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Based on interview, record review, and policy review, the hospital failed to follow policy, which resulted in a delay in treatment for one patient (#32) of 32 Emergency Department (ED) records reviewed. Patient #32 was an accepted transfer from Hospital A (urgent care located approximately 90 minutes away), for an emergency medical condition (EMC) in which the recipient hospital (Freeman Health System) had the capacity and capability to stabilize. While traveling to Freeman Health System's ED, the patient was re-routed to another hospital and her treatment was delayed. This failure had the potential to cause harm by delaying stabilizing treatment to any emergent patient who required the specialized capabilities. The ED average monthly census was 3,186. The hospital census was 232.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," revised 08/2021, showed that the hospital cannot refuse to accept the transfer of a patient who requires specialized care, if the hospital has the capacity and capability to treat the patient. The patient would be accepted by the ED physician, with arrangement for specialty care dependent on the specialty staff on call.

Review of the hospital's policy titled, "Admitting Trauma Patients," revised 08/2008, showed that trauma patients from another hospital would be processed in the ED. The ED physician would evaluate the patient, document their findings and notify the consultant.

Review of the hospital's document titled, "Medical Staff Bylaws," reviewed 12/18/20, showed that once the presence of an EMC was present, and the need for an on call specialist was required, the on call specialist would be responsible for the care of the patient through the entire episode of the EMC.

Review of the hospital's document titled, "EMTALA Review for ED Staff," dated 04/20/22 showed:
- A patient that experienced an EMC must be stabilized, including ancillary services, prior to being transferred.
- Patients would be considered stabilized when the treating physician determined that the patient's EMC had been resolved.
- Stabilization would mean no deterioration of the medical condition would likely result or occur during the patient's transfer.

Patient #32 received an eye injury when she pulled boards from an old barn and a nail punctured her left eye. She went to Hospital A's urgent care center, and was found to have an EMC, when it was determined that she had an open globe injury (a full-thickness wound of the eyewall due to a penetration by a sharp object) which required surgical repair. Hospital A contacted Freeman Health System and Patient #32 was accepted by their on-call ophthalmologist and their ED Physician. Patient #32 and her spouse began the drive to Freeman by private vehicle, after she declined transfer via ambulance, due to related costs because she did not have health insurance. While the patient was en-route to Freeman, the on-call ophthalmologist was informed that that the hospital did not have the appropriate equipment to repair the patient's eye injury. The ophthalmologist notified the ED Physician of the situation, who then contacted Patient #32 by phone to re-route her to hospitals in the Kansas City, Missouri area. The patient and her husband declined, and informed the ED Physician that they would prefer to go to the Tulsa, Oklahoma area, and that they would return home, since they had been driving around for about three hours. The patient returned to Hospital A for intravenous (IV, in the vein) antibiotics, prior to transfer to Hospital D, where she underwent surgical repair of the left eye, approximately nine hours after her initial injury.

Review of Patient #32's medical record (from Hospital D) showed that:
- She signed into Hospital D's ED on 03/28/22 at 11:07 PM.
- Her initial injury occurred at home on 03/28/22 around 4:00 PM, when a rusty nail penetrated her left eye. She immediately pulled the nail out of her eye and noted clear fluid draining. She was able to open and close her eye without difficulty, and could see light.
- She was admitted to Hospital D for surgical repair of her left eye, with a left globe rupture, decreased vision, and acute pain.

During an interview on 05/26/22 at 10:25 AM, Patient #32, stated that she ended up going to Tulsa, Oklahoma (Hospital D) for treatment. She underwent surgery around 1:00 AM, approximately nine hours after her injury. Since then, she has required a second surgery and was told that her retina (a layer of cells that are sensitive to light, in the back of the eye, that trigger nerve impulses to the brain and form visual images) had been destroyed, resulting in loss of vision in her left eye.

Please refer to A-2411 for details.

Based on interview, record review, and policy review, the hospital created a delay in treatment for one patient (#32) of 32 Emergency Department (ED) records reviewed. Patient #32 was an accepted transfer from Hospital A (urgent care located approximately 90 minutes away), for an emergency medical condition (EMC) in which the recipient hospital (Freeman Health System) had the capacity and capability to stabilize. While traveling to Freeman Health System's ED, the patient was re-routed to another hospital and her treatment was delayed. This failure had the potential to cause harm by delaying stabilizing treatment to any emergent patient who required the specialized capabilities. The ED average monthly census was 3,186. The hospital census was 232.

Findings included:

1. Review of the hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)," revised 08/2021, showed that the hospital cannot refuse to accept the transfer of a patient who requires specialized care if the hospital has the capacity and capability to treat the patient. The patient would be accepted by the ED physician, with arrangement for specialty care dependent on the specialty staff on call.

Review of the hospital's policy titled, "Admitting Trauma Patients," revised 08/2008, showed that trauma patients from another hospital would be processed in the ED. The ED physician would evaluate the patient, document their findings and notify the consultant.

Review of the hospital's document titled, "Medical Staff Bylaws," reviewed 12/18/20, showed that once the presence of an EMC was present and the need for an on call specialist was required, the on call specialist would be responsible for the care of the patient through the entire episode of the EMC.

Review of the hospital's document titled, "EMTALA Review for ED Staff," dated 04/20/22 showed:
- A patient who experienced an EMC must be stabilized, including ancillary services, prior to being transferred.
- Patients would be considered stabilized when the treating physician determined that the patient's EMC had been resolved.
- Stabilization would mean no deterioration of the medical condition would likely result or occur during the patient's transfer.

During an interview on 05/26/22 at 10:25 AM, Patient #32 stated that she had been pulling boards out of an old barn and a nail penetrated her left eye. She reached up and pulled the nail out on reflex, and there was a "gush" of fluid when the nail was removed. Her husband took her to an urgent care (in Independence, Kansas), where she was examined. The physician at the urgent care contacted Freeman Health System about the patient's injury and spoke with Staff K, Ophthalmologist (who was on-call for the hospital). The urgent care patched her eye, and she departed for Freeman by private vehicle, after she declined transfer by ambulance due to a lack of insurance and the related expense. When she was approximately 30 minutes away from Freeman, she and her husband were contacted and informed that Freeman did not have the equipment needed to treat her. She was told to travel towards the Kansas City area, which was three hours from her home. She voiced that her preference was to go to Tulsa, Oklahoma, not Kansas City. They were about an hour away from Tulsa when Staff M, ED Physician at Freeman, told them there wasn't a provider that could treat her in Tulsa. Since they had been driving around for about three hours, they told Staff M that they were going to go home until someone figured out where they should go. She contacted the urgent care (in Kansas) and told them that she still had not seen a provider. The physician at the urgent care had her return for intravenous (IV, in the vein) antibiotics.

Review of an e-mail dated 04/01/22 from Staff M, Freeman's ED Physician, to Staff I, Freeman's ED Medical Director, showed that:
- Patient #32 had been accepted as a transfer patient from Hospital A by Staff I, ED Medical Director and Staff K, Ophthalmologist, prior to the start of Staff M's ED shift.
- At 5:30 PM, Staff M received a phone call from Staff K, to inform him about Patient #32, who had an open globe injury (a full-thickness wound of the eyewall due to a penetration by a sharp object). She went on to inform him that while she had attempted to schedule the emergency surgery, she was told that the hospital did not have the surgical microscope (Leica M841) needed for repair of the patient's eye, and Staff K stated that Patient #32 would need to go somewhere else.
- At 5:43 PM, Staff M contacted Hospital A to inform them that they needed to find another hospital for Patient #32's treatment, when he was advised that Patient #32 had already left by private vehicle, approximately one hour prior to his call, to drive to Freeman.
- At 6:00 PM, Staff M spoke with Patient #32's husband, and advised him to re-route in order to avoid a delay in treatment. He relayed to them that Staff K, Ophthalmologist, recommended that they head toward the Kansas City, Missouri area (approximately two hours drive from their estimated location) to be treated. Patient #32's husband stated that they preferred to head toward Tulsa, Oklahoma, due to the proximity to their home.
- At 6:38 PM, Staff M spoke with Patient #32 and her husband again, and explained to them that he did not have a hospital to accept them. Patient #32's husband decided that they would return home and wait for further instructions.
- At 8:05 PM, Staff M spoke with Hospital D (located in Tulsa, Oklahoma), who accepted the patient.
- At 8:29 PM, Staff M, spoke with Patient #32 and her husband via phone. They were no longer at home, but had returned to Hospital A, where Patient #32 received intravenous (IV, in the vein) antibiotics. The patient's husband informed him that they would head toward Hospital D once the infusion was completed.

During an interview on 05/17/22 at 5:10 PM, Staff I, ED Medical Director, confirmed that she, along with Staff K, Ophthalmologist, accepted Patient #32 for transfer.

Review of the hospital's document titled, "Ophthalmology (a branch of medicine specializing in eye care) Schedule," dated March 2022, showed that Staff K, Ophthalmologist, was on call on 03/28/22.

Review of the credentialing file for Staff K, Ophthalmologist, showed that she was listed as a Class Three Ophthalmologist (capable of performing both non-surgical and surgical procedures related to eye care).

During an interview on 05/18/22 at 9:30 AM, Staff K, Ophthalmologist, stated that she accepted Patient #32 around 5:30 PM, and called Freeman Health System to add Patient #32 to the operating room (OR) schedule for 8:00 PM or 8:30 PM, for repair of a ruptured globe. A few minutes later, the OR nurse had called back and told her that they did not have the Leica M841 microscope that was needed for the procedure, and that it was nowhere to be found.

During an interview on 05/18/22 at 9:50 AM, Staff L, OR Nurse, stated that the microscope had been located the following day on 03/29/22, in a storage area in the back hallway of the OR.

Review of Patient #32's medical record (from Hospital D) showed that:
- She signed into Hospital D's ED on 03/28/22 at 11:07 PM.
- Her initial injury occurred at home on 03/28/22 around 4:00PM, when a rusty nail penetrated her left eye. She immediately pulled the nail out of her eye and noted clear fluid draining. She was able to open and close her eye without difficulty, and could see light.
- She was admitted to Hospital D for surgical repair of her left eye, with a left globe rupture, decreased vision, and acute pain.

During an interview on 05/26/22 at 10:25 AM, Patient #32 stated that she underwent surgery at Hospital D on 03/29/22 at 1:00 AM, approximately nine hours after her injury. Since then, she required a second surgery and was told that her retina (a layer of cells that are sensitive to light, in the back of the eye, that trigger nerve impulses to the brain and form visual images) had been destroyed, and that she had lost the vision in her left eye.

Freeman Health System accepted Patient #32, an uninsured individual from Hospital A, for stabilization of an EMC. While Patient #32 was enroute and approximately 30 minutes from arrival to Freeman Health System, the ED physician advised the patient to reroute to unknown hospitals located two hours away in Kansas City, Missouri. This placed the patient at risk for deterioration in her condition, and delayed examination by a qualified on-call ophthalmologist, administration of intravenous antibiotics, pain medication, and any additional treatment while arrangements were made to either perform a more thorough search for the microscope or obtain acceptance from the closest appropriate hospital by the most appropriate means of transport.