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Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide stabilizing treatment within its capability and capacity and an appropriate transfer for one patient (Patient #3 - P#3) of 20 sampled patients.

Specifically, P#3, a five-year-old child was brought to the facility (Facility A) on 9/18/24 at 1:38 p.m. for a laceration to the head sustained while playing. P#3 was discharged at 4:37 p.m. and his parent was instructed to take him to the children's hospital (Facility B). Due to lack of transportation, P#3's parent called emergency medical services (EMS) from home to transport P#3 to Facility B. P#3 arrived at the ED at Facility B at 7:48 p.m. Treatment included sutures, administration of blood products and a CT of the head. P#3 was discharged home with parent on 9/19/24 at 1:41 a.m.

Findings Included:

Cross refer to A-2407 as it relates to the facility's failure to provide stabilizing treatment within their capacity and capability to P#3.

Cross refer to A-2409 as it relates to the facility's failure to effect an appropriate transfer for P#3.

Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide stabilizing treatment within its capability and capacity for one patient (P) #3 of 20 sampled patients.

Specifically, P#3, a five-year-old child was brought to the facility (Facility A) on 9/18/24 at 1:38 p.m. for a laceration to the head sustained while playing. P#3 was discharged at 4:37 p.m. and his parent was instructed to take him to the children's hospital (Facility B). A review of an ambulance report dated 9/18/24 at 7:07 p.m. revealed that EMS was called to pick up P#3 at his residence for bleeding from a laceration. P#3 arrived at the ED at Facility B at 7:48 p.m. Treatment included sutures, administration of blood products and a CT of the head. P#3 was discharged home with parent on 9/19/24 at 1:41 a.m.

Findings Included:

A review of the facility's Medical Screening, Treatment and Related Issues policy", no policy number, effective date 10/3/23 stated that any individual who comes to the Emergency Department or Labor & Delivery Department requesting care would be offered an appropriate Medical Screening Examination to determine if the individual has an Emergency Medical Condition. If an Emergency Medical Condition exists, the Hospital should provide treatment to stabilize the condition or an appropriate transfer in accordance with the policy, "EMTALA - Transfers To/From Other Facilities".
PROCEDURE:
A. Overview
If an Emergency Medical Condition is determined to exist, the individual should be provided necessary stabilizing treatment, within the capacity and capability of the facility, or an appropriate transfer if the Hospital lacks the capacity and capability to provide the stabilizing treatment. Stabilizing treatment should be applied in a non-discriminatory manner (e.g., no different level of care because of diagnosis, financial status, race, ethnicity, insurance status, color, national origin, sexual orientation, disease or handicap).
Pediatric Patients
All pediatric patients who come to the ED are covered by this policy. Pediatric patients are defined as patients who come to the ED and are less than 16 years of age; are 16 years of age or older who have conditions primarily identified as pediatric; or are currently under the care of a pediatric generalist or specialist.

A review of P#3's medical record from Facility A revealed that he arrived to at 1:38 p.m. on 9/18/24 for a head laceration obtained while playing. At 1:52 p.m. Registered Nurse (RN) HH applied "gauze and wraps" on P#3's head. Continued review of ED record revealed that RN HH assigned "Patient Acuity 3 (Urgent)". A review of "Emergency Department Provider Note" by Physician Assistant (PA) GG filed on 9/18/2024 at 5:48 p.m. revealed that P#3 had history of autistic disorder, was nonverbal, came to ED with scalp laceration.
Further review revealed that assessment of "SKIN:1.5 inch laceration (cut) noted to posterior (back) scalp, actively bleeding".Further review of the provider's note failed to reveal any diagnostics data or tests were done.
A review of HPI in "Emergency Department Provider note" failed to reveal any documentation of PECARN Criteria.

A review of "MEDICAL DECISION MAKING" in PA GG's note revealed the case was discussed with Medical Doctor (MD) OO and because P#3 was a pediatric patient and would need to remain still for the laceration repair it was advised to have P#3's parent take him to the children's hospital (Facility B). P#3's head was wrapped, and parent was agreeable to take P#3 to Facility B.

A review of the ambulance 'Rescue Patient Care Report' revealed that the ambulance arrived at P#3's residence for bleeding from an open scalp wound on 9/18/24 at 7:08 p.m. A review of the narrative revealed that P#3 had sustained a head laceration while playing with his siblings. P#3's parent explained that P#3 had been taken to Facility A earlier in the day and was discharged home with instructions to go to Facility B. P#3's parent reported that they had to walk home from Facility A because they do not have transportation. P#3's parent called 911 from home because the wound was still bleeding. While en route to Facility B, P#3 removed the gauze bandage it laceration began bleeding heavily. A softball sized hematoma was observed. The ambulance arrived at Facility B at 7:41 p.m.

A review of P#3's medical record from Facility B revealed that he arrived via ambulance at 7:48 p.m. with a scalp laceration. A review of the 'ED Provider Notes' dated 9/18/24 at 10:01 p.m. revealed that P#3 had a 6 cm scalp laceration with a continuously expanding hematoma. P#3 was initially hemodynamically stable, but the laceration continued to bleed through the dressing and tachycardia worsened. P#3 showed symptoms of anemia, and it was determined that P#3 required a transfusion of packed red blood cells. P#3 had the laceration repaired with sedation. A CT of the head was done, and findings were reviewed with the family. Post transfusion laboratory tests and vital signs were completed. P#3 discharged home with parent on 9/19/24 at 1:49 a.m.

During a telephone interview on 10/1/24 at 4:35 p.m. with Physician Assistant (PA) GG., PA GG recalled that P#3 was brought into the Emergency Department (ED) by his parent. . PA GG stated that based on her (PA GG) evaluation, P#3 looked well overall, and was walking around the room, but was resistant to her (PA GG) touching him (P#3). PA GG stated that P#3 had a bandage, which was 'kinda' oozing some blood, and she (PA GG) told P#3's parent P#3 would need to be still and calm in order to have the laceration sutured. PA GG recalled that she spoke with the attending (MD OO) about whether to attempt intra-nasal sedation (spraying a small amount of a sedative drug into the nose) on P#3, but MD OO said to transfer P#3 to a children's healthcare facility. PA GG further stated that P#3's parent was eager to go, and she (PA GG) assumed P#3's parent had transportation to take P#3 to Facility B.

Based on a review of policy and procedures, medical records, and interviews with staff, it was determined that the facility failed to provide an appropriate transfer for one patient (P) #3 of 20 sampled patients.

Specifically, P#3, a five-year-old child was brought to the facility on 9/18/24 at 1:38 p.m. for a laceration to the head sustained while playing. P#3's was discharged at 4:37 p.m. and his parent was instructed to take him to the children's hospital (Facility B). A review of an ambulance report dated 9/18/24 at 7:07 p.m. revealed that EMS was called to pick up P#3 at his residence for bleeding from a laceration.

Findings included:

A review of the facility's "Medical Screening, Treatment, and Related Issues policy", no policy number, effective date 10/3/23 stated that the purpose of the policy was to set forth procedures to ensure that all Hospitals with Dedicated Emergency Departments (DED) in the EHC system met all the requirements set forth in the Emergency Medical Treatment and Labor Act ("EMTALA"), 42 U.S.C. § 1395, for the examination and treatment of patients for whom a request for emergency care was made.
PROCEDURE:
Pediatric Patients
a. All pediatric patients who come to the ED are covered by this policy. Pediatric patients are defined as patients who come to the ED and are less than 16 years of age; are 16 years of age or older who have conditions primarily identified as pediatric; or are currently under the care of a pediatric generalist or specialist.

h. The ED attending physician should utilize the resources of the nearest appropriate pediatric hospital for patients who require transfer to a pediatric facility, transfer to a tertiary pediatric facility for evaluation or care, or follow-up with a pediatric generalist or specialist; or in the case of a patient who has an established relationship with an appropriate pediatric care provider, the ED attending physician may utilize that provider.

Appropriate Transfers of Unstabilized Individuals

1. The Hospital shall provide appropriate transfers of unstabilized individuals only if and when any of the following conditions have been met:

The individual (or person acting on their behalf) requests a transfer and the Hospital
has informed that person of the risks of a transfer as well as the Hospital's obligations under this policy.

b. A physician has signed a certification that the benefits of the transfer of the patient to
another facility outweighs the risks, and such certification is entered into the patient's medical record; or,

2. Unless an unstabilized individual (or person acting on their behalf) requests a transfer pursuant to Section D.1.a above, the Hospital shall not transfer any unstabilized individual if the Hospital has the capability and capacity to stabilize the individual.
3. In order to transfer an unstabilized individual, all of the following criteria must be met:

a. The Hospital must provide all appropriate treatment within its capacity necessary to
minimize the risks inherent in transfer.

b. The receiving hospital must have the available space and qualified personnel for the
treatment of the individual.

c. The Hospital must send all pertinent medical records to the receiving hospital;

d. The Hospital must obtain consent from the receiving hospital prior to initiating the
transfer; and

e. The Hospital must ensure that the transfer of an unstabilized individual is affected
through qualified personnel and transportation equipment, including the use of medically appropriate life support.

A review of P#3's chart revealed a note by PA GG at 4:38 p.m. on 9/18/24 that P#3's mother was instructed as follows: "Please go to facility B for repair of scalp laceration" (a cut on the head). Further review of PA GG's note revealed following: "Disposition: Stabilized/Treated and Discharged".
A review of P#3's ED record failed to reveal documentation that P#3's parent was offered an appropriate transfer for P#3 to facility B. Instead, P#3's mother was instructed to take P#3 to facility B.
An interview was conducted on 10/1/24 at 2:27 p.m. with ED Unit Director (UD) CC in the conference room of the facility. During the interview UD CC acknowledged that P#3 should have been transferred to the facility B for further care.

During a telephone interview on 10/1/24 at 4:35 p.m. with Physician Assistant (PA) GG., PA GG recalled that she spoke with the attending (MD OO) about whether to attempt intra-nasal sedation (spraying a small amount of a sedative drug into the nose) on P#3 to perform sutures on the laceration, but MD OO said to transfer P#3 to a children's healthcare facility. PA GG further stated that P#3's parent was eager to go, and she (PA GG) assumed P#3's parent had transportation to take P#3 to Facility B.

During a follow up telephone interview with PA GG on 10/4/24 at 3:04 p.m. PA GG stated that during her conversation with P#3's mother, it never came up that P#3 and his family did not have transportation. PA GG acknowledged that she (PA GG) did not offer to transfer P#3 via ambulance to P#3's parent. .PA GG stated that a transfer to another facility would have been triggered when the attending physician assessed P#3 and approved the transfer. Since MD OO did not come to assess P#3, PA GG assumed that P#3's mother would take P#3 to Facility B and that was why she (PA GG) instructed P#3's mother to take the P#3 to facility B.