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Based on review of hospital policies and procedures, medical records, and interviews with hospital staff, the hospital failed to enforce its policies and procedures to comply with the requirements of 42 CFR 489.24 to provide an appropriate transfer for Patient #3 who had an emergency medical condition (EMC).

Findings:
1. On 09/13/2011, Patient #3 presented to the ER with complaints of upper and lower abdominal pain since 13:00 P.M. and rated pain at 8 out of 10. The physician ordered tests which included a computerized tomography (CT). The CT report showed "tubular structure within the right upper quadrant swollen suspicious for an appendicitis. Dilated CBD, measuring 1.0 cm in AP dimension." He documented "IHS (Indian Health Services) contacted." However, when the physician was interviewed during the survey, he stated that he could not remember contacting IHS and thought that he couldn't reach them. The physician wrote under "Patient d/c counseling/f/u" section of the note "will f/u with IHS this a.m. for referral to surgeon for eval. (evaluation)." The patient was discharged at 04:50 P.M. on 09/14/2011 with written discharge instructions to "1. Follow up this a.m. at 0730 Lawton IHS in walk-in to see surgeon. 2. Return if worse prior to appt (appointment) this a.m. 3. No eating or drinking this a.m." When the physician was questioned about the 7:30 AM appointment at Lawton IHS, he responded that "they need to go early, if no appointment, so they can be seen."

2. The hospital did not follow its policy that requires patients with an EMC to be transferred appropriately after the hospital had obtained acceptance from the receiving hospital. Patient #3 had a possible appendicitis which would need a surgical intervention. The hospital physician discharged the patient with instructions to go to Lawton IHS at 07:30 A.M..

Based on review of hospital policies and procedures, medical records, and interviews with hospital staff, the hospital failed to provide an appropriate transfer for one (Patient #3) of six patients who had an emergency medical condition (EMC).

1. On 09/13/2011, Patient #3 presented to the ER with complaints of upper and lower abdominal pain since 13:00 P.M. and rated pain at 8 out of 10. The physician ordered tests which included a computerized tomography (CT). The CT report showed "tubular structure within the right upper quadrant swollen suspicious for an appendicitis. Dilated CBD, measuring 1.0 cm in AP dimension." He documented "IHS (Indian Health Services) contacted." However, when the physician was interviewed during the survey, he stated that he could not remember contacting IHS and thought that he couldn't reach them. The physician wrote under "Patient d/c counseling/f/u" section of the note "will f/u with IHS this a.m. for referral to surgeon for eval. (evaluation)." The patient was discharged at 04:50 P.M. on 09/14/2011 with written discharge instructions to "1. Follow up this a.m. at 0730 Lawton IHS in walk-in to see surgeon. 2. Return if worse prior to appt (appointment) this a.m. 3. No eating or drinking this a.m." When the physician was questioned about the 7:30 AM appointment at Lawton IHS, he responded that "they need to go early, if no appointment, so they can be seen."

2. When interviewed on 10/17/11 at 16:55 P.M., the physician said he did not think the patient had appendicitis. He stated the patient presented with a "benign" abdomen, not a surgical/acute abdomen. The physician stated the patient had a "soft belly" and no rebound. He stated what he wanted to do was to have the patient follow-up in the clinic (IHS) and have further evaluation to see if she needed to be seen by a surgeon. He could not remember contacting IHS - thought he couldn't reach them. The physician stated he felt the CT report was "iffy" with the right upper quadrant notation and mention of common bile duct dilation.

3. At the time of discharge, Patient #3 was not stable. The CT scan of Patient #3's abdomen and pelvis showed an enlarged appendix. To discharge a patient with this status posed an Immediate Jeopardy to the patient's health and safety as the potential for the rupture of the appendix was high if surgical intervention was not provided.

4. Patient #3 was seen at the ED of Lawton IHS at 07:58 AM on 09/14/2011 and underwent an emergency appendectomy.

5. This hospital failed to effect an appropriate transfer in that it did not contact the Lawton IHS to ensure it has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment.

6. This hospital failed to send to Lawton IHS all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent.

7. This hospital failed to inform the patient of the risks and benefits of the transfer.