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Based on review of Hospital policies, clinical record review and staff interview, it was determined that in 1 of 8 (Pt #1) clinical records reviewed of patients requiring transfer,the Hospital failed to ensure stabilizing treatment was completed prior to discharging the patient (CFR 489.24 (d)(1-3) and the Hospital failed to ensure appropriate transfers were completed for all transferred patients (CFR 489.24(e)(1)-(2).

A. Based on review of Hospital policy, clinical record review, review of receiving Hospital record, and staff interview, it was determined that in 1 of 8 (Pt #1) Emergency Department (ED) records reviewed of patients requiring transfer, the Hospital failed to ensure stabilizing treatment was completed prior to discharging the patient.

Findings include:

1. Hospital policy entitled, "Emergency Medical Screening," reviewed on 1/18/11 at approximately 12:00 PM required, "3. treatment to Stabilize Required: If such an individual is determined to have an emergency medical condition and treatment is required to stabilize that condition, the appropriate health care personnel must provide such further medical examination and treatment within the capabilities of the staff (including physicians from the on-call list) and facilities available unless the individual refuses to consent to such examination and treatment."

2. The clinical record of Pt #1 was reviewed on survey date 1/18/11 at approximately 10:30 AM. Pt #1 was a 26 year old male that presented to the Hospital 's ED on 1/5/11 at 4:44 PM with a complaint of Jaw Pain. The record indicated that Pt #1 was mugged and kicked in the left side of the jaw after being knocked unconscious. Pt #1 was triaged at 4:44 PM as a level A3 (level 1 to 5 with 1 as most urgent) with the following documented vital signs; blood pressure 128/75, pulse 84, respirations 16, and temperature 97.2, and the patient had pain. At 5:17 PM Pt #1' s category was elevated to a level A2 based on an elevated blood pressure of 151/99. Pt #1's medical screening exam was completed at 9:06 PM. While in the ED Pt #1 received intravenous (IV) antibiotics, IV pain medications times 2, IV anti nausea medications, and a maxillofacial CT scan. The impression of the CT scan included, Bilateral Mandibular fractures, sinus disease, and Right nasal septal deviation with bony spur.

Pt #1 was discharged on 1/6/11 at 1:59 AM with documentation by the treating physician that included, " at time of disposition, the patient is in stable condition " and with the diagnosis of Closed Fracture of Unspecified Site of Mandible. Discharge instructions include, " Please fill your prescription and take as directed. Follow up with Cook County ER this morning at 6:00 AM. Return to the ER immediately if you have any other concerns."

The Hospital failed to perform the necessary surgery in order stabilize Pt. #1's mandible.

3. The Chief of Plastic and Reconstructive Surgery was interviewed on 1/18/11 at approximately 12:30 PM. The Chief stated that the Hospital does not have Oral Maxillofacial Surgery at the Hospital. Plastic Surgery provides oral surgery within their scope of care, which includes mandibular fractures. The Chief further stated that all mandibular fractures are considered open fractures, by Plastic Surgery standards, whether or not there is exposed bone. The Chief further stated that unless there is an airway problem or excessive pain; and all patients with mandibular fractures are considered stable and discharged home and can be scheduled for surgery within one (1) to one and a half (1 ?) weeks.

4. The receiving Hospital's clinical record was reviewed on survey date 2/1/11 at approximately 8:15 AM. The record indicated that Pt #1 presented to Stroger Hospital Emergency Department on 1/6/11 at 3:03 AM (date discharged from original treating Hospital) with complaints of Jaw Injury. Pt #1 received a medical screening at 8:15 AM that included a Mandible and head CT scan which indicated "Open fracture of the angle of the mandible on the right side extending through last molar tooth . Open fracture is also seen in the body of the mandible on the left side extending through the premolar tooth" and pain medicine. At 4:00 PM on 1/6/11, Pt #1 underwent oral surgery which included Jaw wiring, and discharged home at 9:04 PM on 1/6/11.

5. A telephone interview was conducted with the Oral Surgeon at the receiving Hospital (Stroger Hospital) on 2/1/11 at approximately 10:30 AM. The surgeon stated that Pt #1 was seen and was in need of stabilization of his jaw to prevent infection Further corrective surgery could have waited up to seven (7) days. The surgeon stated that Pt #1 had his jaw stabilized with wires and was taken back to surgery two days later and had a plate inserted for corrective measures and that Pt #1 has been seen in follow up and doing fine.

6. The Vice President of Risk Management, Patient Safety and Compliance on 1/19/11 at approximately 10:00 AM confirmed that the Hospital did not perform surgery on Pt #1 prior to discharged.

A. Based on review of Hospital policy, clinical record review and staff interview, it was determined that in 1 of 8 (Pt #1) Emergency Department (ED) records reviewed for patients requiring transfer, the Hospital failed to ensure an appropriate transfer was completed.

Findings include:

1. Hospital policy entitled, "Hospital Transfers," reviewed on survey date 1/18/11 at approximately 12:00 PM required, "Policy:..B. Transfers from UCMC: 1. Medically Stable - Prior to transfer of an individual in stable medical condition from UCMC to another hospital, the following steps will be accomplished:..b. The physician or nurse practitioner shall discuss the transfer with a responsible party at a hospital that is willing to accept the transfer and treat the patient and that such facility has available space and qualified personnel to treat the patient....d. Immediately prior to the transfer, a physician or nurse practitioner shall review the transfer forms to assure completeness...C. Transfer Consent and Refusal For Medically Stable and Medically Unstable Patients: 1. Transfer Consent - If the patient consents to a transfer and a transfer is effectuated..."

2. The clinical record of Pt #1 was reviewed on survey date 1/18/11 at approximately 10:30 AM. Pt #1 was a 26 year old male that presented to the Hospital 's ED on 1/5/11 at 4:44 PM with a complaint of Jaw Pain. The record indicated that Pt #1 was mugged and kicked in the left side of the jaw after being knocked unconscious. Pt #1 was triaged at 4:44 PM as a level A3 (level 1 to 5 with 1 as most urgent) with the following documented vital signs; blood pressure 128/75, pulse 84, respirations 16, and temperature 97.2, and the patient had pain. At 5:17 PM Pt #1' s category was elevated to a level A2 based on an elevated blood pressure of 151/99. Pt #1' s medical screening exam was completed at 9:06 PM. While in the ED Pt #1 received intravenous (IV) antibiotics, IV pain medications times 2, IV anti nausea medications, and a maxillofacial CT scan. The impression of the CT scan included, Bilateral Mandibular fractures, sinus disease, and Right nasal septal deviation with bony spur.

Pt #1 was discharged on 1/6/11 at 1:59 AM with documentation by the treating physician that included, " at time of disposition, the patient is in stable condition " and with the diagnosis of Closed Fracture of Unspecified Site of Mandible. Discharge instructions include, " Please fill your prescription and take as directed. Follow up with Cook County ER this morning at 6:00 AM. Return to the ER immediately if you have any other concerns. "

The clinical record lacked documentation that Hospital had discussed Pt #1 with the receiving Hospital and that the receiving Hospital had agreed to accept Pt #1. The clinical record lacked an appropriate transfer form sending Pt #1 to the receiving Hospital, indicating acceptance and room.

3. A telephone interview was conducted with the ED treating physician (Resident) on 1/18/11 at approximately 10:45 AM. The physician stated Pt #1 was treated with antibiotics and pain medicine. Pt #1 had a CT scan of the mandible which indicated a non displaced fracture. Pt #1 was seen by a plastic surgeon while in the ED, deemed to be stable, did not need emergency surgery, and could wait for up to 6 days. Pt #1 was discharged home with prescriptions for a special diet, and liquid medications with instructions to return to the ED for any problem. The treating physician indicated that he felt Pt #1 was going to be unable to purchase the required medications and therefore noncompliant, so he told Pt #1 it may be a good idea to go to Cook County Hospital that day to start the process for treatment and to acquire the prescribed medications.

4. The finding were confirmed by the Vice President of Risk Management, Patient Safety and Compliance on 1/19/11 at approximately 10:00 AM.