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Based on document review, and staff interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.20 and 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure that a patient presenting to the Emergency Department was provided stabilizing treatment. See deficiency at A-2407.

2. The Hospital failed to ensure that a patient received an appropriate transfer. See deficiency at A-2409.

3. The Hospital failed to ensure the risks and/or benefits for transfer were explained to the patient/family/caregiver. See deficiency at B-2409.

Based on a document review and staff interview, it was determined for 1 of 20 (Pt #1) patients, whom presented to the Emergency Department (ED) for treatment, the Hospital failed to ensure necessary stabilizing treatment, within the Hospitals' capabilities was provided. This has the potential to affect all patients receiving care in the ED. (daily census of approximately 20 patients)

1. On 07/08/19 at 12:30 PM, the ED record for Pt #1 was reviewed. This was a 61 year old male who presented to the Emergency Department (ED) on 06/30/19 at 8:28 AM with complaint of shortness of breath. The patient had a history of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Anemia, status post Coronary Artery Bypass Grafting, Renal Failure, and Chronic Lymphaedema. Vital signs taken at 8:35 AM as follows: Blood Pressure (BP) 103/47; Heart rate (HR) 115 regular, tachycardic (fast) and strong (normal resting heart rate for adults ranges from 60 to 100 beats per minute); Respirations (RR) 26 regular, labored and rapid (normal rate for an adult at rest is 12 to 20 breaths per minute); Oxygen (O2) saturation at 98% on room air; Temperature 96.9 Fahrenheit (F) oral. Pain level 0/10 with 0 as no pain and 10 as severest pain patient has ever experienced. The patient was placed on O2 at 2 liters/minute per nasal cannula for comfort. Blood was collected and an Electrocardiography (EKG) and Chest X-ray were completed. Numerous unsuccessful attempts were made by 3 different nurses and 2 paramedics to obtain an intravenous (IV) access. At 10:12 AM the ED Physician (E #4) was made aware of critical lab values: Hemoglobin 5.29 (Reference Range 12.3 - 17.3); Hematocrit 19.1 (Reference Range 36.9 - 49.3); Potassium 7.2 (Reference Range 3.3 - 5.1); and PH (acid/base) 6.910 (Reference Range 7.350 - 7.450). At 10:30 AM, ED Registered Nurse (E #7) questioned E #4 about placing a central venous catheter (catheter placed into a large vein using sterile technique) since they had, up to that point, been unable to establish an IV access peripherally. E #7 was instructed by E #4 to call the Peripherally Inserted Central Catheter (PICC) team. E #4 was informed the PICC team was only on call Monday-Friday (06/30/19 was on a Sunday). At 11:21 AM a 20 gauge intravenous catheter was able to be inserted in Pt #1's left forearm. (No medication ordered). Vitals taken at 11:49 AM as follows: BP 107/56; HR 80; RR 20, 02 saturation 100% on nasal cannula at 2 liters/minute; temp 98 F; and pain level 0/10. At 11:55 AM Pt #1 was transported by Advanced Cardiac Life Support ambulance to an acute care Hospital, approximately 30 minutes away. Pt #1's clinical record lacked documentation that any medication, other than oxygen was administered to the patient, while in the Emergency Department or en-route to the receiving Hospital.

2. On 07/08/19 at 11:00 AM, the Ambulance "Patient Care Report" run #20579, dated 06/30/19 was reviewed. The report indicated Pt #1 was transported from the transferring Hospital at 11:55 AM and arrived at the receiving Hospital at 12:45 PM. Pt #1's report lacked documentation to indicate the patient received any medication except oxygen at 2 liters/minute per nasal cannula during transport.

3. On 07/09/19 at 11:30 AM, the Hospital policy "Appropriate Transfer to Another Facility" revised by the Hospital on 01/25/08 was reviewed. Under "Guidelines B." it reads "The term stabilize means with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability to result from the transfer of the individual from a facility. 7. The hospital has a duty to stabilize a patient with an emergency medical condition when it has capabilities to do so, prior to patient transfer, which minimizes the risks to the individual's health....."

4. On 07/08/19 at 11:12 AM, an interview with the Hospital Medical Director (E #6) was conducted. E #6 stated that the Nurse Manager/Quality (E #1) notified E #6 the following day (07/01/19) about the care Pt #1 received on 06/30/19 in the ED. After reviewing Pt #1's medical record, E #6 stated that there were areas of concern from a "quality of care" standpoint and not from an EMTALA point of view that needed to be addressed. The patient's potassium level and PH (acid/base) level should have been addressed and treated. E #6 explained that the patient was awake, alert and oriented, so medication such as an albuterol inhaler and oral medication could have and should have been ordered. E #6 also explained that there should have been an attempt to use an intraosseous infusion (the process of injecting directly into the marrow of a bone to provide fluids and medication when intravenous access is not available or feasible) when staff was having difficulty obtaining an IV access.

5. On 07/08/19 at 10:12 AM, an interview with the Director of Quality (E #1) was conducted. After a review of Pt #1's record, E #1 stated that "all the bases were covered" related to EMTALA, including a medical screening, physician to physician contact, and the patient was transferred in an Advanced Cardiac Life Support (ACLS) ambulance. However, E #1 stated that more medications should have been given prior to transfer.

A. Based on a document review and staff interview, it was determined for 1 of 20 (Pt #1) patients, whom presented to the Emergency Department (ED) for treatment and was transferred, the Hospital failed to ensure the patient was transferred appropriately. This has the potential to affect all patient receiving care in the ED. (daily census of approximately 20 patients)

1. On 07/08/19 at 12:30 PM, the ED record for Pt #1 was reviewed. this was a 61 year old male who presented to the Emergency Department (ED) on 06/30/19 at 8:28 AM with complaint of shortness of breath. The patient had a history of Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, Anemia, status post Coronary Artery Bypass Grafting, Renal Failure, and Chronic Lymphaedema. Vital signs taken at 8:35 AM as follows: Blood Pressure (BP) 103/47, Heart rate (HR) 115 regular, tachycardic (fast) and strong (normal resting heart rate for adults ranges from 60 to 100 beats per minute); Respirations (RR) 26 regular, labored and rapid (normal rate for an adult at rest is 12 to 20 breaths per minute); Oxygen (O2) saturation at 98% on room air; Temperature 96.9 Fahrenheit (F) oral. Pain level 0/10 with 0 as no pain and 10 as severest pain patient has ever experienced. The patient was placed on O2 at 2 liters/minute per nasal cannula for comfort. Blood was collected and an Electrocardiography (EKG) and Chest X-ray were completed. Numerous unsuccessful attempts were made by 3 different nurses and 2 paramedics to obtain an intravenous (IV) access. At 10:12 AM the ED Physician (E #4) was made aware of critical lab values: Hemoglobin 5.29 (Reference Range 12.3 - 17.3); Hematocrit 19.1 (Reference Range 36.9 - 49.3); Potassium 7.2 (Reference Range 3.3 - 5.1); and PH (acid/base) 6.910 (Reference Range 7.350 - 7.450). At 10:30 AM, ED Registered Nurse (E #7) questioned E #4 about placing a central venous catheter (catheter placed into a large vein using sterile technique) since they had, up to that point, been unable to establish an IV access peripherally. E #7 was instructed by E #4 to call the Peripherally Inserted Central Catheter (PICC) team. E #4 was informed the PICC team was only on call Monday-Friday (06/30/19 was on a Sunday). At 11:21 AM, a 20 gauge intravenous catheter was able to be inserted in Pt #1's left forearm. (No medication ordered). Vitals taken at 11:49 AM as follows: BP 107/56; HR 80; RR 20, 02 saturation 100% on nasal cannula at 2 liters/minute; temp 98 F; and pain level 0/10. At 11:55 AM Pt #1 was transported by Advanced Cardiac Life Support ambulance to an acute care Hospital, approximately 30 minutes away. Pt #1's clinical record lacked documentation that any medication, other than oxygen was administered to the patient, while in the Emergency Department or en-route to the receiving Hospital.

2. On 07/08/19 at 11:00 AM, the Ambulance "Patient Care Report" run #20579, dated 06/30/19 was reviewed. The report indicated Pt #1 was transported from the transferring Hospital at 11:55 AM and arrived at the receiving Hospital at 12:45 PM. Pt #1's report lacked documentation to indicate the patient received any medication except oxygen at 2 liters/minute per nasal cannula during transport.

3. On 07/09/19 at 11:30 AM, the Hospital policy "Appropriate Transfer to Another Facility" revised by the Hospital on 01/25/08 was reviewed. Under "Guidelines B." it reads "The term stabilize means with respect to an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability to result from the transfer of the individual from a facility. 7. The hospital has a duty to stabilize a patient with an emergency medical condition when it has capabilities to do so, prior to patient transfer, which minimizes the risks to the individual's health....."

4. On 07/08/19 at 11:12 AM, an interview with the Hospital Medical Director (E #6) was conducted. E #6 stated that the Nurse Manager/Quality (E #1) notified E #6 the following day (07/01/19) about the care Pt #1 received on 06/30/19 in the ED. After reviewing Pt #1's medical record, E #6 stated that there were areas of concern from a "quality of care" standpoint and not from an EMTALA point of view that needed to be addressed. The patient's potassium level and PH (acid/base) level should have been addressed and treated. E #6 explained that the patient was awake, alert and oriented, so medication such as an albuterol inhaler and oral medication could have and should have been ordered. E #6 also explained that there should have been an attempt to use an intraosseous infusion (the process of injecting directly into the marrow of a bone to provide fluids and medication when intravenous access is not available or feasible) when staff was having difficulty obtaining an IV access.

5. On 07/08/19 at 10:12 AM, an interview with the Director of Quality (E #1) was conducted. After a review of Pt #1's record, E #1 stated that "all the bases were covered" related to EMTALA, including a medical screening, physician to physician contact, and the patient was transferred in an Advanced Cardiac Life Support (ACLS) ambulance. However, E #1 stated that more medications should have been given prior to transfer.

6. A review of Pt #1's receiving Hospital records was conducted. Pt #1 was a direct admit on 6/30/19 at 1:14 PM to the Telemetry B Unit. "Hospitalist History and Physical" notes dated 06/30/2019, indicated under "HISTORY OF PRESENT ILLNESS...On request for transfer, E #4 reported that there was difficulty establishing IV access and patient needed a PICC in the past. Explained to E #4 that patient would need IV access before acceptance given for transfer...Also recommended that a blood transfusion be started prior to transfer. A 20G peripheral IV was placed. No transfusions were given." Documentation under "ASSESSMENT & PLAN... Went to patient's bedside shortly after arrival to the floor. While reviewing patient's records from Sparta ED at bedside, I noted patient's ABG (Arterial Blood Gas) of 6.91/28/121. K 7.2 at Sparta ED. These results were not reported to me by E #4 when we discussed the transfer request. Just as I informed the RN of the results and that I would be immediately ordering STAT labs, further testing, I saw that the patient had agonal breathing. I called a Code Blue shortly thereafter (an emergency situation announced in a hospital in which a patient in cardiopulmonary arrest, requiring immediate resuscitative efforts). Patient subsequently expired." Documentation under "Hospitalist Death Summary Admit date: 6/30/2019 1: 14 PM Date of Death and Time: 6/31/2019 [sic] 1:51 PM Preliminary Cause of Death: Cardiac arrest"


B. Based on a document review and staff interview, it was determined for 3 of 20 (Pt #1, Pt #9, Pt #12) patients whom presented to the Emergency Department (ED) for treatment, and were transferred, the Hospital failed to ensure the risks and/or benefits for transfer were explained to the patient/family/caregiver. This has the potential to affect all patients transferring from the ED. (daily census of approximately 20 patients)

1. On 07/08/19 at 11:00 AM to 07/09/19 at 1:00 PM, the medical records of Pt #1, Pt #9, and Pt #12 were reviewed and the following was found:

a) Pt #1 - Date of Service (DOS): 06/30/19: Transfer document "Physician's Certificate for Transfer" undated, lacked documentation under "risks for transfer".
b) Pt #9 - DOS: 06/25/19: Transfer document "Physician's Certificate For Transfer" dated 06/25/19, lacked documentation under "risks for transfer".
c) Pt #12 - DOS: 04/12/19 Transfer document "Physician's Certificate For Transfer" dated 04/12/19, lacked documentation under "risks or benefits for transfer".

2. On 07/09/19 at 11:30 AM, an interview with the Director of Quality (E #1) was conducted. E #1 confirmed that the transfer documents for Pt #1, Pt #9 and pt #12 were not complete and accurate and stated, "We need to make sure they are completed."