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Based on reviews of medical records, hospital policies and procedures, and staff interviews, the facility failed to ensure that an appropriate transfer was provided for an individual by failing to ensure: 1. An individual with an identified emergency medical condition and in need of an appropriate transfer to another hospital for specialized treatment was not offered at the transferring hospital; 2. An individual was accepted through an appropriate referral to the receiving hospital with a physician written certification of transfer; and 3.) An appropriate transfer was effected through qualified personnel and transportation equipment as required including the use of necessary medically appropriate life support measures during the transfer for 1 (Patient #9) of 20 emergency department patients charts reviewed for appropriateness of transfer to receiving hospitals. Refer to findings in Tag A-2409.

Based on reviews of medical records, hospital policies and procedures, and staff interviews, the facility failed to ensure that an appropriate transfer was provided for an individual by failing to ensure: 1. An individual with an identified emergency medical condition and in need of an appropriate transfer to another hospital for specialized treatment not offered at the transferring hospital; 2. An individual was accepted through an appropriate referral to the receiving hospital with a physician written certification of transfer; and 3.) An appropriate transfer was effected through qualified personnel and transportation equipment as required including the use of necessary medically appropriate life support measures during the transfer for 1 (Patient #9) of 20 emergency department patients charts reviewed for appropriateness of transfer to receiving hospitals.

The findings are:

Review of the facility policy, titled, "Guidelines Department of Emergency Medicine: Practice Guidelines" Original 1973, Revised August 2013, reads, "....The ED patient's transition for hospital to home or other facility will be planned....1. ....The physician is responsible for coordinating the discharge plan.... 4.... Patients transferred to another facility or unit will have a transfer form completed by the nursing staff and the physician....".

Facility policy, titled, "Patient Transfers" Effective 3/99, Revised and Reviewed 11/14, reads, "....All patients who are in need of specialty care, higher level of care, more expeditious care or continuing care not available at Lexington Medical Center will be transferred to an appropriate facility that can provide the needed services....2. When the patient requires or requests transfer to another acute care facility, the patient's attending physician must call the receiving facility and speak to the physician who will accept the patient to discuss reason for transfer, degree of stabilization and accepting facility resources....4. The transferring physician shall determine the appropriate method of transport (air, ground, etc.) Hospital staff will arrange for appropriate level of transport based on the patient's condition/needs".


On 11/24/2014 at 3:00 p.m., review of Patients #9's emergency department chart revealed the patient presented to Lexington Medical Center's emergency department triage via car on 11/16/2014 p.m., with chief complaint of " Jaw Pain hit in face while playing football; relates to right facial and lower jaw pain; unable to move mouth." Documentation by the ED physician in the patient's history, indicated in part, "Mouth Injury Duration of episode (s) is 1 hour. The problem occurs constantly. This is an acute problem. Head/Neck injury location; jaw. The symptoms are associated with trauma. Symptoms are exacerbated by activity. The symptoms are worsening. The pain is severe. The quality of the pain is throbbing and sharp. Associated symptoms include arthralgia (jaw) and facial swelling. " Further review of the patient's medical record indicated Patient #9's initial emergency department (ED) vital signs were Blood Pressure 169/117 (Normal BP ranges Systolic: 100 - 140 -Diastolic: 60 - 90 ) mmHg (millimeters of mercury) and pain level of 10 (worst pain ever). Review of Patient #9's ED progress notes dated 11/16/14 revealed at "09:21 p.m.: Pt. (Patient) able to open mouth but with pain. Missing tooth noted to left lower. Bleeding controlled. No swelling noted at this time. 09:22 p.m.: ED acuity "2." 9:23 p.m.: Patient to room 22. 9:24 p.m.: MD (Medical Doctor) assigned as attending. 9:27 p.m.: Peripheral IV (intravenous - line - needle inserted in a vein for infusion of fluids and medications) placed in left anterior antecubital. 9:37 p.m.: Dilaudid (pain medication/narcotic used to treat moderate to severe pain) 1 mg (milligram) IV, Zofran (anti-nausea) 4 mg IV administered. Pain score: "10" - worst pain ever. " 9:24 p.m.: patient transported to X-ray. ED progress notes: Pt is for generalized jaw pain 10/10 post playing football at running into someone. Pt is (CA) x 4 (Conscious, alert, oriented) denies visual deficits, or passing out. Pt reports difficulty opening his jaw. 9:43 p.m.: HEENT (Head Ears Eyes Nose Throat) ...throat-intact. Painful to swallow. 10:08 p.m.: Blood pressure 151/105. 10:16 p.m.: Dilaudid 1 mg IV. 10:18 p.m.: Ancef (antibiotic) IVPB (Intravenous piggy back-used for medication infusion) 1 g (gram)/10:26 p.m.: Oxygen saturation - 98%. 10:26 p.m.: Xray Preliminary result: " Panorex Impression: There is an acute fracture of the anterior mandibular (facial bone that forms the lower jaw facial and contains the lower teeth) body on the left, near the mental symphysis. Mandibular condyles and rami appear intact bilaterally. Fracture fragments appear nondisplaced. 10:44 p.m.: Disposition/Condition by MD-Disposition-Discharge; Departure Condition - Stable. Discharge orders placed: Amoxicillin (Amoxil- Antibiotic to treat infection) 500 mg capsule; Oxycodone-acetaminophen (Percocet- pain medication)5-325 MG per tablet. 11:23 p.m.: MD removed as attending; Dilaudid 1 mg administered. Pt is drowsy and oxygen saturation 92% (normal -95%-100%). Pt awaken and instructed to take some deep breaths. VS (Vital Signs- blood pressure, pulse, respirations) stable. NAD (no acute distress) noted." "11:45 p.m.: Registered Nurse ED notes addendum (Lexington Medical Center) - Spoke with the charge nurse at Hospital 2 (Hospital where patient presented to after the patient's (Patient #9) emergency department visit to Lexington Medical Center emergency department) , informed her Charge Nurse -Hospital 2) of the patient coming by POV (privately owned vehicle) to her ER (Emergency Room). Informed her (Charge Nurse- Hospital -2) we (Lexington Medical Center) were sending a copy of his x-rays with him in his discharge paper work and that the pt. will have a patent IV 11:55 p.m.: ED notes - D/C (Discharge) instructions explained to pt. and girlfriend both parties verbalize understanding. Pt wheeled out to his girlfriend ' s car and assisted to vehicle. Pt. sent with copy of x-ray. 11:57 p.m.: Patient discharged. Discharge and follow-up Instructions: Final diagnosis-open fracture of mandible. Follow-up Information - "Please follow up. (Find an oral surgeon to see you) Follow up with ... (Can call and see if they see a jaw fracture)."

Patient #9's medical record from Hospital B was reviewed. Review of the "Emergency Department Record" dated 11/17/2014 at 12:15 a.m. The ED physician documented in the history section in part, "Broken jaw playing football ...transfer from LMC (Lexington Medical Center) ...They do not have oral surgeon ...no accepting physician ....INT in LUE (Left upper Extremity) upon arrival ... Clinical Impression: Open Mandibular Fx (Fracture). Patient #9 was admitted on 11/17/2014 and underwent a surgical procedure, "Open reduction, internal fixation of the mandible fracture and placement of internal maxillary fixation with arch bars."

On 11/25/14 at 8:40 a.m., an interview with Emergency Department Physician 1(Physician responsible for Patient 9) revealed, "I remember this patient (referring to Patient 9 and the patient's emergency department chart) well. I discussed the need to find an oral surgeon with the girlfriend. We do not provide the services (oral surgery) at our hospital. I gave them the ENT's(Ear, Nose, and Throat) address to follow up the next morning. If I am transferring a patient to another facility, I will have an accepting physician. My intention here was to discharge the patient to follow-up on Monday morning. I tried calling the hospital (Hospital 2) several times for an oral surgeon, but I never received a return call from the hospital (Hospital 2). When I was speaking to the patient and his girlfriend about discharge, she (girlfriend) asked me about seeing an oral surgeon at another hospital. When I explained that I never received a call back from the hospital (Hospital 2), I assumed that was the end of it. No one asked me about leaving the INT(intravenous needle) in or about transferring the patient to another hospital. When I got home that evening, the charge nurse from my ED called me and said there were allegations of an EMTALA from the ED physician at the hospital (Hospital 2). The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that the attending emergency room physician made contact and spoke directly with the accepting physician who was to accept the patient and discuss the reason for transfer of patient #9 on 11/16/2014.

On 11/25/14 from 9:05 a.m. to 9:20 a.m., an interview with emergency department Registered Nurse (RN) 1, after RN 1 reviewed Patient 9's ED chart, revealed, "Basically, what I remember is he (Patient 9) came in through triage. We ordered an x-ray and gave him pain meds(medications) because he had a facial fracture. The patient was stable and was put up for discharge and was to follow up the next day with the ENT. I was precepting that night and I told my preceptee that I would discharge the patient for her because the girlfriend of the patient was asking about going to another hospital for oral surgery. So I told her if that's what they wanted to do, that was fine. I told the girlfriend when she left here just to show the other hospital the discharge paperwork, and I also sent a copy of his x-rays with them. Next, I called the charge nurse at the hospital (Hospital 2) and told her that they would be coming and that I was going to leave his INT in place. I was thinking of this all as continuity of care. He was going over there to be seen, report was called, and the charge nurse didn't take it as a transfer. When we have a patient to transfer, the physician will let us know. We have to have an accepting physician, fill out the EMTALA transfer forms, call report, and then arrange transport. The doctor had discharged him and I wasn't sure who the doctor was in that zone then, but I ran it by my charge nurse and she said it was okay to leave the INT in. That was pretty much it." The facility failed to ensure that Policy and Procedure was followed as evidenced by failing to ensure that a written certification for transfer or their transfer form was completed for Patient #9 on 11/16/2014 by the physician or nurse as stated in their policies.

On 11/25/14 at 10:10 a.m., ENT Physician 1 revealed in an interview that Patient 9 would not have been an appropriate referral for ENT since the ENT practice provides general ENT services such as tonsils, excision of neck masses, and facial trauma, but not mandible fractures.
Patient 9 was discharged without an appropriate referral for follow up and the hospital did not initiate an appropriate transfer to a hospital within the capability and capacity to treat the patient's injuries. The facility failed to ensure that their transfer policy and procedure was followed as evidenced by failing to arrange for an appropriate transfer of Patient #9 on 11/16/2014 to minimize the risks of the transfer by failing to utilize qualified personnel and appropriate equipment, was required based on his condition because of his low oxygen saturation levels and drowsiness of the patient.