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Based on record reviews and interviews, the hospital failed to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. There was no documented evidence that the on-call specialist was consulted and/or presented to the ED to examine the patient prior to transferring 9 (#2, #3, #4, #7, #10, #11, #12, #16, #20) of 18 ED patients who were determined to have an emergency medical condition and were transferred to other acute hospitals from a total sample of 20 patients.

Findings:

Review of the hospital policy titled "EMTALA Compliance 8305-C", presented as a current policy by S1VPN, revealed that individuals shall receive an appropriate medical screening examination (MSE), necessary stabilizing treatment for an EMC, and if necessary, a safe and proper EMTALA transfer to another facility. EMC was defined as a medical condition manifesting itself by acute symptoms of sufficient severity that the absence of immediate medical attention could reasonably be expected to result in placing the health of the individual or unborn child in serious jeopardy, serious impairment to any bodily functions, serious dysfunction of any bodily organ or part, or jeopardy to a pregnant woman or fetus. This hospital has determined that a physician and mid-level provider must perform the MSE. The MSE shall include access to all services offered at the hospital through the expertise of the medical staff. The NFD (no family doctor) call schedule is utilized to access care to those specialties necessary to stabilize the patient. If the screening physician determines that the individual has an EMC, the hospital will provide either additional medical treatment within the capabilities of the available staff and facilities necessary to stabilize the medical condition or, if a specialty is not represented on the NFD Call Schedule or if the physician on call is unavailable because of circumstances beyond the physician ' s control, the ED physician will provide a safe and proper EMTALA transfer, attempt to stabilize for discharge, or if unable, will stabilize and transfer the patient to a hospital with the required specialty.

Review of the hospital policy titled "Coordination of Private Physician and Emergency Physician Services", presented as a current policy by S1VPN, revealed that each patient or designee is asked to identify their private physician. Each patient reserves the right to designate the physician of their choice. If the patient so desires or if the patient has recently undergone surgery or hospitalization, the private physician will be notified. The private physician may refer the patient to the ED physician for evaluation and care. If the patient has no established physician relationship, the ED physician will care for the patient referring to the "No Family Doctor" call schedule for consult and/or follow-up.

Patient #2
Review of Patient #2's ED medical record revealed he was a 9 month old male who presented to the ED on 04/24/16 at 4:48 a.m. with reports from the parent of fever, cough, and congestion. Examination by S6EDMD revealed he had a bulging fontanelle.

Review of Patient #2's CT of the head without contrast performed on 04/24/16 at 5:28 a.m. revealed a normal brain and right Otomastoiditis.

Review of Patient #2's ED record revealed S6EDMD performed a lumbar puncture secondary to bulging fontanelle and suspected Meningitis on 04/24/16.

Review of the "NFD On-Call Schedule" for April 2016 revealed there was on-call coverage for pediatrics. There was no documented evidence in Patient #2's ED record that the on-call pediatrician was consulted prior to Patient #2 being transferred to another acute care hospital at 7:40 a.m.

A telephone interview was attempted on 04/26/16 at 3:50 p.m. with S6EDMD. There was no answer to the phone call.

Patient #3
Review of Patient #3's ED record revealed he was a 20 year old male who presented to the ED on 03/23/16 at 12:20 p.m. by ambulance with a chief complaint of motorcycle trauma. He had no primary care physician, and the attending physician was S4EDMD. History was provided by the ambulance record which revealed Patient #3 was a helmeted motorcycle rider who was thrown 15 feet, positive for loss of consciousness, and had an open laceration to the right knee and deformity to the right ankle and foot with multiple abrasions.

Review of S4EDMD's progress note documented on 03/23/16 at 12:20 p.m. revealed Patient #3 was alert with a C (cervical)-collar and backboard in place. Further review revealed he was mildly distressed with a depressed mood, recent memory impairment, no evidence of head trauma, neck non-tender with pain on movement of neck, pupils equal and reactive to light. Review x-rays interpreted by S4EDMD revealed fracture/dislocation of right foot #5 and right patellar open fracture.

Review of radiology findings revealed the following:
CT of abdomen and pelvis with IV contrast: no acute findings in abdomen or pelvis status post trauma.
CT of cervical spine: no evidence of cervical spine fracture status post trauma.
CT of chest with IV contrast: non-displaced right lateral 6th and 7th rib fractures; otherwise unremarkable exam.
CT of head without contrast: normal head CT.
Chest PA (posterior/anterior): normal chest.
AP (anterior/posterior) x-ray of pelvis: normal AP of the pelvis.
X-ray right foot 3 views: diffuse disruption of the tarsometatarsal joints with comminuted fractures throughout all the metatarsals with significant displacement and malalignment as above.
X-ray right knee AP and Lateral: diffuse skin lacerations and air in the soft tissues with a fracture of the inferior patella with displacement inferiorly of 1.5 cm (centimeter).
X-ray right shoulder 4 views: the humeral head is properly located in the glenoid fossa. The bones are intact. Impression: normal right shoulder.

Review of the "NFD On-Call Schedule" for March 2016 revealed S3MD was on-call for orthopedics.

There was no documentation in Patient #3's ED record that S4EDMD consulted S3MD, and that S3MD examined Patient #3 prior to him being transferred to another acute care hospital at 4:41 p.m.

In an interview on 04/26/16 at 2:40 p.m., S4EDMD reviewed his documentation of Patient #3's ED visit and indicated he couldn't read/understand what he wrote on the picture diagram related to Patient #3's right foot. He indicated Patient #3 had x-rays, and he called the on-call orthopedist. He indicated he spoke with S12NP. He further indicated the person he speaks with doesn't always correlate to name on the on-call schedule, because the physicians in the orthopedic group cover for one another in the group practice. He further indicated S12NP is the NP one of the staff in the orthopedic group. S4EDMD indicated S12NP indicated she would speak with the physicians about Patient #3. When S12NP called back, she indicated that 3 of the orthopedists had looked at the x-rays, and all of them said it was more than they could handle. S12NP indicated the orthopedists recommended he call Hospital A. S4EDMD indicated he called Hospital A, but they didn't call back. S4EDMD indicated called Hospital B but doesn't remember if he spoke with someone at Hospital B or if the charge nurse did. He further indicated he "definitely didn't speak with the orthopedist." He indicated if he placed the call, he would have spoken with the Admit Coordinator. When asked if he is supposed to speak physician-to-physician when transferring, he said "ideal situation is to have physician-to-physician conversation", but if the person spoken to is comfortable with the history given, he/she will accept the patient. S4EDMD indicated he didn't write the receiving physician's name on the "Patient Transfer Order." He further indicated it was written by the ED charge nurse. When asked what stabilizing treatment he performed for Patient #3, S4EDMD indicated he applied a temporary splint on the right foot and dressed the right knee. He further indicated Patient #3 wasn't actively bleeding.

In a telephone interview on 04/26/16 at 3:35 p.m., S5RN indicated she was the ED charge nurse on 03/23/16 when Patient #3 was treated. She further indicated she didn't remember if she called Hospital B or if S4EDMD did. She indicated if she actually called Hospital B, she doesn't remember who she spoke with. S5RN indicated the nurse may call for a transfer after having a discussion with the ED physician. She further indicated if she calls and there's difficulty with the receiving hospital, she goes back to the ED physician to discuss the situation. She further indicated the ED physician usually speaks with the physician at the receiving hospital.

In an interview on 04/26/16 at 4:20 p.m., S1VPN was requested to contact one of the 3 orthopedists who reviewed Patient #3's radiology films for an interview with this surveyor. After waiting 40 minutes, at 5:00 p.m. S1VPN informed the surveyor that she was not able to get any of the 3 orthopedists to call her back to arrange the interview. She confirmed that S13MD was on-call for the orthopedic group at the time of the attempted contact. An interview was not conducted as of the exit time of the survey on 04/26/16 at 5:05 p.m.

Patient #4
Review of Patient #4's ED medical record revealed she was a 9 year old who presented to the ED on 04/23/16 at 10:22 p.m. with a right 3rd digit amputation at the first joint. Review of the nursing documentation revealed S7EDMD placed the amputated digit on new ice and applied a wet-to-dry dressing to third digit at 11:40 p.m.

Review of S7EDMD's progress note revealed he spoke with S14MD (on-call orthopedist) who indicated he couldn't reimplant a finger but was willing to come in if needed. Review of the entire medical record revealed no documented evidence that S14MD examined Patient #4 prior to her being transferred to Hospital C via personal vehicle at 11:55 p.m.

In an interview on 04/26/16 at 1:55 p.m., S7EDMD indicated Patient #4's father is a physician at this hospital. He further indicated the father wanted someone to reattach the fingertip. S7EDMD indicated he checked with a physician at the acute hospital in Thibodaux, but he was out of town. He further indicated he called Hospital A, but they said they don't do re-implantations. He further indicated the person he spoke to at Hospital A indicated they could do a revision. After checking with two other hospitals, S7EDMD indicated he was given the name of a physician at Hospital C. He further indicated the physician indicated he would accept Patient #4 and assess the child.

Patient #7
Review of Patient #7's ED medical record revealed he was a 37 year old who presented on 04/08/16 at 3:18 p.m. with complaints of right heel pain who recently had a cast removed and was requesting for it to be wrapped.

Review of Patient #7's nursing documentation revealed he cannot bear weight to walk. His father reported his right foot was fractured. He was a patient at Hospital E and was sent down to have his cast removed and was supposed to be wearing a walking boot. His father indicated Patient #7 was supposed to go back to the psychiatric unit, but Hospital E sent him home.

Review of S11EDMD's progress note revealed Patient #7 had a swollen right foot, was anxious, paranoid, agitated, hallucinating with delusional thoughts, and had bruising to the right foot. Labs were drawn, and no radiology exam was ordered.

Review of the "NFD On-Call Schedule" for April 2016 revealed orthopedic coverage was provided by S9MD.

Patient #7 had a Physician's Emergency Certificate completed in the ED due Patient #7 being paranoid, delusional, and suicidal and a danger to self.

There was no documented evidence that Patient #7's complaints of a swollen right foot were evaluated and that the on-call orthopedist S9MD was consulted and examined Patient #7 prior to his being transferred to Hospital D at 6:25 p.m.

In an interview on 04/26/16 at 3:05 p.m., S2EDD indicated S11EDMD had worked the previous night and was unavailable to be interviewed.

Patient #10
Review of Patient #10's ED medical record revealed he was a 24 year old who presented to the ED on 03/24/16 at 2:23 a.m. with a report from the ambulance attendant that he punched a window and had a large laceration to the right wrist that was actively bleeding. His family indicated they thought he was drugged, because "he is never like this."

Review of S8EDMD's progress note revealed Patient #10 was disoriented to time and situation, had recent memory impairment, was intoxicated, and agitated. Further review revealed Patient #10 had a decreased pulse to the right forearm with suspicion that occlusion may be due to the tourniquet placed in the field. A pressure dressing was applied to the right forearm wound. Patient #10 was intubated by S8EDMD who documented that as patient was being sedated, he displayed decerebrate posturing that was visualized by the nurse. A CT of the head was then ordered. The family reported that he was slamming his head against the cement when the police were attempting to restrain him.

CT Arteriogram revealed the following: Clinical History - Trauma, vascular injury; Impression - diffuse occlusion of radial artery; large soft tissue laceration at level of wrist; 8 mm subcutaneous foreign body & possible deeper punctate foreign body.
CT of the head with contrast revealed no acute intracranial abnormalities status post head trauma.

Review of the "NFD On-Call Schedule" for March 2016 revealed S3MD was on-call for orthopedics. There was no documented evidence S3MD was consulted and examined Patient #10 prior to him being transferred to Hospital A at 6:35 a.m.

In a telephone interview on 04/26/16 at 3:45 p.m., S8EDMD indicated Patient #10 had a vascular injury, so the hospital had no coverage. He further indicated he spoke with S15MD who is a cardiothoracic surgeon about the patient.

Patient #11
Review of Patient #11's ED medical record revealed he was a 38 year old who presented to the ED on 03/08/16 at 7:21 p.m. with amputation to the 2nd digit of the right hand from a table saw and laceration to the 3rd and 4th digit and was actively bleeding.

Review of the "NFD On-Call Schedule" for March 2016 revealed S13MD was on-call for orthopedics on this date.

Review of S7EDMD's progress notes revealed he spoke with S9MD (a partner of S13MD) who indicated Patient #11 needed a hand specialist, and he would not be able to take care of this. There was no documented evidence that S13MD or S9MD examined Patient #11 in the ED prior to him being transferred to Hospital A at approximately 8:54 p.m. (certificate of transfer not dated and timed when signed by S7EDMD).

There was no documented evidence that the on-call orthopedist examined the patient prior to the patient being transferred.

In an interview on 04/26/16 at 1:55 p.m., S7EDMD indicated he knew the hospital's orthopedists do not perform a reimplant of the finger. He called two other hospitals and found that they didn't perform reimplants of a finger or have a hand surgeon available. He indicated he spoke with S9MD who said the patient would need a hand surgeon, and this wasn't something he could handle. S7EDMD indicated he then called Hospital A who said they would just do a revision. He further indicated the physicians in the orthopedic group with S9MD do revisions sometimes.

Review of S9MD's "Clinical Privileges In Orthopedic Surgery" revealed core privileges include the performance of procedures of hand and foot surgery in adults and children; core privileges do not include use of the surgical laser, vascular grafts of the hands and forearm, complex hand trauma surgery.

Patient #12
Review of Patient #12's ED medical record revealed he was a 17 year old who presented to the ED on 03/03/16 at 11:10 p.m. after having been ejected from a car and found laying on a culvert, unresponsive on arrival by the ambulance attendant.

Review of S7EDMD's progress notes revealed Patient #12 was unconscious, and he intubated him for airway protection.

Review of Patient #12's radiology reports revealed the following:
CT cervical spine without contrast - increased density around area of odontoid and C1 (cervical 1). Spinal stenosis caused by this material; uncertain etiology. Prevertebral space widening, accentuated on this noncontrast study due to fluid in posterior oropharynx and hypopharynx. CT head without contrast - minimal foci of peripheral contusion in frontal lobes. Minimal amount of subarachnoid hemorrhage in frontal areas bilaterally, more prominent on left. Soft tissue edema &/or contusion. CT chest without contrast - significant areas of pulmonary contusion.

Review of the "NFD On-Call Schedule" for March 2016 revealed neurology and neurosurgery were on-call.

There was no documented evidence that the on-call neurologist or neurosurgeon was consulted and examined Patient #12 prior to him being transferred to Hospital A at 1:55 a.m. on 03/04/16.

In an interview on 04/26/16 at 2:10 p.m., S7EDMD indicated Patient #12 had the potential of an unstable cervical spine fracture. He further indicated he attempted to call S16MD, had him paged, and he never called back. After waiting for the return call, he decided to transfer Patient #12 to Hospital A.

Patient #16
Review of Patient #16's ED medical record revealed he was a 58 year old who presented to the ED on 10/08/15 at 3:31 p.m. with report of being a restrained driver in a moderate motor vehicle accident.

Review of S11EDMD's progress notes revealed Patient #16 had a high force collision with a "shredded" seat belt and was extricated by a bystander before the ambulance attendants arrived.

Review of Patient #16's radiology reports revealed the following:
CT cervical spine - fracture of right C6 foramen transversarium; fracture of right C7 transverse process; diffuse subcutaneous emphysema.
CT chest with contrast - small bilateral pneumothraces; moderate pneumomediastinum and subcutaneous emphysema; right 3rd through 6th and left 1st through 5th rib fractures.
CT head without contrast - normal non-contrast cranial CT.
Portable chest - diffuse subcutaneous emphysema and pneumomediastinum and some probable bilateral apical pneumothoraces; bibasilar discoid atelectasis.
Right humerus one image - right mid humeral fracture.

Review of the medical record revealed S11EDMD inserted bilateral chest tubes and applied a right humerus splint.

Review of the "NFD On-Call Schedule" for March 2016 revealed S16MD was on-call for neurosurgery and S14MD was on-call for orthopedics. There was no documented evidence that the ED physician consulted S14MD or S16MD. There was no documented evidence that S14MD and S16MD examined Patient #16 prior to him being transferred to Hospital A at 9:20 p.m.

In an interview on 04/26/16 at 3:05 p.m., S2EDD indicated S11EDMD worked last night and is unavailable to be called for an interview

Patient #20
Review of Patient #20's ED medical record revealed she was a 12 year old who presented to the ED on 11/25/15 at 9:28 p.m. with a report of being an unrestrained backseat passenger in a motor vehicle accident with complaints of obvious left femur deformity and mid back pain, pedal pulses present, and neuro intact.

Review of Patient #20's left femur x-rays revealed a displaced fracture of mid left femoral shaft.

Review of the "NFD On-Call Schedule" for November 2015 revealed S14MD was on-call for orthopedics.

Review of S7EDMD's progress note revealed he spoke with S13MD (same practice with S14MD) who said they don't have appropriate equipment to perform surgery. There was no documented evidence that S14MD or S13MD presented to the ED to examine Patient #20 prior to her being transferred to Hospital F at 12:20 a.m. on 11/26/16.

In an interview on 04/26/16 at 2:10 p.m., S7EDMD indicated he spoke with S13MD who said they don't have the appropriate equipment to perform surgery the night of the visit and recommended transferring the patient. S7EDMD indicated he was able to explain to S13MD where the fracture was, and he (S7EDMD) didn't request that S13MD come to examine the patient.

In an interview on 04/26/16 at 4:10 p.m., S2VPN indicated she spoke with S10ORCC who is the OR Clinical Coordinator. She further indicated S10ORCC said if it's a planned, scheduled orthopedic procedure for a child, arrangements are made with the equipment representative to bring the needed equipment/supplies to perform the surgery but wouldn't have equipment/supplies needed in an emergent situation.

Based on record reviews and interviews, the hospital failed to ensure:
1) The physician certification signed by the ED physician at the time of transfer included a summary of the risks and benefits upon which the decision to transfer was made as evidenced by having the space on the form for documenting the risks and benefits of transfer left blank for 15 (#1, #2, #4, #5, #7, #8, #10, #11, #12, #13, #14, #16, #17, #19, #20) of 18 ED patient transfers reviewed from a sample of 20 patients.
2) The physician informed the patient, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefits of the transfer as evidenced by failure to have documented evidence that 3 (#8, #10, #11) of 18 ED patients (or their responsible party) transferred were informed of the risks and benefits of transfer from a sample of 20 patients.

Findings:

1) The physician certification signed by the ED physician at the time of transfer included a summary of the risks and benefits upon which the decision to transfer was made:
Review of the hospital policy titled "EMTALA Compliance 8305-C", presented as a current policy by S1VPN, revealed the transferring physician signs a certification that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the individual from being transferred. The certification must contain a summary of the specific risks and benefits on which it is based.

Review of the "Medically Indicated Transfer & (and) Physician's Certificate of Transfer" for Patients #1, #2, #4, #5, #7, #8, #10, #11, #12, #13, #16, #17, #19, and #20 revealed no documented evidence of a summary of the specific risks and benefits on which the physician based his/her decision to transfer the patient.

Review of the "Medically Indicated Transfer & Physician's Certificate of Transfer" for Patient #14 revealed no documented evidence of a summary of the specific risks on which the physician based his decision to transfer the patient.

On 04/26/16 at 3:50 p.m. an unsuccessful attempt was made to call S6EDMD to discuss the certification of transfer. There was no answer to the telephone call.

In an interview on 04/26/16 at 1:55 p.m., S7EDMD indicated he usually discusses the risks and benefits of transfer with the patient or family member, but this area of the form is usually completed by the ED nurse, and he signs the form. He further indicated he must have failed to check to be sure all areas of the form were completed.

In an interview on 04/26/16 at 3:30 p.m., S2EDD indicated the physician should complete the risks and benefits section of the certificate of transfer, but the ED nurse should check to assure the form is appropriately completed before the patient is transferred.

In a telephone interview on 04/26/16 at 3:45 p.m., S8EDMD indicated the nurse usually documents the risks and benefits for transfer, and he signs the form. He further indicated most of the time he speaks with the patient and informs them of the plan, but the nurse documents so we "can move as fast as possible."

In an interview on 04/26/16 at 3:05 p.m., S2EDD indicated S11EDMD worked last night and was unavailable to be called for an interview.

2) The physician informed the patient, or a legally responsible person acting on the patient's behalf, in writing of the risks and benefits of the transfer:
Review of the hospital policy titled "EMTALA Compliance 8305-C", presented as a current policy by S1VPN, revealed the request for transfer must be in writing and must indicate the reasons for the request and that the individual is aware of the risks and benefits of the transfer.

Review of the "Medically Indicated Transfer & Physician's Certificate of Transfer" for Patients #8, #10, and #11 revealed no documented evidence that the patient or their family member was informed in writing of the risks and benefits of the transfer. The section on the form that required the signature with the time and date of the patient or legally responsible party and a witness was blank. There was no documented evidence in the ED medical record that they were informed of the risks and benefits of transfer.

In an interview on 04/26/16 at 1:55 p.m., S7EDMD indicated he usually discusses the risks and benefits of transfer with the patient or family member, but this area of the form is usually completed by the ED nurse, and he signs the form. He offered no explanation for not having a signature of Patient #11 signifying he was informed of the risks and benefits of the transfer.

In an interview on 04/26/16 at 3:05 p.m., S2EDD indicated S11EDMD worked last night and was unavailable to be called for an interview to discuss the transfer of Patient #8.

In a telephone interview on 04/26/16 at 3:45 p.m., S8EDMD indicated Patient #10 was "completely out of his mind". He confirmed his parents were present in the ED. He offered no explanation for not having a signature of Patient #10's parents signifying they were informed of the risks and benefits of the transfer.