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Based on interview, record review and policy review, the Critical Access Hospital (CAH, a small facility that gives limited outpatient and inpatient hospital services to people in rural areas) failed to arrange an appropriate transfer for one patient (#17) of 25 Emergency Department (ED) records reviewed from 11/01/23 through 04/23/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC).

Findings included:

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 01/29/24, showed the following:
- Physicians shall comply with the Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) rules and regulations as outlined herein.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an individual at the hospital has an EMC that has not been stabilized, the hospital will not transfer the individual unless it is an appropriate transfer.
- To make an appropriate transfer to another medical care facility, the hospital must provide the stabilizing medical treatment within its capability and capacity minimizing the risk to the individual, verify that the receiving facility has the space and qualified personnel available for the treatment of the individual, verify that the receiving hospital has agreed to accept the transfer of the individual and to provide the appropriate medical treatment, send pertinent medical records available at the time of the transfer to the receiving hospital and effect the transfer through qualified persons and transportation equipment.
- An appropriate transfer is only permitted where the patient requests the transfer or a physician has signed a certification that, based upon information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risk to the individual.

Review of the hospital's policy titled, "Inter-Hospital Patient Transfer," dated 04/2018, showed the following:
- Patients who are stable and not suffering from an EMC as defined by these policies may be transferred at their request or upon the direction of their physician, consistent with the procedures set forth below.
- A patient transfer is movement of the patient, for any reason, including discharge from the premises of the hospital, except as a result of a departure against medical advice (AMA) or as the result of death.
- A written order for transfer is issued by the transferring physician indicating the destination hospital, and/or office, the reason for transfer, medical orders for care prior to and during transport, the mode of transfer and the necessary level of attendant care and equipment required for the transfer.
- An informed consent to transfer is obtained from the patient or person acting on behalf of the patient.
- The responsible nurse shall verify directly with the receiving facility that they are able and willing to accept the patient and shall document the details of date, time and accepting individual on the transfer order form.
- The responsible nurse shall verify transfer arrangements with the appropriate ambulance agency and note the details on the transfer order form. If the patient has refused ambulance transport and will be going by private auto, document the refusal using the standard refusal form.
- The responsible nurse shall prepare the patient for transfer.

Patient #17 was a 39-year-old female who presented to the ED on 03/15/24 with a chief complaint of vision loss in the right eye. Staff L, Physician, was not able to visualize areas of the eye with the equipment available at the CAH. She contacted an ophthalmologist (eye care specialist) at Hospital B and did not contact the hospital transfer line. Patient #17 was given discharge paperwork that instructed her to present to the ED at Hospital B. She left by private vehicle and presented to the ED of Hospital B at 10:13 PM. Administration became aware of the possible EMTALA violation on 03/18/24 and began an investigation. Staff L was removed from the schedule and her contract with the hospital was terminated. EMTALA education, including review of the hospital's transfer policy were provided to all ED Physicians and nursing staff.

Based on interview, record review and policy review, the hospital failed to arrange an appropriate transfer for one patient (#17) of 25 Emergency Department (ED) records reviewed from 11/01/23 through 04/23/24. These failed practices had the potential to cause harm to all patients who presented to the ED seeking care for an Emergency Medical Condition (EMC).

Findings included:

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 01/29/24, showed the following:
- Physicians shall comply with the Emergency Medical Treatment and Labor Act (EMTALA, an act/law that obligates the hospital to provide medical screening, treatment and transfers of individuals with an EMC) rules and regulations as outlined herein.
- An EMC is a medical condition manifesting itself by acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in impairment to bodily function or serious dysfunction of any bodily organ or part.
- If an individual at the hospital has an EMC that has not been stabilized, the hospital will not transfer the individual unless it is an appropriate transfer.
- To make an appropriate transfer to another medical care facility, the hospital must provide the stabilizing medical treatment within its capability and capacity minimizing the risk to the individual, verify that the receiving facility has the space and qualified personnel available for the treatment of the individual, verify that the receiving hospital has agreed to accept the transfer of the individual and to provide the appropriate medical treatment, send pertinent medical records available at the time of the transfer to the receiving hospital and effect the transfer through qualified persons and transportation equipment.
- An appropriate transfer is only permitted where the patient requests the transfer or a physician has signed a certification that, based upon information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risk to the individual.

Review of the hospital's policy titled, "Inter-Hospital Patient Transfer," dated 04/2018, showed the following:
- Patients who are stable and not suffering from an EMC as defined by these policies may be transferred at their request or upon the direction of their physician, consistent with the procedures set forth below.
- A patient transfer is movement of the patient, for any reason, including discharge from the premises of the hospital, except as a result of a departure against medical advice (AMA) or as the result of death.
- A written order for transfer is issued by the transferring physician indicating the destination hospital, and/or office, the reason for transfer, medical orders for care prior to and during transport, the mode of transfer and the necessary level of attendant care and equipment required for the transfer.
- An informed consent to transfer is obtained from the patient or person acting on behalf of the patient.
- The responsible nurse shall verify directly with the receiving facility that they are able and willing to accept the patient and shall document the details of date, time and accepting individual on the transfer order form.
- The responsible nurse shall verify transfer arrangements with the appropriate ambulance agency and note the details on the transfer order form. If the patient has refused ambulance transport and will be going by private auto, document the refusal using the standard refusal form.
- The responsible nurse shall prepare the patient for transfer.

Review of Patient #17's medical record dated 03/15/24, from Harrison County Community Hospital, showed the following:
- She was a 39-year-old female who presented to the ED at 5:36 PM with a chief complaint of loss of vision in her right eye.
- Physician documentation showed Patient #17 denied eye trauma, watering, redness, floaters, headaches, nausea or vomiting. The patient reported gradual decreased vision that was constant and progressively getting worse.
- Past medical history included diabetes (a disease that affects how the body produces or uses blood sugar and can cause poor healing).
- Treatment prior to her arrival included over the counter eye drops and removal of her contact lens.
- Vital signs (VS, measurements of the body's most basic functions: blood pressure (BP) normal between 90/60 and 120/80; pulse/heartbeats normal 60 to 100 beats per minute; respiration rate (RR) normal 12 to 20 breaths per minutes; and body temperature normal 97.8 to 99 degrees) showed a BP of 139/81, pulse rate of 90, temperature of 98.6 and RR of 16. A bedside blood glucose (sugar that circulates in the blood and when too high or too low can be detrimental to a person's health. Normal range for a known diabetic is 80 to 180) level was 115. No other testing was completed.
- An eye exam showed the extraocular muscles (any of the six small muscles that control movement of the eye and one muscle that controls eyelid elevation) were intact, conjunctiva (membrane that covers the front of the eye and lines the inside of the eyelids) were normal, no yellowing of the eye was noted and both pupils reacted normally to light. There was a total loss of vision to the right eye and the right pupil measured 1 millimeter (mm) larger than the left.
- Staff L, Physician, documented she was not able to get a good look at the right retina with the equipment available in the hospital. She spoke with an ophthalmologist (eye care specialist) at Hospital B who requested the patient present to the ED at Hospital B for further evaluation. She discharged the patient to go to Hospital B by private car at 7:14 PM.
- Discharge paperwork included instructions to go to the ED at Hospital B that day.

Review of Patient #17's medical record dated 03/15/24, from Hospital B, showed the following:
- She presented to the ED at 10:13 PM, as a transfer from a different hospital, for vision loss.
- Patient #17 reported to staff that initially she was seen at a different ED, discharged and instructed to present to Hospital B.
- VS showed a BP of 149/102, pulse rate of 83, RR of 20 and temperature of 97.2.
- An ultrasound (a test that uses sound waves to create images of structures within the body), blood work and computed tomography angiography (CTA, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones], computer and intravenous [IV, in the vein] injection of contrast material to produce detailed images of blood vessels and tissues in a part of the body) were completed.
- Physician documentation showed he consulted with the ophthalmologist after testing was completed and it was determined the patient could be admitted to the hospital for an ophthalmology consult, but the patient decided to go home and return the next morning for an outpatient appointment. She was discharged on 03/16/24 at 1:29 AM.

Review of the hospital's document titled, "Timeline of Events," dated 03/26/24, showed the following:
- On 03/18/24 an incident report related to Patient #17's ED visit on 03/15/24 was reviewed by Staff B, Risk Manager, and an investigation immediately began.
- On 03/20/24 the first root cause analysis (RCA, a tool to help study events where patient harm or undesired outcomes occurred in order to find the root cause) meeting occurred and a plan of action was created. Actions included interviews with staff; removal of Staff L, Physician, from the schedule; created EMTALA education for all physicians and nursing staff; and an increase in chart audits would occur.
- On 03/20/24 Staff G, Paramedic, stated that Patient #17 was already in the ED when she arrived for her shift. Staff L, Physician, called somebody at Hospital B, but she did not know who. Staff L told Staff G to give Patient #17 discharge paperwork, the patient was going to the ED at Hospital B via private vehicle. Staff G did not know if the transfer center at Hospital B had been contacted. Staff L took a telephone call regarding Patient #17, then stated she was going to be in trouble for EMTALA and Hospital B was not happy.
- On 03/22/24 a RCA meeting was held and interviews were completed. During an interview Staff N, Paramedic, stated that he triaged Patient #17, but was not aware of Staff L, Physician, talking on the telephone at his shift change.
- On 03/25/24 Staff B contacted Patient #17 to inquire about her experience in the ED. Patient #17 denied any concerns regarding her visit.
- On 03/26/24 EMTALA education was provided to staff via electronic mail (email).

Review of the hospital's document titled, "Interview," dated 03/22/24, showed Staff L, Physician, stated that she spoke with the ophthalmologist at Hospital B after contacting the transfer center there. The ophthalmologist told her that Patient #17 did not have an emergency condition and he could just see her outpatient on 03/18/24. If the patient was transferred to Hospital B, he would not go in to evaluate her. She discharged Patient #17 from the ED on 03/15/24 and did not send her to Hospital B. Staff B, Risk Manager, reminded Staff L that documentation in the medical record did not match her statements. Staff L confirmed that someone from Hospital B contacted her and told her that she had violated EMTALA, she should have called a report on Patient #17 and followed proper transfer protocol. Staff B explained to Staff L that per her physician documentation, Patient #17 would have been a transfer and not a discharge.

Review of the hospital's document titled, "Focused Chart Review," dated 03/27/24, showed Patient #17 was a 39-year-old female who presented to the ED with acute progressive vision loss in the right eye. Patient #17 was otherwise stable and had no other symptoms. The physician appropriately consulted an ophthalmologist at Hospital B and documented that she was instructed to have the patient go to the ED at Hospital B for further evaluation. Patient #17 was then discharged and told to go directly to the ED at Hospital B. The patient should have been transferred to Hospital B, rather than discharged, since it was a higher level of care. It was not clear from the documentation if the ophthalmologist requested the discharge. If the ophthalmologist requested discharge, it was the responsibility of the ED Physician to recognize that the patient needed to be transferred rather than discharged. There should have been direct communication with Hospital B's ED to give a heads up regarding the request by the ophthalmologist to the have the patient go to their hospital; so the proper process could have been put in place to move the patient through the system with communication and an accepting physician, care team, proper paperwork and check out provided prior to the patient arriving there.

Although requested, Staff L, Physician, was not available for an interview.

During an interview on 04/25/24 at 10:00 AM, Staff K, ED Medical Director, stated that Staff L, Physician, was not able to provide the services Patient #17 needed when she presented to the ED on 03/15/24. It was obviously an EMTALA violation to transfer the patient without speaking with the ED Physician at Hospital B prior. Staff L had issues prior to that event regarding documentation, patient care and professional interactions. Staff L was a contracted physician and the agency was notified of the event. Staff K was involved in the decision to terminate the hospital's contract with Staff L. Nursing staff were not comfortable with Staff L and she had previously been spoken to about concerns. Staff L "just did whatever she wanted to do."

During an interview on 04/25/24 at 8:45 AM, Staff G, Registered Nurse (RN), stated that she was Patient #17's nurse for a short time as she began her shift just prior to the patient's departure. She was told in report that the patient would be leaving but Staff N, Paramedic, did not know if she was being discharged or transferred. Staff L, Physician, did call Hospital B and spoke to another physician, but she did not know who. An appropriate transfer included a telephone call to the transfer line of the hospital the patient was being sent to and the call was typically made by the physician. She did not know if Staff L called the transfer line at Hospital B to give a report. She was present when Staff L spoke with the patient and Staff G pointed to the EMTALA transfer paperwork that would have been needed. Staff L told her to discharge Patient #17. Staff G took VS and gave the patient discharge paperwork.