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The hospital failed to comply with the Special Responsibilities of Medicare Hospitals in Emergency Cases (42 CFR 489.24) by inappropriately transferring at least one (1) of twenty (20) cases reviewed (patient #13). See the findings at 2409.

Based on reviews of medical records and interview with staff, it was determined the hospital failed to ensure an appropriate transfer was done for at least one (1) of twenty (20) cases reviewed (patient #13). This has the potential to affect the safety and quality of care provided to any patient who needs to be transferred to another acute care hospital for continued treatment.

Findings include:

1. Review of the medical record for patient #13 shows the 63 year old male patient arrived to the Emergency Department (ED) at 03:04 on 12/8/2011. The patient's presenting complaint was "Had spinal procedure done on 11/28/2011, now is having back pain and has a high fever." At 3:06, the patient's vital signs were documented as pulse 129, respirations 22, temperature 101.6 and his pain was rated as a 6/10. At 03:09, the blood pressure (BP) was recorded as 100/58. The patient was placed in the treatment room at 03:10. The initial medical screening examination occurred at 03:13. At 3:43, the patient received Dilaudid 1 mg intravenously for complaints of pain. The Registered Nurse (RN) assessment was conducted at 03:50-03:54. The RN documented the patient's "Skin is dry, Skin is red, Skin temperature is hot"..

At 03:47, blood was drawn for testing, including a blood culture. At 03:49, the patient was taken to the CT area for a CT scan without contrast of his spine. At 03:53, the patient received Benadryl 25 mg and Zofran 8 mg intravenously. The patient returned to the ED treatment room at 04:15. At 04:36, the patient's BP was recorded as 85/55 and at 04:38 the temperature was 101.1. At 04:53, a bolus of 1000 milliliters of normal saline was started intravenously. At 04:57, 1000 mg Tylenol was administered.

At 05:14, the ED physician dictated a note "A healing laceration of surgical incision from the mid upper thoracic all the way down to the lumbosacral region. Staples area all intact. The wound site looked clearly intact and it seems they are healing well and no evidence of any irritation or cellulitis around the edges of the wound...CT scan of his thoracic and lumbar spine reveal no evidence of soft tissue swelling or hematoma noted. At this point in time, everything looks clean. There is no evidence of an abscess collection at all. So think that can be discharged to home to follow up with his neurosurgeon. He will be able to talk with him in the morning. In the meantime, he has pain medicine at home. We are going to have him just at home (sic) and use his oral pain medicine, follow up with the oral (sic) surgeon if necessary and keep ahead of the temperature with Tylenol every 4 hours if needed." At 05:15, the "Disposition" note was written "Discharged to Home/Self Care. Impression: Postoperative Pain - Acute. Condition is Stable. Discharge Instructions: Post Surgical Instructions, General, Adult, Pain Relief Pre and Post-Operatively. Follow up: Private Physician; When: Today; Reason: Further diagnostic work-up, Recheck today's complaints. Problem is an ongoing problem. Symptoms have worsened."

There was no further note, dictated or hand written by any physician in the record.

At 05:38, the patient's BP was recorded as 90/57 and the temperature was 101.5. At 06:07 the BP was 90/57 and the temperature was 101.5. At 06:07 the BP was 81/50, pulse was 103, respirations were 26 and the temperature was 100.3. The patient's oxygen saturation was recorded as 96% on 2 liters of oxygen. Also at 06:07, the RN recorded a note "Dr.---- (ED physician) has been made aware of the patient BP and pain. An order was given to give a 500 cc bolus when the 1000 cc bolus is complete and then if the patient pressure has improved, an order for an additional order of Dilaudid may be given. At 06:10, the RN noted "Appears uncomfortable, Behavior is agitated, anxious, restless. Pain: Complains of pain in back. Pain currently is 8.5 out of 10 on a pain scale." At 06:11, the RN documented "Per the patient request and with Dr.--- (ED physician) permission, a copy of the patient results were faxed to a Dr. ____ ." At 06:18, the RN documented "Patient wife has asked that the doctor come in and see that the patient's rash has increased and gotten worse. Dr. ---- (ED physician) made aware and an order for a second dose of Benadryl has been given." At 06:20, the RN noted "Derm: Rash noted that is macular, itchy, red, raised, urticaria, on back, chest, abdomen, right arm and left arm. At 06:29, the order for the Dilaudid was cancelled and the patient was given Percocet by mouth for pain and Benadryl 25 mg was given intravenously.

At 06:44, the patient's BP was 85/52 and the patient rated his pain as 4/10. At 06:49, the nurse noted "Follow up: pain 4/10 adult; Response: No adverse reaction; patient rash is starting to lighten and is no longer itching." The 500 cc bolus was started at 06:44 and ended at 08:45.

At 07:13, the patient's BP was 91/40 and his pain remained a 7/10.

At 08:50, the RN documented "Converted IV (intravenous) to saline lock on patient's IV, left in per ambulance service request during transport to Riverside Hospital" (in Columbus, Ohio). There was no documentation in the medical record to indicate who called for ambulance transport or why.

Under the heading "Outcome" the physician noted at 05:15 "Discharge ordered by MD." At 08:50 the nurse noted "Discharged to Med Corb ambulance service to take patient to Riverside Hospital. Report called to receiving nurse at Riverside Hospital. Patient belongings upon disposition: Left with patient. Condition: stable. Discharge instructions: Follow up and referral plans." At 08:52 it was documented "Patient left the ED."

An addendum note written on 12/12/2011 indicated the patient's final blood culture was positive for Methicillin Resistant Staph Areus (MRSA) and the result was called to Riverside Hospital.

The medical record did not have a physician note between 05:15 and 08:52, when the patient actually left the hospital. Medical intervention was continuing (IV bolus to correct low BP, Benadryl to correct a rash, and pain medicine to treat continued pain) after the discharge order was written. There was no assessment by the physician to determined if the patient was stable to be discharge. When the ambulance was called to transport the patient, the physician did not certify the patient to be stable for transfer.

2. The Clinical Director of the ED was interviewed on 6/12/2012. She stated patient #13 was not logged as a transfer. She stated the patient was not considered to be a transfer because the ED physician had discharged the patient. She stated the nursing staff had called an ambulance to transport the patient to Riverside Hospital per the request of the patient's wife at the time of discharge.

3. The ED Medical Director was interviewed on 6/12/2012. He stated the ED physician who was caring for patient #13 should have checked the patient after he wrote the discharge at 05:15 a.m. when the nursing staff had requested it. He stated the ED physician's shift had ended at 07:00 that morning. He stated that because the night shift physician had considered the patient to be discharged, he had not reported the patient's case to the oncoming ED physician, and the oncoming physician had not assumed the care of the patient.