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Based on record review and interview, the hospital failed to ensure compliance with the requirements of CFR 489.24 as evidenced by:

1) failing to provide a medical screening exam on all patients that presented to the emergency department with an emergency complaint for 1 (#F9) of 20 patients sampled. This deficient practice is evidenced by Patient #F9 not receiving a medical screening exam after presenting to the ED with a chief complaint of pain and abnormal ultrasound results (see findings tag C-2406).

2) failing to provide further stabilizing treatment when the hospital had the capacity and capability to further stabilize and minimize the risk for 1 (#F16) out of 6 (#F15-#F20) patients reviewed for appropriate transfer. This deficient practice is evidenced byPatient #F16 having a significant decrease in blood pressure and not being re-evaluated by the physician after initial treatment was provided and prior to the time of transfer (see findings tag C-2407).

3) failing to stabilize a patient prior to transferring and minimize the risk for 1 (#F16) out of 6 (#F15-#F20) patients reviewed for appropriate transfer. This deficient practice is evidenced by Patient #F16's blood pressure dropping while in the ED and not being stabilized before being placed into an ambulance and transferred (see findings tag C-2409).

4) failing to ensure a central log was maintained on each individual who came to the ED seeking emergency assistance. This deficient practice was evidenced by failure to have a patient who presented for ED services included in the ED log for 1 (#F9) of 20 sampled patient records reviewed (see findings tag C-2405).

Based record review and interviews, the hospital failed to provide further stabilizing treatment when the hospital had the capacity and capability to further stabilize and minimize the risk for 1 (#F16) out of 6 (#F15-#F20) patients reviewed for appropriate transfer. This deficient practice is evidenced byPatient #F16 having a significant decrease in blood pressure and not being re-evaluated by the physician after initial treatment was provided and prior to the time of transfer.

Findings:

On 1/22/19 at 9:10 a.m. a review of the Emergency Room Policy Transfer Policy-EMTALA Reference Number A-8 revealed in part:
Stabilize: No material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition.

A review of Patient #F16's medical record revealed Patient #F16 was admitted to the ED on 1/15/19 at 8:14 p.m. with a complaint of vaginal bleeding. Vital signs documented at 8:23 p.m. were Temp. 98.7, BP 145/90, Pulse 112, Resp. 20, SaO2 99%, Pain Scale 5/10 by SF12RN; at 10:46 p.m. vital signs were BP 79/51, Pulse 111, Resp. 20, SaO2 99%, Pain Scale 10/10 by SF9RN; at 11:002 p.m. BP 88/62, Pulse 91, Pain Scale 5/10 by SF9RN.

Patient #F16's Nursing Note documented on 1/15/19 at 8:10 p.m. by SF9RN stated, Pt reports soaking 10 pads within 3 hrs. note pt. has large blood clots. SF9RN documented the patient was stable at 8:24 p.m. and 10:46 p.m. Further review revealed a note at 8:24 p.m. stating, "Physician is at the bedside". At 9:43 p.m. SF9RN documented, Pt to be transferred to Hospital B SF8MD accepted at 10:46 p.m. SF9RN documented she called report to the receiving hospital at 11:22 p.m.

A review of the Emergency Department Physician Medical Record for Patient #F16 revealed on 1/15/19 at 8:22 p.m., SF6MD made initial contact with Patient #F16. SF6MD documented the history of present illness as: The location is the vagina. The quality is acute. The severity is severe. The duration is prior to arrival. The timing is abrupt. Patient began to have vaginal bleeding after a fall. Denies head, neck, back injury.

A review of the Physical Exam portion of Patient #F16's medical record revealed the following:
Genitourinary: No rashes; external genital exam appears normal; speculum exam shows presence of blood; speculum exam shows presence of blood at the cervical OS. There is moderate continuous bleeding with bright red blood and clotting. Unable to see the cervix well due to continuous movement of patient.

A review of SF6MD's Physician's Orders for Patient #F16's revealed on 1/15/19 at 10:09 p.m. an order for NS Bolus of 1000 ml followed by 100 ml/ hr. Reason for infusion: Hydration. The laboratory orders included the following: On 1/15/19 at 8:26 p.m. order was placed for CBC, CMP, PTT, Blood Alcohol and Serum Pregnancy Test. The labs were drawn by the lab at 8:34 p.m. and interpreted by SF6MD at 9:19 p.m. A review of the results revealed the following: Red Blood Cells 4.20, Hemoglobin 13.0, Hematocrit 39.7, Protime 9.5, INR 1.0, Partial Thromboplastin Time 27.5, blood alcohol 95.0, and serum pregnancy test negative.

Further review of the medical record Patient Reevaluation and Observation section failed to reveal any documentation by SF6MD of a reevaluation of Patient #F16 after the fluid bolus.

The Medical Decision Making section of Patient #F16's medical record revealed the following documentation by SF6MD: On 1/15/19 at 9:34 p.m. SF8MD was notified of Patient #F16's vaginal bleeding and accepts patient for transfer to Hospital B. On 1/15/19 at 11:16 SF6MD documented, Patient #F16's last blood pressure of 88/62 with a pulse of 91 was not reported to me until the ambulance in transport to Hospital B. SF8MD called back and stated that he would report the transfer as an EMTALA violation.

SF6MD documented Patient #F16's transfer was stable. Patient being transferred to Hospital B on 1/15/19 at 10:22 p.m.
A review of Patient #F16's Informed Consent to Transfer revealed SF6MD signed the consent on 1/15/19 at 10:05 p.m. and Patient #F16 signed it on 1/14/19 at 9:56 p.m. The consent notes Patient #F16's condition as stable.

A review of the Transfer Order revealed SF6MD as the transferring MD and SF8MD as the accepting MD on 1/15/19 at 9:43 p.m. Reason for transfer documentation reveals patient requested transfer- higher level of care OBGYN services. Transfer Vitals were documented at 9:51 p.m. as Temperature 98.3, Blood Pressure 79/51 mmHg, Pulse Rate 111, Respirations 20, SaO2 99%, Pain Scale 10/10. Physician Signature: SF6MD, electronic signature.

On 1/23/19 at SF1DON reviewed and confirmed by record review a time outline of the events surrounding Patient #F16 which revealed the following:
20:14 - Patient #F16 arrived to West Feliciana Parish Hospital ER by POV with Vaginal bleeding after a fall down 3 steps. 1week s/p biopsy of cervix at Hospital B. Pt. AAOx4 in NAD.
20:23 VS- BP: 145/90, HR 112, RR 20, O2 99%, during Triage;
20:34 Labs drawn, by lab staff;
21:19 Labs interpreted by SF6MD;
21:22 SF6MD ordered saline lock and NS 1000 ml bolus;
21:34 Per SF8MD accepted patient for Vaginal bleeding at Hospital B
21:43 (transfer form) Accepted by SF8MD at Hospital B for OBGYN services
21:51 (Transfer form) VS- BP: 79/51, HR 111, RR 20, O2 99% -
21:56 Patient #F16 signed consent to transfer
22:05 SF6MD signed consent to transfer
22:22 SF6MD Pt. Transferred to Hospital B in stable condition
22:23 EMS Dispatched for transfer
22:24 1000ml NS Bolus started
22:25 EMS at West Feliciana Parish Hospital for transport
22:46 (Per EMS) VS 92/65, HR 97, RR 16
22:46 Report called by SF9RN to SF14RN at Hospital B
22:46 VS- BP: 79/51, HR 111, RR 20, O2 99
22:55 (Per EMS) VS 88/62, HR 102, RR 16
22:57 EMS left West Feliciana Parish Hospital with transfer Patient #F16
23:02 - VS- BP: 88/62, HR 91, RR - SF6MD stated he was not notified of the VS
23:05 -(Per EMS while in route to Hospital B) VS 72/52, HR 99, RR 16
23:16- Per SF6MD Patient #F16's decreased vital signs were not reported to him until the ambulance was in transport to Hospital B, when SF8MD called him to state he would report the transfer as an EMTALA violation.
23:18 - EMS arrived at Hospital B
23:19 - (Per EMS) VS 88/50, HR 96, RR 16

In an interview via telephone on 1/23/19 at 2:30 p.m.,SF9RN verified she was the primary nurse caring for Patient #F16 from admission to the ED through transport to Hospital B. SF9RN stated Patient #F16 presented to the ED with a feminine pad in place and the pad and her clothes were saturated with normal colored blood and clots. SF9RN stated while Patient #F16 was being transported to Hospital B she notified SF6MD of Patient #F16's pre transport vital signs of 88/62. SF9RN said SF6MD stated he would have preferred the blood pressure to be 100. SF9RN admits that she failed to notify SF6MD of Patient #F16's vital signs prior to being transported out of West Feliciana Parish Hospital. SF9RN states she called SF7Paramedic after speaking with SF6MD about Patient #F16's vital signs. SF7Paramedic informed SF9RN Patient #F16's blood pressure dropped into the 70's while in route and SF7Paramedic applied a pressure bag to the 1000cc normal saline that was infusing.

In an interview via telephone on 1/23/19 at 2:20 p.m. SF7Paramedic stated upon her arrival West Feliciana Parish Hospital ED Patient #F16 was pale and weak, but alert and oriented to person, place and time. After moving Patient #F16 to the ambulance stretcher SF7Paramedic pressure infused 100cc Normal Saline to Patient #F16. SF7Paramedic stated Patient's Blood Pressure declined while in route to the Hospital B to 72/52 at which time she placed a pressure bag on the 1000cc Normal Saline that was initiated at West Feliciana Parish Hospital. SF7Paramedic verified Patient #F16's VS were 88/50, Pule 96 and respirations 18 upon arrival to the Hospital B. She also stated SF8MD at Hospital B questioned her as to accepting the transfer of Patient #F16 with unstable vital signs. SF7Paramedic stated that SF8MD said Patient #F16 should have been stabilized prior to transfer.

In an interview on 1/24/19 at 8:15 p.m., SF8MD stated when he accepted Patient #F16 via telephone call with SF6MD, he was informed Patient #F16's vital signs were stable at 145/90, HR 112. SF8MD also stated that he asked SF6MD to notify them if there were any changes in Patient #F16's condition prior to transport. He verified that upon discovering Patient #F16's vital signs were not stable at the time report was being called, he contacted West Feliciana Hospital and spoke with SF6MD who stated he was not informed of Patient #F16's BP 88/62, HR 91. SF8MD stated he would have expected Patient #F16 being stabilized with fluid and or blood prior to transferring the patient. SF8MD stated by the time he spoke with SF6MD, Patient #F16 was in route to Hospital B. SF8MD stated Hospital B stabilized Patient #F16 with fluids, completed and repeated labs and performed and documented a vaginal exam which failed to reveal any arterial bleeding. SF8MD reported he did notify the hospital's ED Administration of the potential EMTALA violation.

Based record review and interviews, the hospital failed to stabilize a patient prior to transferring and minimize the risk for 1 (#F16) out of 6 (#F15-#F20) patients reviewed for appropriate transfer. This deficient practice is evidenced by Patient #F16's blood pressure dropping while in the ED and not being stabilized before being placed into an ambulance and transferred.

Findings:

A review of the hospital policy titled "Transfer Policy- EMTALA", Reviewed 2018 states in part:
Stabilize: No material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or with respect to an emergency medical condition.
West Feliciana Parish Hospital may not transfer or discharge a patient who may be reasonably at risk to deteriorate from, during or after said transfer or discharge. If the patient is at reasonable risk to deteriorate due to the natural process of his/ her medical condition, he/she is legally unstable as per EMTALA.
West Feliciana Parish Hospital may not transfer patients who are potentially unstable as long as the hospital has the capabilities to provide treatment and care to the patient. A transfer of a potentially unstable patient to another facility may only be for reason of medical necessity.

A review of Patient #F16's medical record revealed Patient #F16 was admitted to the ED on 1/15/19 at 8:14 p.m. with a complaint of vaginal bleeding. Vital signs documented at 8:23 p.m. were Temp. 98.7, BP 145/90, Pulse 112, Resp. 20, SaO2 99%, Pain Scale 5/10 by SF12RN; at 10:46 p.m. vital signs were BP 79/51, Pulse 111, Resp. 20, SaO2 99%, Pain Scale 10/10 by SF9RN; at 11:002 p.m. BP 88/62, Pulse 91, Pain Scale 5/10 by SF9RN.

Patient #F16's Nursing Note documented on 1/15/19 at 8:10 p.m. by SF9RN stated, Pt reports soaking 10 pads within 3 hrs. note pt. has large blood clots. At 9:43 p.m. SF9RN documented, Pt to be transferred to Hospital B SF8MD accepted at 10:46 p.m. SF9RN documented she called report to the receiving hospital and at 11:22 p.m. Patient #F16 arrived at Hospital B per SF7Paramedic. SF7Paramedic reported BP 88/50, heart rate 94. Patient #F16 reports being in pain and cramping.

A review of the Emergency Department Physician Medical Record for Patient #F16 revealed on 1/15/19 at 8:22 p.m. SF6MD made initial contact with Patient #F16. SF6MD documented the history of present illness as: The location is the vagina. The quality is acute. The severity is severe. The duration is prior to arrival. The timing is abrupt. Patient began to have vaginal bleeding after a fall. Denies head, neck, back injury. Patient had a cervical biopsy by SF13 (OB/GYN) one week prior. A review of the Physical Exam portion of Patient #F16's medical record revealed the following:
Constitutional: No apparent distress; general appearance is normal; awake, alert, and oriented to person, place, and time.
Genitourinary: No rashes; external genital exam appears normal; speculum exam shows presence of blood; speculum exam shows presence of blood at the cervical OS. There is moderate continuous bleeding with bright red blood and clotting. Unable to see the cervix well due to continuous movement of patient.

A review of SF6MD's Physician's Orders for Patient #F16's revealed on 1/15/19 at 10:09 p.m. an order for NS Bolus of 1000 ml followed by 100 ml/ hr. Reason for infusion: Hydration. Further review revealed SF9RN initiated the order at 10:24 p.m. The laboratory orders included the following: On 1/15/19 at 8:26 p.m. order was placed for CBC, CMP, PTT, Blood Alcohol and Serum Pregnancy Test. The labs were drawn by the lab at 8:34 p.m. and interpreted by SF6MD at 9:19 p.m. A review of the results revealed the following: Red Blood Cells 4.20, Hemoglobin 13.0, Hematocrit 39.7, Protime 9.5, INR 1.0, Partial Thromboplastin Time 27.5, blood alcohol 95.0, and serum pregnancy test negative.

The Medical Decision Making section of Patient #F16's medical record revealed the following documentation by SF6MD: On 1/15/19 at 9:34 p.m. SF8MD was notified of Patient #F16's vaginal bleeding and accepts patient for transfer to Hospital B. On 1/15/19 at 11:16 SF6MD documented, Patient #F16's last blood pressure of 88/62 with a pulse of 91 was not reported to me until the ambulance in transport to Hospital B. SF8MD called back and stated that he would report the transfer as an EMTALA violation.

SF6MD documented Patient #F16's transfer was stable. Patient being transferred to Hospital B on 1/15/19 at 10:22 p.m.
A review of Patient #F16's Informed Consent to Transfer revealed SF6MD signed the consent on 1/15/19 at 10:05 p.m. and Patient #F16 signed it on 1/14/19 at 9:56 p.m. The consent notes Patient #F16's condition as stable.

A review of the Transfer Order revealed SF6MD as the transferring MD and SF8MD as the accepting MD on 1/15/19 at 9:43 p.m. Reason for transfer documentation reveals patient requested transfer- higher level of care OBGYN services. Transfer Vitals were documented at 9:51 p.m. as Temperature 98.3, Blood Pressure 79/51 mmHg, Pulse Rate 111, Respirations 20, SaO2 99%, Pain Scale 10/10. Physician Signature: SF6MD, electronic signature.

On 1/23/19 at 11:00 a.m. at 11:37 a.m. SF1DON reviewed and confirmed by record review a time outline of the events surrounding Patient #F16 with this surveyor which revealed the following:
20:14 - Patient #F16 arrived to West Feliciana Parish Hospital ER by POV with Vaginal bleeding after a fall down 3 steps. 1week s/p biopsy of cervix at Hospital B. Pt. AAOx4 in NAD.
20:23 VS- BP: 145/90, HR 112, RR 20, O2 99%, during Triage;
20:34 Labs drawn, by lab staff;
21:19 Labs interpreted by SF6MD;
21:22 SF6MD ordered saline lock and NS 1000 ml bolus;
21:34 Per SF8MD accepted patient for Vaginal bleeding at Hospital B
21:43 (transfer form) Accepted by SF8MD at Hospital B for OBGYN services
21:51 (Transfer form) VS- BP: 79/51, HR 111, RR 20, O2 99% -
21:56 Patient #F16 signed consent to transfer
22:05 SF6MD signed consent to transfer
22:22 SF6MD Pt. Transferred to Hospital B in stable condition
22:23 EMS Dispatched for transfer
22:24 1000ml NS Bolus started
22:25 EMS at West Feliciana Parish Hospital for transport
22:46 (Per EMS) VS 92/65, HR 97, RR 16
22:46 Report called by SF9RN to SF14RN at Hospital B
22:46 VS- BP: 79/51, HR 111, RR 20, O2 99%, per SF1DON
22:55 (Per EMS) VS 88/62, HR 102, RR 16
22:57 EMS left West Feliciana Parish Hospital with transfer Patient #16
23:02 - VS- BP: 88/62, HR 91, RR - SF6MD stated he was not notified of the VS
23:05 -(Per EMS while in rout to Hospital B) VS 72/52, HR 99, RR 16
23:16- Per SF6MD Patient #F16's decreased vital signs were not reported to him until the ambulance was in transport to Hospital B, when SF8MD called him to state he would report the transfer as an EMTALA violation.
23:18 - EMS arrived at Hospital B
23:19 - (Per EMS) VS 88/50, HR 96, RR 16

In an interview via telephone on 1/23/19 at 2:30 p.m., SF9RN verified she was the primary nurse caring for Patient #F16 from admission to the ED through transport to Hospital B. SF9RN stated Patient #F16 presented to the ED with a feminine pad in place and the pad and her clothes were saturated with normal colored blood and clots.

SF9RN stated while Patient #F16 was being transported to Hospital B, she notified SF6MD of Patient #F16's pre transport vital signs of 88/62. SF9RN said SF6MD stated he would have preferred the blood pressure to be 100. SF9RN admits that she failed to notify SF6MD of Patient #F16's vital signs prior to being transported out of West Feliciana Parish Hospital. SF9RN states she called SF7Paramedic after speaking with SF6MD about Patient #F16's vital signs. SF7Paramedic informed SF9RN Patient #F16's blood pressure had dropped into the 70's while in route.

In an interview via telephone on 1/23/19 at 2:20 p.m., SF7Paramedic stated upon her arrival West Feliciana Parish Hospital ED Patient #F16 was pale and weak, but alert and oriented to person, place and time. After moving Patient #F16 to the ambulance stretcher SF7Paramedic pressure infused 100cc Normal Saline to Patient #F16. Patient #F16's color and strength returned to normal. SF7Paramedic stated Patient's Blood Pressure declined while in route to the Hospital B to 72/52 at which time she placed a pressure bag on the 1000cc Normal Saline that was initiated at West Feliciana Parish Hospital. SF7Paramedic verified Patient #F16's BP were 88/50 upon arrival to the Hospital B. She also stated SF8MD at Hospital B questioned her as to accepting the transfer of Patient #F16 with unstable vital signs. SF7Paramedica stated that SF8MD said Patient #F16 should have been stabilized prior to transfer.

In an interview on 1/24/19 at 8:15 p.m. SF8MD stated when he accepted Patient #F16 via telephone call with SF6MD, he was informed Patient #F16's vital signs were stable at 145/90, HR 112. SF8MD also stated that he asked SF6MD to notify them if there were any changes in Patient #F16's condition prior to transport. He verified that upon discovering Patient #F16's vital signs were not stable at the time report was being called, he contacted West Feliciana Hospital and spoke with SF6MD who stated he was not informed of Patient #F16's BP 88/62, HR 91. SF8MD stated he would have expected Patient #F16 being stabilized with fluid and or blood prior to transferring said patient. SF8MD stated by the time he spoke with SF6MD Patient #F16 was in route to Hospital B. SF8MD stated Hospital B stabilized Patient #F16 with fluids, completed and repeated labs and performed and documented a vaginal exam which failed to reveal any arterial bleeding. SF8MD said he did notify the hospitals ED Administration of the potential EMTALA violation.