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Based on record review and interview the hospital failed to ensure compliance with EMTALA requirements of ?489.24 by:

1.) failing to provide the required stabilizing medical treatment after identifying an emergency medical condition for 2 of 25 sampled patients (#3, #25) by transferring the patients to another hospital for surgical treatment when the hospital had the capability and capacity to provide the treatment as evidenced by having a general surgeon on-call (S7, MD, Gen Surgery). (see findings at A2407)

2.) failing to ensure the hospital ED maintained a current and accurate list of physicians on call for duty in the Emergency Room which resulted in the inappropriate transfer of 1 of 25 sampled patients. (#25) (see findings at A2404)

Based on record review and interview the hospital failed to 1) ensure it maintained a current and accurate list of physicians on call for duty by failing to have an accurate on call list posted in the Emergency Room resulting in the inappropriate transfer of 1 of 25 sampled patients. (#25) and 2) ensure that all staff understood how to properly use the on call list by listing a physician's name on the on call sheet in a manner that confused staff.

1)

Patient #25

Review of the documentation by S6MD under Consultation & Critical Thinking" dated/timed 12/20/09 at 10:48 a.m. revealed "Time of consult: 10:48. First call placed to consultant at:10:48. Case discussed with Dr. *NOT ON, STAFF. Discussed with ER doctor (name of ER MD at hospital "b"). Accepts patient in transfer."

Review of the "Clinical Impression" documented by S6MD at 10:48 a.m. on 12/20/09 reads: "1. Abdominal Pain, Right Lower Quadrant."

Review of the "Disposition" documented by S6MD at 10:49 a.m. on 12/20/09 reads: "Patient (#25) will be transferred to (hospital "b"). Transfer forms complete. Condition: stable. Certified Med (medical) Emerg (emergency): Patient's condition was emergent."

Review of the Hospital Transfer Log revealed a form titled "Transfer Cases." Review of these forms revealed a document dated/timed 12/20/09 at 1100 (11:00 a.m.) with the name of patient #25 listed as the patient. Further review of this document revealed: "1. Is it a life or limb injury? Yes is circled. 2. Reason for transfer: Appendicitis. "No" and "availability" are noted to be circled. Can the the on-call MD treat the patient? is documented as "no" and handwritten next to this is "No surgery on call?"

Review of the Women's and Children's Hospital On-Call list for 12/20/09 revealed S7MD, General Surgery, was on call for the ER on 12/20/09.

In an interview on 04/07/10 at 12:00 noon with S10RN she confirmed that she was the triage nurse on 12/20/10. S10RN stated that she believed the handwriting on the "Transfer Cases" form was written by S11RN, House Supervisor. S10RN reviewed the on-call lists for 12/20/09 and confirmed that S7MD was on call for the ER. S10RN further stated that this was not an appropriate transfer because Women's and Children's Hospital had a General Surgeon, S7MD, on call.

In a telephone interview on 04/07/10 at 12:50 p.m. with S2DON (who is identified as the Administrator On Call (AOC) for 12/20/10) she stated that she does not take an on-call list with her when she is the AOC. S2DON further indicated that she relies on the House Supervisor to advise her whether or not a specialist is on call when she approves or disapproves a transfer in or out of the hospital. S2DON further indicated that she "would expect that the ER nurses and House Supervisor would be aware of who is on call."

In an interview on 04/07/10 at 11:05 a.m. with S3RN, Chief Quality Officer, she reviewed the chart of patient #25. S3RN reviewed the on-call list for December 2009 and confirmed that S7MD was on call on 12/20/09. S3RN, Chief Quality Officer, was asked to review the "reason for transfer." S3RN replied "on no" and confirmed that the hospital did have the capability to care for patient #25. S3RN, Chief Quality Officer, was asked by the surveyor if she takes an on-call list home with her during her AOC duties and she responded "no."

In an interview on 04/07/10 at 1:10 p.m. with S5RN, ER Director, he was asked to review the medical record of patient #25. After reviewing the chart and on-call list S5RN, ER Director, stated that the transfer of patient #25 was an "inappropriate transfer."

In an interview on 04/07/10 at 1:20 p.m. with S11RN, House Supervisor on 12/20/09, she stated that it was her handwriting on the "Transfer Cases" form. S11RN indicated that the reason for transfer of patient #25 was for "surgical eval." S11RN stated she calls the AOC to notify them of the transfer and get approval. S11RN further indicated that the AOC will usually ask if the needed service is on call. S11RN reviewed the 12/20/09 on-call list and confirmed that S7MD was on call for the ER on 12/20/09.

In the same interview S11RN, House Supervisor on 12/20/09 stated that "the wrong list was up on 12/20/09." S11RN stated that a "couple of hours" after the transfer of patient #25 that S6MD called her and told her the on-call list for 12/19/09 was still posted in the ER. S11RN could not recall what time this occurred but stated that it was during the same shift on 12/20/09. S11RN stated she did not fill out an incident report but that she had verbally reported the incident to her supervisor. S11RN further stated "there is no written documentation of the hospital having knowledge of the mistake at all." S11RN was asked by the surveyor if she notified the AOC of the mis-information given to her regarding the on-call list. S11RN stated she "is unaware if she notified the AOC of the mistake."

In a telephone interview on 04/07/09 at 1:48 p.m. with S6MD he stated that he did not remember any of the events of 12/20/09 including calling S11RN to report the error with the on-call list.

In an interview on 04/07/09 at 2:15 p.m. with S8MD, Co-ER Medical Director, he was asked to review the chart and transfer information of patient #25. S8MD stated that S7MD was on call and this was an inappropriate transfer as the hospital had the capability to treat the patient. S8MD further indicated that he would expect the ERMD to follow hospital Policies and Procedures as well as the Medical Staff By- Laws governing EMTALA.

Review of a hospital policy titled "EMTALA - Provision of On Call Coverage", reference number: 780-3.5, effective 01/99, last revised 04/09, presented as current hospital policy reads in part; "Purpose: To ensure that the Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide necessary treatment to stabilize individuals with emergency medical conditions. Procedure: 1. Women's and Children's Hospital has a documented system for providing on call coverage, so that the emergency department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide screening and treatment necessary to stabilize individuals with emergency medical conditions...

Review of a hospital policy titled "EMTALA - Transfer", reference number 780-3.6, effective 01/99, last revised 04/09, presented as current hospital policy reads in part: "Procedure. 2. If a patient that comes to the hospital and has an emergency medical condition, the hospital will provide either: a. further medical examination and treatment, including hospitalization, if necessary, as required to stabilize the medical condition within the capabilities of the staff and facilities available....

Review of a hospital policy titled "Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions", reference number: 900-1.31, effective 10/01. last reviewed 09/08, presented as current hospital policy reads in part: "1.0 Purpose. This policy is designed to provide professional nursing staff, medical staff, ancillary department staff and hospital credentialed Licensed Independent Practitioners (LIP) with appropriate direction for the prompt handling of patient's who may or may not have an Emergency Medical Condition. 2.0 Policy....2.5. If it is determined that the individual has an Emergency Medical Condition, to provide the individual with further medical examination and treatment as required to stabilize the Emergency Medical Condition within the Capability of the Hospital......4.10 Capabilities: that there are physical space, equipment, supplies, and specialized services that the hospital provides (e.g., surgery, psychiatry, obstetrics......) and refers to the level of care that hospital personnel can provide within the training and scope pf their professional licenses, including coverage available through the hospital's on-call roster."

Review of the Medical Staff By-Laws, signed by the CEO 10/21/09, section 6.2 Consultations, Referrals and Emergency Department Call 6.2(a) reads in part: "When the Emergency Department Physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Physician is needed, the patient shall be permitted to request the services of a specific private physician.....in the event the patient does not have a private physician......the rotation call list should be used...."

2)

Review of the Emergency Room on-call lists from October 2009 through April 2010 revealed the General Surgery On-Call schedule listed S7MD by his last name on the 7 days of on-call as required by the Medical Staff By-Laws.

As there was only one other General Surgeon covering his 7 mandatory days the hospital was without coverage for approximately half of each month.

Review of a contract dated 03/23/09 between Women's and Children's Hospital and S7MD titled "Excess On-Call Coverage Agreement Face Sheet" revealed a contract between the two listed parties for S7MD to be monetarily compensated for taking On-Call days above the 7 as mandated by the Medical Staff By-Laws.

In an interview on 04/06/10 at 10:00 a.m. with S4, Medical Staff Coordinator, she indicated that the two on staff General Surgeons give her the dates of the coverage they will provide the hospital under the Medical Staff By-Laws. After these days are entered she places "X(S7MD)" on every remaining day unless S7MD has specifically notified her he will be unavailable. S4, Medical Staff Coordinator, stated that she has never seen the contract between the hospital and S7MD.

In an interview on 04/06/10 at 10:17 a.m. with S6MD, ER, he stated that if the on-call list indicates "X(S7MD)" it means if the patient is not S7's patient then there is "no on call surgeon."

In an interview on 04/06/10 at 10:00 a.m. with S3RN, Chief Quality Officer, she stated that "(S7MD) takes (by contract - for monetary compensation) extra call for the hospital." She further stated that "nursing or the ER MD call S7MD on "X(S7MD)" days and tell S7MD about the patient they have and he (S7MD) decides whether or not to take patient." S3RN further indicated that "sometimes the ER MD or ER nurses know if a patient is not (S7MD's) patient and they just don't call him."

In an interview on 04/06/10 at 2:30 p.m. with S6MD he was asked what was the difference between "S7MD" being on the call list vs. "X(S7MD)" being on the call list. S6 MD replied "I don't really know after I spoke to you this a.m."

In an interview on 04/06/10 at 10:18 a.m. with S5RN, ER Director, he indicated that the "X(S7MD)" means that S7MD is in town. S5RN was asked by this surveyor who decides to call or not call S7MD. S5RN stated that S7MD would be on call for all patients.

In an interview on 04/05/10 at 2:03 p.m. with S9MD, Co-ER Medical Director, he stated that the intention is that for the normal (Med Staff mandated) 7 days S7MD is on-call for all patients in the ER. He further indicated that on the "other" days he "is available." S9MD stated that the "X(S7MD)" days are not mandatory call days and that S7MD "can refuse" patients. S9MD was asked by this surveyor where this information was obtained, since he is the Co-Medical Director. S9MD stated that it was "word of mouth" of optional acceptance/refusal. S9MD stated that he believed he was given this information through either the Administrator or S5RN, ER Director.

In the same interview S9MD reviewed the Hospital Policy and Procedure for On-Call Physicians and the Medical Staff By-Laws covering on-call physicians. He then stated that the physician on the on-call list is obligated to see all patients the ER physician requests him to see.

In an interview on 04/06/10 at 10:50 a.m. with S8MD, Co-ER Medical Director, he stated that S7MD is paid by the hospital to take extra call days. He further indicated that there is no "selectivity." S8MD indicated that patients "should not be selectively transferred/accepted on "X" days. In a continuation of the interview on 04/06/10 at 11:12 a.m. S8MD stated that if a physician is on the on-call list then he is available, period. He further stated that Administration should have notified the ER Medical Director(s) if any changes were made by Administration. S8MD further stated that "if the MD is being paid then it does not change his on-call obligation."

In an interview on 04/06/10 at 1:30 with S1Administrator he confirmed that there was a contract with S7MD to provide additional coverage beyond the 7 days required by the Medical Staff By-Laws. S1 further indicated that the reason was due to too many openings in the call schedule for specialists. S1 was asked what was the difference between "X(S7MD)" and (S7MD) call days. The Administrator indicated the expectation was no difference. He further indicated that the on call physician cannot choose patients. S1Administrator stated he became aware of possible confusion regarding the meaning of the "X" this a.m. when the surveyor's received different definitions of what staff thought it meant. S1Administrator stated that he had instructed S3RN, Chief Quality Officer, to "take care of this misperception."

In an interview on 04/06/10 at 2:50 p.m. with S7MD, General Surgery, he stated that he treats all on call days the same. S7MD stated that he has never refused to come and see any patient that the ER MD requested him to see, whether he was or was not on call.

Based on record reviews and interviews, the hospital failed to provide further medical treatment after identifying an emergency medical condition for 2 of 14 focused sampled record reviews out of a total of 25 sampled patients (#3, #25) by transferring 2 patient's to another hospital for surgical evaluations when there was a general surgeon on-call (S7, MD, Gen Surgery) to provide the services needed. Findings:

Patient #3:
Review of the medical record for patient #3 revealed she was a 32 year old female with a past medical history of Post Partum three (3) weeks ago per Caesarian Section, (C-Section). Patient #3 had no known medications. Patient #3 had an allergy to Phenergan according to her medical record.
Review of the "Initial Assessment Form" dated 3/28/10 revealed patient #3 presented to the Emergency Room (ER) at 7:09 p.m. (19:09). Chief Complaint documented was "Abdominal Pain-Epigastric <55 (less than 55) years of age by the triage nurse. Under "Brief Assessment" section, the nurse documented, "Epigastric pain onset yesterday, S/P (status post) Lap (Laparoscopic) Band 2006 per (physician ' s name) in Houston, Post Partum 3 weeks ago per C-Section, Eating Worsens Pain." Initial vital signs: T (temperature) 97.7 PO (oral), P (pulse) 101, R (respiratory rate) 20, Pain intensity 10/10. Patient #3 was assigned a triage Priority of 3 - Urgent.

Further review of the Nursing Assessment documented by S13RN on 3/28/10 at 7:48 p.m. (19:48) revealed, "Patient assigned to room 6. Patient moved to room at 7:20 p.m. " ...Gastrointestinal: ....Abdomen appears distended, with multiple scars. Palpation of the abdomen elicits tenderness, epigastric. Bowel sounds are hyperactive. Patient rates pain as 10 on a one-to-ten scale with ten as the worst pain ever. Patient complains of nausea. Last bowel movement this morning. Patient describes vomited 1 - 3 times a day. Under "Reassessment" dated/timed 3/28/10 at 21:04 (9:04 p.m.) S14RN documented "...patient was transported to Radiology at 3/28/10 21:04 (9:04 p.m.), for CT Scan... " Reassessment dated/timed 3/28/10 22:42 (10:42 p.m.) by S13RN read, " ... Time: The patient was reassessed at 21:00 (9:00 p.m.) S13RN, Gastrointestinal: Abdomen appears normal, flat and without scars. Bowel sounds hypoactive. Patient rates current pain at a 6 on 1-10 scale with 10 as the worst pain ever. Patient localizes pain to generalized abdomen ...."

Review of the physician's documentation (S6MD, ER) dated/timed 3/28/10 at 7:10 p.m. (19:10) revealed the following: "Chief Complaint/History of Present Illness:....(patient #3) is a 32 year old F (female) that presented to the Emergency Department at 19:09 (7:09 p.m.) by AMB (ambulatory) - POV (privately owned vehicle). The patient was triaged at 19:09 with the following vital signs: T: 97.7 PO, P: 101 regular, R 20 unlabored, BP: 110/056, SPO2 (oxygen saturation) 99 (%), Amt: RA (room air), Pain: 10 abdomen.....Chief Complaint - Abd pain (abdominal pain) -Epigastric < (less than) 55 yrs (years) of age...History obtained from : patient, ...Onset of symptoms was 1 day(s) ago. Symptoms came on suddenly. Symptoms are present and increased from onset. Symptoms located in the abdomen but are generalized, without localization. Patient describes quality of symptoms as sharp, stabbing. Patient states symptoms are of moderate intensity...Patient has undergone recent abdominal surgery. Symptoms exacerbated by movement. Symptoms relieved by nothing. Associated signs and symptoms:...positive decreased appetite. Patient relates sudden onset of abdominal pain this AM (morning) with walking."

Review the documentation under, "Review of Systems" dated/timed 3/28/10 at 19:30 (7:30 p.m.) by S6MD read, "...Gastrointestinal: negative constipation, negative diarrhea, negative vomiting, negative nausea, positive abdominal Pain...All (other) systems have been reviewed and are negative..."

Review of the "Physical Examination" documented by S6MD dated/timed 3/28/10 at 19:33 (7:33 p.m.) revealed the following: "...General:..Patient in mild distress. Patient appears mildly anxious. Disheveled...Respiratory: No respiratory distress. Lungs clear with equal breath sounds bilaterally...Abdomen: Appearance: obese. Bowel sounds are normoactive. Moderate tenderness to palpation in epigastrum. Mild diffuse tenderness without localization Voluntary guarding, generalized. No masses are palpable. There is no organomegaly. Rebound tenderness is absent. Abdomen is normal to percussion..."

Review of the physician's orders entered at 7:28 p.m. (19:28) on 3/28/10 revealed the following orders were entered into the computer for patient #3: IV Zofran 8 mg (milligrams), IV Demoral 25 mg, and an IV (intravenous) insertion. At 7:29 p.m. (19:29) a CT (computerized tomography) Scan Abdomen and Pelvis w (with) contrast (fluid taken orally to assist visualization of the gastrointestinal tract during the CT scan), CMP (comprehensive metabolic panel), CBC (complete blood count), Urinalysis, Urine Preg (urine pregnancy test), and Normal Saline (fluids) 150 ml/hr (milliliters per hour - intravenously).

Review of the documentation by S13RN revealed patient #3 had the IV started on 3/28/10 at 7:30 p.m. and the fluids were started at 7:35 p.m.. Further review revealed S13RN administered IV Zofran 8mg 1st push given over 2 -5 minutes initiated on 3/28/10 19:43 (7:43 p.m.) and IV Demoral 25mg 2nd push, given over 2 - 5 minutes initiated at 3/28/10 19:47 (7:47 p.m.) with no documentation of when the 1st IV push of Demoral 25 mg was initiated by S13RN.

Review of the "Diagnostic Test Results" dated/timed 3/28/2010 at 10:16 p.m. (22:16) by S6 MD read, "Radiology: Computerized Tomography Scan: Abdomen/Pelvis - 1. Dilated small bowel and cecum. Partial colon obstruction. Laboratory: Abnormal laboratory results: WBC (white blood count) 14.3, Urinary Blood 150, Urinary LE 25."

Review of the laboratory reports revealed the reference (normal) range for the WBC is 4.6 - 10.2 K/UL (thousand per microliter), Urinary Blood reference (normal) range is negative (none), and Urinary LE (leukocyte esterase) reference (normal) range is negative (none).

Review of the documentation by S6MD under "Consultation & Critical Thinking" dated/timed 3/28/10 at 10:18 p.m. (22:18) revealed "Time of consult 22:18. First call placed to this practitioner/service was at 22:18. Case discussed with ER doctor (name of ER MD at hospital "b")... agrees to accept patient in transfer."

Review of the "Clinical Impression" documented by S6MD at 10:17 p.m. (22:17) on 3/28/10 read, "1. Small Bowel Obstruction, 2. Acute Abdominal Pain."

Under the "Disposition" section on 3/28/10 and timed 10:18 p.m., S6MD documented "Patient (#3) will be transferred to (hospital "b"). Transfer forms complete. Condition: stable. Certified Med (medical) Emerg (emergency): Patient's condition was emergent."

Review of the Patient Transfer Form on 3/29/10 at 0000 (12:00 am) documented by S6MD, Section B, read, the Physician (S6) initiated the transfer. Section C, titled, "Additional Physician Documentation To Be Completed For Transfers From The Emergency Room Only" read, "...The patient presented to the Hospital requesting emergency medical treatment and the Hospital has provided a medical screening examination and stabilization services to the extent possible, given the Hospital's current capacity and/or capabilities. Transfer of the patient to a hospital with additional capacity and/or capabilities is medically indicated, or has been requested by the patient or the patient's legal guardian...". The reason for transfer section was left blank by S6MD. The "Physician Certification" section for the Expected Benefits and Specific Risks of the Transfer was left blank. S6MD signed as the "Transferring Physician/Qualified Medical Personnel. The "Physician Countersignature" line was left blank. There was no documented evidence S7MD, Gen Surgery was consulted prior to the patient's transfer to hospital "b".

Further review of the documentation by S13RN for patient #3 read, "...Transfer: Patient left the department at 3/29/10 00:24 (12:24 a.m.). Transferred disposition: TRANS -(hospital " b " ). *S6MD arranged transfer...Transfer was initiated for: HIGHER LEVEL OF CARE... V/S (vital signs) taken at 00:26 (12:26 a.m.) were: 100 (T), 64 and is regular (P), 20 and unlabored (R), 112/051 (BP), 99% (SP02), pain level is 3 on a 1-10 scale in the abdomen. "

The Physician's On-Call List for 3/28/10 was reviewed. S7MD, Gen Surgery was the surgeon on-call for the emergency department.

Review of the ICU census for 3/28/10 revealed there was a bed available.

Further review of Patient #3's medical record revealed there was no documented evidence S7MD, Gen Surgery was called and/or consulted by S6MD or the emergency room staff during #3's emergency room visit from 3/28/10 at 19:09 through 3/29/10 at 00:24.

An interview was conducted with S8MD, Co-ER Medical Director on 4/6/10 from 10:50 a.m. to 11:25 a.m.. He reviewed Patient #3's medical record. He reviewed the physician's on-call list for 3/28/10. He reported S7MD, Gen Surgery was the surgeon on-call for the emergency room on 3/28/10. He verified there was no documented evidence in the record S6MD consulted S7MD, Gen Surgery on 3/28/10 prior to the patient's transfer to another facility for a higher level of care. He indicated S6MD should had consulted with S7MD, Gen Surgery prior to transferring the patient to another facility.

In an interview with S1, Administrator on 4/6/10 from 1:30 p.m. to 1:45 p.m., he indicated Patient #'3 was transferred to another facility for a higher level of care. He reviewed the On-Call List on 3/28/10. He confirmed S7MD, Gen Surgery was the surgeon on-call for the emergency room. He stated the hospital had an adult ICU bed available. He indicated Patient #3 should had been admitted into the hospital. He further indicated #3 should not had been transferred because the hospital had both a Surgeon (S7) on-call and an adult ICU bed available.

S7MD, Gen Surgery was interviewed on 4/6/10 from 1:45 p.m. to 2:00 p.m.. He reviewed Patient #3's medical record. He indicated the patient had a small bowel obstruction. He confirmed he was the surgeon on-call for the emergency room on 3/28/10. He did not recall the patient. He verified there was no documented evidence in the record S6MD consulted him prior to the transferring the patient to another facility. He indicated he should had been consulted by S6MD on 3/28/10 before the patient was transferred to another facility. He continued the patient could had been admitted and provided care at the hospital. He denied knowledge why S6MD transferred Patient #3 for a higher level of care when there was a surgeon and an ICU bed available to treat the patient's condition.

In an interview with S9MD, Co-ER Medical Director on 4/6/10 from 2:00 p.m. to 2:25 p.m., he reviewed Patient #3's medical record. He indicated the patient could have been provided care here at the hospital on 3/28/10. He reported an ICU bed and a surgeon, (S7MD, Gen Surgery) were available to treat the patients condition. S9MD indicated this transfer was not necessary.

An interview was held with S5RN, ERDir on 4/7/10 at 12:10 p.m.. He reported Patient #3 was transferred to another facility with a surgeon (S7MD, Gen Surgery) and an ICU bed available on 3/28/10. S5RN, ERDir indicated Patient #3 was an inappropriate transfer.

During an interview with S6MD on 4/6/10 from 2:45 p.m. to 3:00 p.m., he reviewed Patient #3's medical record. S6 verified he was the emergency room physician that provided Patient #3 medical treatment in the emergency department on 3/28/10. He indicated patient #3 was transferred to another facility was for a higher level of care for abdominal cancer. He reported the patient would need an ICU (Intensive Care Unit) bed. He verified there was no documented evidence in #3's medical record that the patient had abdominal cancer. He confirmed the hospital had an ICU bed available to provide the patient medical treatment. He indicated the ICU department at the other facility was better qualified to treat adult patient's medical conditions. He reviewed the On-Call Physician's List for 3/28/10. He confirmed S7MD, Gen Surgery was the surgeon on-call on 3/28/10. He confirmed he did not consult the surgeon (S7MD, Gen Surgery) on 3/28/10 prior to transferring the patient to another facility. He reported the hospital had a surgeon (capability) and an ICU bed available (capacity) to admit and treat the patient's small bowel obstruction. He indicated it was his decision as the emergency room physician to determine if the patient was to be transferred to another facility for a higher level of care to assure the patient's continuity of care.

Patient #25:

Review of the medical record for patient #25 revealed he was a 12 year old male with a medical history of Seizure Disorder. Review of the "Initial Assessment Form" dated 12/20/09 revealed that patient #25 presented to the Emergency Room (ER) at 7:27 a.m.. Chief Complaint is documented as as "Dyspnea--Pediatric by S10RN. Under "Brief Assessment" the nurse documented "Mom states he is complaining of Rt. (right) side pain and now it's hard for him to breathe. Onset of pain is Friday." Initial vital signs are documented as T (temperature) 100.0 PO (oral), P (pulse) 118, R (respiratory rate) 26, Pain intensity 5/10. Patient #25 was assigned a triage Priority of 3 - Urgent.

Further review of the Pediatric Assessment documented by S10RN on 12/20/09 at 7:45 a.m. revealed "Patient assigned to room 2. Patient moved to room at 7:36 a.m. The minor is accompanied by at least one parent.....Respiratory:....Respiratory effort is noted to be mildly labored. patient states has pain with inspiration. patient c/o (complain of) pain to rt lower rib area and down to rt leg. denies any trauma hx (history)."

Review of the physician's documentation (S6MD) dated/timed 12/20/09 at 7:43 a.m. revealed the following vital signs: T: 100 PO, P: 118 regular, R 26 unlabored, SPO2 (oxygen saturation) 96 (%), Amt: RA (room air), Pain: 5.....Chief Complaint -- Dyspnea -- Pediatric. ....History obtained from : patient, mother...Patient came home from school with right sided chest pain, states "it hurts when he takes a deep breath."

Under "Review of Systems" dated/timed 12/20/09 at 07:44 (7:44 a.m.) S6MD documented "All (other) systems have been reviewed and are negative. Constitutional: negative chills, positive fever. Cardiovascular: positive chest pain. Respiratory: positive shortness of breath, negative cough, negative congestion. gastrointestinal: negative abdominal pain, negative diarrhea, negative nausea, negative vomiting, positive constipation...."

Review of the "Physical Examination" documented by S6MD dated/timed 12/20/09 at 07:44 (7:44 a.m.) revealed the following: ".....Respiratory: No respiratory distress. Lungs clear with equal breath sounds bilaterally.....Abdomen: Appearance: flat. Bowel sounds are hypoactive. Moderate tenderness to palpation over McBurney's point (McBurney's point is the name given to the point over the right side of the abdomen that roughly corresponds to the most common location of the base of the appendix where it is attached to the cecum. Wikipedia.). Abdomen is dull to percussion. Positive psoas sign, obturator sign......"

Review of the physician's orders entered at 7:48 a.m. on 12/20/09 revealed the following orders were entered into the computer for patient #25: CT (computerized tomography/CAT scan) Scan Abdomen and pelvis w (with) contrast (fluid taken orally to assist visualization of the gastrointestinal tract during the CT scan), BMP (basic metabolic panel), Urinalysis, Chest (x-ray) 2 view, and a CBC (complete blood count).

Under "Reassessment" dated/timed 12/20/09 at 9:46 a.m. S10RN documented "...patient was transported to Radiology at 12/20/09 07:50 (7:50 a.m.), for regular x-ray studies.....Time: The patient was reassessed at 08:25 (8:25 a.m.) Gastrointestinal: PATIENT VOMITED CONTRAST."

Review of the physician's orders for 08:20 (8:20 a.m.) revealed S10RN entered a verbal order per S6MD for patient #25 to be administered IV Zofran 4 mg. Review of the nursing documentation revealed S10RN administered IV Zofran 4mg 1st push given over 2 -5 minutes initiated at 12/20/09 08:30 (8:30 a.m.) by (S10RN).

Further review of the nursing notes revealed documentation by S12RN, ER that patient #25 was discharged to home at 09:51 (9:51 a.m.) on 12/20/09. Review of handwritten documentation, author unknown, on the top of the physician's computer notes reads "pt d/c'd (discharged) from computer by accident." Review of the medical record revealed 4 addendums. Addendum 1 was entered by S10RN on 12/20/09 at 10:52 a.m. and revealed documentation timed at 1053 (10:53 a.m.) that read: "....ERMD (S6) spoke to (ERMD) at (hospital "b") ER. - Accepted patient. Addendum 2 was dated/timed 12/20/09 at 11:31 a.m. and read "Acceptance to (hospital "b") ER per EMS (ambulance) made by (house supervisor at hospital "b"). (ambulance service) notified........Addendum 3 was dated/timed 12/20/09 at 11:40 a.m. by S12RN read: "Pt given home seizure meds.......V/S (vital signs) 99.1 (T), 106 (P), 138/076 (BP), 24 (R), 98% (SP02). Addendum 4 was also documented by S12RN and dated timed 12/20/09 at 12:03 p.m. and read: "Report to (name), RN at (hospital "b") ER. EMS staff here for transfer."

Review of the documentation by S6MD under "Diagnostic Test Results" dated/timed 12/20/09 at 10:47 a.m. read: "Radiology: Computerized Tomography Scan: Abdomen/Pelvis -- No acute disease. Negative study does not exclude appendicitis. Laboratory: Abnormal laboratory results: WBC (white blood count) 23.6 (normal renge 4.6 - 10.2 K/UL), Urinary Blood 10 (Normal - None), Urinary LE 25 (Normal - None)."

Further review of the documentation by S6MD under Consultation & Critical Thinking" dated/timed 12/20/09 at 10:48 a.m. revealed "Time of consult: 10:48. First call placed to consultant at :10:48. Case discussed with Dr. *NOT ON, STAFF. Discussed with ER doctor (name of ER MD at hospital "b"). Accepts patient in transfer."

Review of the "Clinical Impression" documented by S6MD at 10:48 a.m. on 12/20/09 reads: "1. Abdominal Pain, Right Lower Quadrant." Review of the "Disposition" documented by S6MD at 10:49 a.m. on 12/20/09 reads: "Patient (#25) will be transferred to (hospital "b"). Transfer forms complete. Condition: stable. Certified Med (medical) Emerg (emergency): Patient's condition was emergent."

Review of the Hospital Transfer Log revealed a form titled "Transfer Cases." Review of these forms revealed a document dated/timed 12/20/09 at 1100 (11:00 a.m.) with the name of patient #25 listed as the patient. Further review of this document revealed: "1. Is it a life or limb injury? Yes is circled. 2. Reason for transfer: Appendicitis. "No" and "availability" are noted to be circled. Can the the on-call MD treat the patient? is documented as "no" and handwritten next to this is "No surgery on call?"

Review of the Women's and Children's Hospital On-Call list for 12/20/09 revealed S7MD, General Surgery, was on call for the ER on 12/20/09.

In an interview on 04/07/10 at 12:00 noon with S10RN she confirmed that she was the triage nurse on 12/20/10. S10RN stated that she believed the handwriting on the "Transfer Cases" form was written by S11RN, House Supervisor. S10RN reviewed the on-call lists for 12/20/09 and confirmed that S7MD was on call for the ER. S10RN further stated that this was not an appropriate transfer because Women's and Children's Hospital had a General Surgeon, S7MD, on call. The patient was transferred on 12/20/09 at 12:03 p.m.

Review of a hospital policy titled "EMTALA - Provision of On Call Coverage", reference number: 780-3.5, effective 01/99, last revised 04/09, presented as current hospital policy reads in part; "Purpose: To ensure that the Emergency Department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide necessary treatment to stabilize individuals with emergency medical conditions. Procedure: 1. Women's and Children's Hospital has a documented system for providing on call coverage, so that the emergency department is prospectively aware of which physicians, including specialists and sub-specialists, are available to provide screening and treatment necessary to stabilize individuals with emergency medical conditions...

Review of a hospital policy titled "EMTALA - Transfer", reference number 780-3.6, effective 01/99, last revised 04/09, presented as current hospital policy reads in part: "Procedure. 2. If a patient that comes to the hospital and has an emergency medical condition, the hospital will provide either: a. further medical examination and treatment, including hospitalization, if necessary, as required to stabilize the medical condition within the capabilities of the staff and facilities available....

Review of a hospital policy titled "Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions", reference number: 900-1.31, effective 10/01. last reviewed 09/08, presented as current hospital policy reads in part: "1.0 Purpose. This policy is designed to provide professional nursing staff, medical staff, ancillary department staff and hospital credentialed Licensed Independent Practitioners (LIP) with appropriate direction for the prompt handling of patient's who may or may not have an Emergency Medical Condition. 2.0 Policy....2.5. If it is determined that the individual has an Emergency Medical Condition, to provide the individual with further medical examination and treatment as required to stabilize the Emergency Medical Condition within the Capability of the Hospital......4.10 Capabilities: that there are physical space, equipment, supplies, and specialized services that the hospital provides (e.g., surgery, psychiatry, obstetrics......) and refers to the level of care that hospital personnel can provide within the training and scope pf their professional licenses, including coverage available through the hospital's on-call roster."

Review of the Medical Staff By-Laws, signed by the CEO 10/21/09, section 6.2 Consultations, Referrals and Emergency Department Call 6.2(a) reads in part: "When the Emergency Department Physician determines that a consultation or specialized treatment beyond the capability of the Emergency Department Physician is needed, the patient shall be permitted to request the services of a specific private physician.....in the event the patient does not have a private physician......the rotation call list should be used...."