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Based on review of facility policy, medical record review, and interviews, the facility failed to ensure transfer requirements were met for 1 patient (Patient #1) of 8 transferred Emergency Department (ED) patients who presented to the ED of 30 ED patients reviewed.

The findings include:

Patient #1 presented to Facility A's ED by ambulance on 6/12/2022 due to left upper abdominal pain and left lower back pain which began the same evening after he turned and felt a sharp pain. The patient was concerned because he had recently had a biopsy of his spleen (body organ which controls level of blood cells) on 6/9/2022. Diagnostic studies were performed and the patient was evaluated by the on call general surgeon. Patient #1 was transferred to Facility B for splenic embolization (procedure to stop bleeding). Medical record review of Patient #1's Patient Transfer to Another Facility form (Facility A) did not show the patient's medical record was sent to Facility B. Medical record review of Patient #1's ED medical record for Facility B showed the patient's medical records from Facility A were not sent with the patient to Facility B.

Refer to A-2409.

Based on review of facility policy, medical record review, and interview the facility failed to ensure medical records were sent to the accepting facility for 1 patient (Patient #1) of 8 transferred Emergency Department (ED) patients of 30 ED patients reviewed.

The findings include:

Review of Facility A's policy "Transfer Policy-Emergency Medical Treatment and Active Labor Act (EMTALA)" revised 7/21/2021 showed "...The transferring hospital shall send to the receiving facility with approval of patient all medical records (or copies thereof) related to the emergency medical condition that the individual has presented that are available at the time of transfer, including available history, records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or written certification as required above...Other records (such as test results not yet available from the transferring hospital at the time of the patient transfer) must be sent as soon as practical after such transfer. Records must accompany the patient whether or not the patient's emergency medical condition is stabilized..."

Medical record review of a triage note showed Patient #1 arrived by ambulance to Facility A's ED on 6/12/2022 at 9:39 PM with complaint of left upper abdominal pain and left lower back pain which began the same evening after he turned and felt a sharp pain. Patient #1's blood pressure was 88/52 (normal for most adults 120/80), oxygen saturation was 91% (percent - normal 95%-100%) in room air, and his pain level was 9 out of 10 with 10 being the worst possible pain. The patient was triaged as a level 2 (emergent) on the Emergency Severity Index (ESI) system (a 5 level system used to categorize ED patients).

Medical record review of an ED Physician note showed a medical screening exam was performed by a qualified medical provider on 6/12/2022 at 10:16 PM. Patient #1 complained of left upper abdominal and left lower back pain which began the same evening after he "...moved and twisted..." The patient was concerned because he had recently had a biopsy (removal of body tissue) of his spleen (body organ which controls level of blood cells) on 6/9/2022. Patient #1's physical exam showed "...Some left upper quadrant [abdominal] pain Abdomen without rebound tenderness or guarding present. Bowel sounds are active in all 4 quadrants [areas of abdomen]..." A CT (computed tomography-detailed x-rays) scan of the patient's abdomen/pelvis showed a "...large subcapsular hematoma [pool of clotted blood] in the spleen with active bleeding...small volume [amount] hemoperitoneum (blood in space between the organs and inner lining of the abdominal wall) in the abdomen and pelvis...His hemoglobin (carries oxygen from lung to tissues and organs) has dropped nearly 4 points since surgery. Patient having abdominal discomfort. I reached out to the general surgeon for evaluation..." The patient's disposition was set to admit with diagnoses including Acute (severe and sudden onset) Splenic Hematoma (clotted blood) and Acute Blood Loss Anemia (low blood).

Medical record review of Patient #1's laboratory results performed at Facility A on 6/12/2022 at 10:17 PM.

Medical record review of Patient #1's CT scan with contrast (dye) of the abdomen and pelvis performed at Facility A report dated 6/12/2022 and dictated/discussed with an ED Registered Nurse (RN) on 6/13/2022 at 12:56 AM showed "...Large subcapsular hematoma in the spleen with active bleeding focus...Small volume hemoperitoneum in the abdomen and pelvis..."

Medical record review of a Surgical Consult note at Facility A showed Patient #1 was evaluated by a surgeon on 6/13/2022 at 2:11 AM. At the time of the evaluation, Patient #1 was stable with a blood pressure of 110/55. The surgeon determined it would be best to transfer Patient #1 to a higher level of care as he was a candidate for splenic embolization (procedure to stop bleeding) and had an increased risk for embolization failure due to the subcapsular hematoma.

Medical record review of Patient #1's Patient Transfer to Another Facility form completed on 6/13/2022 at 3:45 AM showed Patient #1 was transferred to Facility B to obtain a higher level of care not available at Facility A. The section for accompanying documentation showed the box in front of "...Copy of Transfer Form..." was checked indicating it had been sent with Emergency Medical Services (EMS). The check box in front of "...Copy of Pertinent Medical Record..." was not checked.

Medical record review of a Daily Focus Assessment Report (Nursing) showed Patient #1 was transferred to Facility B by EMS on 6/13/2022 at 4:13 AM. "...Other Hospital Transfer Checklist...Chart copy to go with patient...Facesheet...Transfer Form (yellow copy to facility)...Scan original Transfer Form into chart..."

Medical record review of a Triage note showed Patient #1 arrived by ambulance to Facility B's ED on 6/13/2022 at 4:39 AM. The patient had a spleen biopsy on 6/9/2022 and was transferred from Facility A's ED "...PT [Patient #1] HYPOTENSIVE [low blood pressure] UPON ARRIVAL...NO LAB WORK OR SCAN RESULTS SENT WITH EMS FROM [Facility A]..." The patient's blood pressure was 86/53, oxygen saturation was 90% on 4 liters of oxygen by nasal cannula, and his pain score was 4/10 upon arrival to the facility. The patient's ESI was 3 (urgent but not emergent).

Medical record review of Facility B's ED Physician Note dated 6/13/2022 at 4:40 AM showed Patient #1 was initially evaluated at Facility A "...where he apparently had labs and imaging revealing splenic hemorrhage. Unfortunately, no medical record or imaging has been transferred with the patient via EMS, and his hemoglobin level or the extent of the bleeding are unknown at the time of arrival...Patient has a concerning peritoneal abdominal exam on arrival, markedly hypotensive. I suspect hemorrhagic shock [loss of both circulating blood volume and oxygen-carrying capacity] due to that splenic hemorrhage reported at the outside facility..." Vascular/general surgery were consulted emergently while awaiting imaging results. A CT Angiogram with contrast of abdomen/pelvis was performed on 6/13/2022 at 5:09 AM and showed "...Splenic subcapsular hematoma and focal areas of active extravasation [active bleeding]...Moderate volume hemoperitoneum..." A CBC was performed on 6/13/2022 at 4:59 AM and showed Patient #1's HGB was 8.4, HCT 26.1, and platelet count was 228,000.

Medical record review showed Patient #1's medical record from Facility A was faxed to Facility B on 6/13/2022 at 5:20 AM (41 minutes after Patient #1's arrival to the ED).

Medical record review showed Patient #1 had Interventional Radiology Embolization performed on 6/13/2022. The report showed the embolization procedure was successful.

Medical record review of a Surgical Critical Care Progress Note for 6/14/2022 showed Patient #1 was admitted to the Trauma Surgical Intensive Care Unit following the embolization procedure on 6/13/2022.

During an interview on 6/22/2022 at 10:05 AM, in the ED, the ED Director stated "...anything done...goes with the patient..." The patient's medical record was to be copied and sent to the accepting facility with EMS. The ED Director stated there was never a time a medical record would not be sent with the patient "...even in an emergency..."

During a telephone interview on 6/22/2022 at 4:10 PM, the complainant stated Patient #1 arrived to Facility B's ED with "...no data...lab...radiology results...nothing sent..." The complainant stated EMS reported they had specifically asked for the patient's medical record. Facility B's ED had to repeat stat (immediate) lab work and CT Angiogram. The complainant stated he probably could have asked for records but he "...couldn't sit and wait...patient was very ill..." The complainant reported Patient #1 had an emergent Embolization by Interventional Radiology. He went on to say the patient's "...belly basically full of blood..." The complainant stated he called Facility A's ED between 4:00 AM-5:00 AM and spoke with the ED charge nurse to let them know what had happened.

During a telephone interview on 6/23/2022 at 8:37 AM, RN #1 recalled Patient #1 was transferred to Facility B due to a splenic bleed. RN #1 stated pertinent information from the medical record including a face sheet, transfer form, medication administration record, and radiology disc were sent with patients who were being transferred. RN #1 stated "...I know I sent the transfer form and face sheet..." but could not recall if he sent Patient #1's entire medical record when the patient was transferred. He went on to say the ED didn't typically send the "...full chart...always send transfer form and face sheet..."

During a telephone interview on 6/23/2022 at 11:50 AM, RN #2 stated an ED physician from Facility B called Facility A's ED after Patient #1 arrived in the ED at Facility B. The physician was upset and reported the patient had arrived with no medical record. RN #2 stated he "...went ahead and faxed..." the patient's medical record to the physician "...just in case the medical record was accidentally left behind or left in the ambulance..."