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Based on medical record reviews, staff interviews and observation, it was determined the hospital failed to comply with the requirements at §289.24 by failing to ensure an appropriate transfer occurred for one (1) of twenty (20) patient records reviewed (patient #1). This has the potential for patients to have negative outcomes when proper continuity of care is not provided (see Tag C 2409).

Based on medical record reviews, staff interviews and observation, it was determined the hospital failed to ensure an appropriate transfer occurred for one (1) of twenty (20) patient records reviewed (patient #1). This has the potential for patients to have negative outcomes when proper continuity of care is not provided. Findings include:

Review of the Summers County Appalachian Regional Healthcare Hospital (SCARHH) medical record for patient #1 revealed the male patient arrived at the Emergency Department (ED) on 4/17/16 at 4:20 p.m. There is a brief physician note on which it is documented "Patient presented with a degloving of his third digit distal phalanx. Finger portion wrapped in frozen peas. Immediate triage to Beckley for surgical intervention, placed finger piece in sterile gauze soaked in sterile saline, placed back in frozen peas after wrapping in plastic bag. Total patient time: 2 minutes." The nurse also wrote a brief note including "Disposition status is discharge. Vital signs were not taken at discharge because patient was not seen by a nurse; patient left with verbal intstructions by physician."

Review of the Raleigh General Hospital (RGH) medical record for the same patient (patient#1) revealed the patient arrived at the RGH ED on 4/17/16 at 5:12 p.m. The patient had a documented medical screening examination including x-rays of the injured finger. A surgeon examined the patient while in the ED. The ED physician documented that attempts were made to transfer to two (2) different tertiary care hospitals. The consulting surgeon documented the patient was advised the tip of the finger could not be re-attached. The patient's finger was cleaned and dressed and the patient received medications while in the ED. He was discharged to home with instructions to follow-up with the surgeon.

The Registered Nurse (RN) who was working in the ED when patient #1 arrived was interviewed on 4/25/16 at 1:35 p.m. She stated that the ED was busy on Sunday 4/17/16 in the afternoon. She stated she was with a patient in the triage room when patient #1 presented to the registration window. She stated the physician was at the desk with the registration clerk, and the physician took the patient directly to an examination room. She stated the physician asked her to get some dressing supplies, which she did for him. She stated she was not in the examination room with the physician or the patient. She stated a few minutes later, the registration clerk informed her the physician had stated he did not want the patient to be registered. She stated she told the clerk to call the nursing supervisor. She stated the supervisor promptly arrived to intervene, but the patient had already left the premises.

The registration clerk who was present in the ED when patient #1 arrived was interviewed on 4/25/16 at 3:00 p.m. She confirmed the RN's statement and stated that sometime between 4:10 and 4:20 p.m. on 4/17/16 she was registering a patient. She stated patient #1 arrived at the registration window with his family. She stated the ED physician was sitting at the same office area as herself and he (the physician) got up to assist the patient. She stated the physician took the patient to an examination room. She stated that when she completed the other patient's registration, she went to the examination room to complete a bedside registration for patient #1. She stated the physician told her "We aren't going to register this patient - time is of the essence." She stated she immediately informed the RN, who asked her to call the nursing supervisor and she did as she was instructed.

The CCNO and the hospital Administrator were jointly interviewed on 4/25/16 at 10:15 a.m. They both stated that when the incident occurred with patient #1, the nursing supervisor called to inform the CCNO. The nursing supervisor informed her that attempts had been made to stop the patient from leaving the hospital, but the patient was present only a few minutes total in the ED and left before any staff could intervene. The CCNO stated she watched security video tapes and confirmed the patient was in the hospital a total of four (4) minutes. She stated that after the nursing supervisor called herself, she immediately informed the Administrator. They both stated they had conversations that evening and the next morning with both the ED physician and the ED Medical Director. They stated the decision was made by the administrative team to have the ED physician removed from the schedule. They stated the physician has not worked at the hospital since the 4/17/16 shift and will not be placed on any future schedule. The ED physician was not available for interview.