: Patient's condition remained stable during Emergency Department evaluation." Further review of ED Provider Notes at 2231 revealed "Discussed case with Surgeon #1 requests patient to higher level of care due to splenic laceration as he does not have trauma service ...CONDITION ON DISCHARGE: Stable ..."

Review of Hospital B medical record for Patient #3 revealed Chief Complaint Transferred from Hospital A for partial small bowel obstruction. History is taken from the son over the phone and also from the history of present illness note from ED ... He was evaluated by surgery who had initially accepted the patient and then in the ED recommended that patient be transferred to medical services. (Named hospitalist service) consulted for admission for partial small bowel obstruction and splenic laceration ....Assessment and Plan: Partial small bowel obstruction ... grade II splenic laceration, may be related to fall 1 month ago ...Surgery does not recommends any surgical intervention as it is conservative management only ..." Review revealed the patient was monitored during hospital stay with no surgery intervention needed and discharged back to long-term facility on 10/22/2018.

Interview with Resident #1 on 11/07/2018 at 1100 revealed he conducted the MSE on Patient #3. Interview revealed due to the CT scan findings the patient needed to be admitted so he consulted on-call surgery. Interview revealed he contacted Surgeon #1 and Surgeon #1 would not admit the patient and said to transfer the patient due to splenic laceration.

Interview with Surgeon #1 on 11/07/2018 at 1330 revealed he suggested to transfer the patient due to the "possibility" of needing interventional radiology procedures which Hospital A does not have. Interview revealed he could perform a splenectomy but believes the care for Patient #3 was beyond the capabilities of the hospital. Interview revealed "a 96 year old patient should go to a trauma center." Interview revealed he would transfer out basic falls due to being traumatic in nature.

Review of Surgeon #1 credential file revealed "Department: Surgery; Specialty: General Surgery Appointment Date 06/25/2018-06/24/2020." Review of approved delineation of privileges revealed "Abdomen Spleen- splenectomy (open and laparoscopic) and Abdomen: Spleen Splenorrhaphy."

Interview with Surgeon #2 on 11/07/2018 at 1555 revealed grade II splenic injuries are treated without surgical intervention unless the injury begins to actively bleed. Interview revealed if the spleen bleeds he would treat depending upon the severity of blood loss. Interview revealed he recently cared for a patient (Patient #23) with a grade II splenic injury and they managed the patient at Hospital A by monitoring the hemoglobin and hematocrit for signs of bleeding. Interview confirmed Hospital A has the capability to care for a patient with a grade II splenic laceration.

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