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Based on record review, facility policy review and staff interview the facility failed to ensure staff followed their policies and did not provide within its capabilities, stabilizing treatment prior to transferring 1 of 10 sampled transfer patients ( Patient 1). Based on information provided by the facility, the emergency department staff transfer on average 10 patients per month since 10/1/18. Failure to follow EMTALA policies and procedures and not provide stabilizing treatment has the potential for harm related to delay in treatment of an Emergency Medical Condition. The total sample was 20. Findings are:

A. Review of facility policy titled "Treatment of Patients with Emergency Medical Conditions" last reviewed May 2018 indicated that: An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in: placing the heath of the patient in serious jeopardy; serious impairment to any bodily functions; or serious dysfunction of any bodily organ or part. The policy further states that "if the ED provider determines that an emergency medical condition exists, appropriate treatment shall be offered to stabilize the patient's condition.."

B. Review of Patient 1's medical record dated 4/9/19 revealed the patient came to the ED at 5:10 PM. Review of ED Nurse Practitioner (NP) A's notes showed the patient presented with nausea and vomiting. NP A documented the patient stated he had worked 13 hours in the fields on 4/8/19 and woke up on 4/9/19 with dry heaves and that his blood sugar was elevated to 400 (normal glucose is 70-130). An elevated blood sugar and nausea and vomiting are early signs of diabetic ketoacidosis (serious complication of diabetes). Further documentation showed the patient was an insulin dependent diabetic who last self-administered NovoLOG insulin based on his blood sugar at 4:34 PM prior to coming to the ED. Documentation also showed that the patient recieved a continuous infusion of insulin delivered under the skin via an insulin pump. The medical record did not contain documentation to indicate whether staff checked the insulin pump for proper functioning. Lab tests showed patient 1 had a critically high White Blood Cell count (WBC) of 27,300 (normal level is 4,500 - 10,000). An elevated WBC count may indicate medical problems such as infection, stress, inflammation, trauma, allergy, or certain diseases.

At 5:20 PM the ED nurse began a continuous infusion of intravenous fluids. At 5:50 PM patient 1's blood sugar decreased from 400 to 367. At 5:57 PM an abdominal x-ray showed that patient 1 likely had a mild ileus (lack of movement of digested food through the intestine) without an obstruction or evidence of perforation (a rupture of the bowel leading to a serious infection). A chest x-ray showed normal inflation of the lungs without evidence of pneumonia (an infection in the lungs). At 6:56 PM patient 1 received an intravenous infusion of an antibiotic Zosyn.

At 7:30 PM NP A determined patient 1 required transfer to Hospital B located 2.5 hours away and signed the transfer form indicating the benefits of transfer were "higher level of care", the risks of transfer were "worsening condition." NP A documented she contacted the physician at Hospital B who requested that a CT scan (special type of x-ray) of patient 1's abdomen be performed prior to accepting NP A's transfer request.

At approximately 8:04 PM a CT scan of patient 1's abdomen was obtained. The result of the CT scan were not known by NP A prior patient 1's transport to Hospital B located 2.5 hours away. The medical record did not contain evidence of an examination by NP A or the on-call physician immediately prior to transfer to ensure patient 1 had been stabilized within the CAH's capabilities and capacity, and that the medical benefits of transfer outweighed the risks of a 2.5 hour ambulance trip. The nursing notes reflect documentation indicating NP A last saw patient 1 at 7:27 PM to discuss the plan of care and transfer. At 8:30 PM, patient 1's blood pressure remained low at 91/48 (normal blood pressure ranges from 120/80 to 140/90) and a urine test showed the presence of a large amount of ketones (acid) in the urine. Ketones in the urine and an elevated blood sugar, if left untreated can lead to diabetic ketoacidosis (a life threatening complication of diabetes). Ten minutes later at 8:40 PM, patient 1 was placed in the ambulance for transport to Hospital B without orders for further orders to stabilize the patient's elevated blood sugar or low blood pressure. The CAH did not have a surgeon on call but the CT scan results did not indicate surgery was indicated. Admission, administration of Intravenous Fluids, antibiotics, medications for nausea, low blood pressure, high blood glucose, and monitoring of blood sugars and laboratory tests are within the capabilities of the CAH.

C. During an interview on 4/30/19 at 3:00 PM, NP A revealed that after conducting the initial examination, she contacted the ED Medical Director, physician B, who was also the physician on-call. NP A stated that after discussing her findings, physician B told her to transfer the patient. NP A confirmed that physician B did not come to the hospital to provide further examination or stabilizing treatment. NP A stated the patient had turned his insulin pump off when he came to the ED and later hooked it up. NP A stated the patient had an Emergency Medical Condition. NP A stated she left the hospital and was at home waiting for the CT scan results and that she contacted Hospital B to speak with Physician C after receiving the CT scan results. NP A recalled getting a call from the "Doc Line" (Hospital B's transferring center) and the person she spoke with was upset that there was not an accepting physician. NP A stated afterwards, physician C (at Hospital B) returned her call and told her that the ambulance transporting patient 1 called en route to say that patient 1's blood pressure was dropping and that they needed orders for treatment.

D. Review of the 4/9/19 ambulance trip report showed that patient 1's blood pressure continued to drop during transport to Hospital B. At 9:35 PM patient 1's blood pressure dropped to 85/43. Orders to increase the rate of intravenous fluids were provided by physician C at Hospital B. At 9:46 PM patient 1's blood pressure remained abnormally low at 89/39 and physician C provided additional order to further increase the rate of intravenous fluids.

Refer to tag C-2407 for further details.

Based on record review, staff interviews, provider interviews and physician peer review the facility failed to provide 1 of 10 (Patient 1) sampled patients with an emergency medical condition stabilizing treatment within their capabilities prior to initiating transfer. This failure has the potential for harm related to delay in the provision of stabilizing treatment for a patient with an Emergency Medical Condition. Based on information provided by the facility they have transferred on average 10 patients per month since 10/1/18 for treatment at a higher level of acute care. The total sample size was 20 Emergency Department (ED) records. Findings are:

A. Review of Patient 1's medical record dated 4/9/19 revealed the patient came to the ED at 5:10 PM. Review of the ED notes by ED Nurse Practitioner NP A indicated the patient presented with nausea and vomiting and an elevated blood sugar (signs of diabetic ketoacidosis, a complication of diabetes).

NP A documented the patient stated he had worked in the fields for 13 hours on 4/8/19 and woke up 4/9/19 with dry heaves and blood sugars elevated to 400 (normal glucose is 70-130). Documentation showed the patient had an insulin pump and had been using sliding scale (additional insulin doses used to treat high blood sugars) in addition to his basal (continuous infusion of insulin under the skin by the pump). Lab test results showed patient 1 had a critically high white blood cell count (WBC) of 27,300 (normal 4,500 - 10,000). An elevated WBC count may indicate medical problems such as infection, stress, inflammation, trauma, allergy, or certain diseases. An EKG (electrocardiogram measuring the electrical activity of the heart) was normal. Chest X-ray was normal. Abdominal/KUB (kidney,ureter and bladder) X-rays showed likely mild ileus, a partial non mechanical blockage of the small and or large intestine. The patient also had acute hypotension (low blood pressure).

The NP documented "phone call, consult. Did speak with [name of Medical Doctor MD C] at [Hospital B], she was on-call as well as discharging physician for Patient 1 on Sunday [4/4/19]." MD C told NP A per the notes that the patient was discharged on 4/4/19 with a WBC of 3,000, a normal KUB X-ray and was tolerating food and fluids and had no abdominal complaints. NP A told MD C that today the patient has a WBC of 27, 000 and a Lactate level of 3 (Laboratory test measuring Lactic Acid, elevation can indicate infection/sepsis). NP A documented MD C requested a CT scan of patient 1's chest/abdomen/pelvis prior to accepting a transfer request. The result of the CT scan was not known by NP A prior to transferring the patient to Hospital B 2.5 hours away. There is no evidence of further examination or stabilizing treatment by the NP or an MD immediately prior to transfer to ensure the patient was stable and transfer was necessary and worth the risk of a 2.5 hour ambulance trip. Nursing Notes indicated NP A last saw the patient at 7:27 PM to discuss the plan of care and transfer.

At 8:40 PM the patient's blood pressure remained low and his blood sugar remained elevated. A urine test showed a large amount of Ketones (acid) in the patient's urine. The presence of Ketones in the urine and an elevated blood sugar are signs of Diabetic Ketoacidosis, a life threating complication of diabetes if left untreated. The CAH did not have a surgeon on call but the CT scan did not indicate surgery was necessary. Admission, administration of Intravenous Fluids, antibiotics, medications for nausea, elevated blood sugars, and low blood pressure, and monitoring of blood sugars and laboratory tests are within the capabilities of the critical access hospital for stabilization of the patient.

Review of Nursing Notes (NN) by Registered Nurse (RN) D on 4/9/19 noted the initial vital signs on admission were Temperature 96.8 Fahrenheit - Pulse 111 elevated- Respirations 18, Blood Pressure (BP) of 106/53. Oxygen saturation was normal at 100% on room air. Glasgow Coma Score (GCS) was normal at 15. The Sepsis screen score was 2 indicating possible blood infection. The nurse informed the provider of the score at 5:39 PM. At 6:52 PM the patients BP dropped to 87/53, pulse elevated at 118. The patient's blood pressures remained in the low 100 to 90's systolic during the ED visit. Medications given in the ED included Normal Saline Intravenous (IV) fluids started at 5:20 PM to run at 200 ml (milliliters) per hour, Zofran and Phenergan to treat nausea given at 8:30 PM, and Zosyn, an IV antibiotic, given at 6:55 PM. The nurse's notes documented the patient had the CT scan done at 8:19 PM. The record does not contain any monitoring of the patient's blood sugar since 5:50 PM or if the insulin pump was infusing correctly and /or at what rate. RN D noted at 7:55 PM that report on the patient was called to a nurse at Hospital B.

Nursing Notes indicated the patient transferred at 8:40 PM to Hospital B for further medical care with an Emergency Medical System (EMS) ground crew ambulance with Advanced Cardiac Life Support. Vitals at transfer were low BP 91/41 Temperature 98.24 axillary -pulse 102-respirations 18. Oxygen saturation at 99% on room air. GCS was 15. IV Normal Saline was infusing. No new orders were obtained.

The facility document titled "Physician Certificate and Patient Consent for Transfer" dated 4/9/19 noted the benefits of transfer were to a "higher level of care" with risks being "motor vehicle accident and worsening condition." Reason for transfer stated "Hypotension, Elevated WBC; N/V [nausea and vomiting], sepsis." The patient signed the form at 7:45 PM. NP A signed the form at 7:30 PM. The Medical Director MD B co-signed the form on 4/22/19, 13 days after the patient's transfer. The facility document titled "Transfer Communication Form dated 4/9/19 at 8:30 PM stated Nurse to Nurse communication with the receiving hospital occurred on 4/9/19 at 8:55 PM and physician to physician communication was completed at 7:15 PM by NP A with MD C at Hospital B. The provider NP A signed the form on 4/9/19 at 7:30 PM noting a discharge time of 8:40 PM.

The patient transferred by EMS ground ambulance with ACLS to Hospital B arriving to the ED on 4/9/19 at 11:30 PM. Review of the EMS report noted the patient's BP dropped at 9:35 PM to 85/43. The ambulance crew contacted Hospital B to obtain orders to increase the infusion rate of IV Normal Saline to 300 ml per hour. At 9:46 PM the patient's blood pressure remained low and additional orders were obtained to increase the fluid to 500 ml per hour.

B. Interview with ED NP A on 4/30/19 at 3:00 PM regarding Patient 1 revealed that after conducting the MSE she called MD B, the ED Medical Director, MD B, who was also the back-up Physician on call. NP A went over the exam and tests and was told by MD B to transfer the patient. MD B did not come to the hospital to assist in the provision of stabilizing treatment. NP A stated the patient had turned his insulin pump off when he came to the ED and later hooked it up. NP A called the transfer center (Doc Line) and was connected to MD C who had treated the patient on his prior admission to Hospital B. NP A confirmed MD B told her to get a CT of chest abdomen and pelvis and to get her the report. She then told the ED RN to call for an ACLS transfer. NP A stated she did not specifically tell the nurse she needed to talk to the accepting MD again before transfer. NP A stated the patient had an Emergency Medical Condition. NP A stated she left the hospital and was at home waiting for the CT scan report to be called to her. NP stated the patient had an Emergency Medical Condition the entire ED visit. She called the Doc Line to speak with MD C after the CT and was told they would call back. There was a delay in getting the call back from MD C. NP A then recalled getting a call from the Doc Line and the person was upset that there was not an accepting MD. MD C then returns the call and tells her the ambulance transferring the patient called and said Patient 1's BP is dropping and they need orders. NP A stated the patient was stable when transferred.

C. Interview with ED RN D on 4/30/19 at 4:40 PM. RN D came on duty at 7:00 PM and was told Patient 1 was a potential transfer. She recalled NP A was on the phone talking with the hospitalist (MD C) from Hospital B. RN D called for an ACLS transfer ambulance and stated the patient was stable but had the potential to become unstable. RN D stated the "patient physically looked stable but was pale and it took effort to go back and forth to the bathroom. You could tell he was sick." The patient took his own blood sugar using his blood sugar sensor and it was in the 200's. That compared to our 271 blood sugar "I think." The record lacked documentation regarding this. The patient started up his insulin pump running it at his basal (rate of insulin infusion not documented or known).

D. Telephone interview with MD C on 5/2/19 at 11:00 AM confirmed Patient 1 was not accepted prior to the patient being transferred. MD C stated "I did not accept, specifically told the NP to get a CT scan and call me with results and we would talk further." MD C stated the CT scan results were needed prior to acceptance to determine if the patient required surgery.

E. Review of facility policy titled "Treatment of Patients with Emergency Medical Conditions" last reviewed May 2018 showed that: An emergency medical condition is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in : placing the heath of the patient in serious jeopardy; serious impairment to any bodily functions; or serious dysfunction of any bodily organ or part. The policy further states that "if the ED provider determines that an emergency medical condition exists, appropriate treatment shall be offered to stabilize the patient's condition." Under the section titled "Discharge or Transfer" the policy defines stabilized for transfer as "within reasonable medical probability, that no material deterioration of the condition is likely to result from or during the transfer of the patient to another facility, and that the receiving facility has the capability to manage the patient's condition." The policy further stated that to transfer a patient the ED provider must provide medical treatment "within their capability to minimize the risks to the patient's health."

F. Review of the statutorily mandated Quality Improvement Organization physician peer review of Patient 1's care in the ED on 4/9/19 confirmed the patient had an Emergency Medical Condition. The hospital had the capability to stabilize the patient. Transferring the patient to another facility prior to the return of the CT scan results further delayed stabilization of the patient's condition and that the medical benefits of transfer did not outweigh the medical risks.