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Based on review of facility policy, review of on-call schedules, medical record review, and interviews, the facility failed to provide an appropriate Medical Screening Examination (MSE) and failed to provide an appropriate transfer for 1 patient (#15) who presented to the Emergency Department (ED) with complaints of abdominal pain of 22 ED records reviewed.

The findings include:

Patient #15 was presented to Facility A on 8/31/2024 with a diagnosis of Abdominal Pain.

Medical record review showed a medical screening examination (MSE) was initiated by the Emergency Department (ED) Physician. Diagnostic testing was completed. The Computed Tomography (CT) scan of the abdomen showed a Small Bowel Obstruction. The ED Physician spoke with the on-call general surgeon and bariatric surgeon at Facility A and the on-call bariatric surgeon at Facility B. There were discussions related to the transfer from or retaining the patient at Facility A. Facility A's bariatric surgeon felt the patient should be transferred to Facility B for continued care with the bariatric surgeon who performed an initial gastric bypass procedure (weight loss surgery). Facility B's bariatric surgeon accepted the patient but felt the procedure could be performed at Facility A. There were no additional diagnostics performed, including a repeat CT scan or Lactic Acid blood level, to conclude if the patient had a closed loop bowel obstruction or if the patient was septic. Patient #15 was transferred to Facility B on 9/1/2024, where an exploratory laparoscopy (surgical procedure) with segmental small bowel resection and anastomosis (repair) was performed.

Refer to A-2406 and A-2409

Based on review of facility policy, review of on-call schedules, medical record review, and interviews, the facility failed to provide a thorough and ongoing Medical Screening Examination (MSE) for 1 patient (#15) who presented to the Emergency Department (ED) with complaints of abdominal pain of 22 ED records reviewed.

The findings include:

Review of facility policy, "Emergency Medical Treatment and Active Labor (EMTALA) Guidelines," revised 5/2024, showed "...Medical Screening Examination [MSE] is defined as the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an Emergency Medical Condition [EMC] or not, an MSE is an ongoing process that begins with triage...the MSE may include...other examinations, test, or procedures as deemed necessary by the treating practitioner..."

Review of the on-call schedules for Facility A showed on 8/31/2024, the facility had on-call surgeons for Bariatrics and General Surgery.

Review of the ED Central Logs showed Patient #15 presented to Facility A's ED on 8/31/2024 at 6:16 PM, with Abdominal Pain.

Medical record review of an ED Nursing Triage record, dated 8/31/2024 at 6:27 PM, showed the patient presented with abdominal cramping, stabbing pain into his back and left side. The pain started two hours prior to arrival. The patient was triaged with an Emergency Severity Index (ESI) of a 2, indicating emergent needs.

Medical record review of an ED Physician's Record, dated 8/31/2024 at 9:24 PM, showed the patient had intermittent cramping and pain over the past week. The patient presented with an acute onset of abdominal pain with radiation to his left flank, approximately two hours prior to arrival with nausea and vomiting. The patient's abdomen was mildly distended with diffuse tenderness, which was worse to the left side. Diagnostic testing was ordered and completed to include the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipase, and a Computed Tomography (CT) of the abdomen and pelvis.

Medical record review of the CT of the abdomen and pelvis findings, dated 8/31/2024 at 7:50 PM, showed short segment focally dilated small bowel loop in the mid abdomen measuring up to 4 centimeters (cm) with adjacent fluid and edema, "...this is potentially a closed loop obstruction with dilated short segment closely positioned transition sites. Overall, findings are suspicious for small bowel obstruction/developing obstruction."

Medical record review of the ED Physician's notes dated 8/31/2024, showed the following:
8:35 PM - The case was discussed with Facility A's on-call general surgery, there was some uncertainty if this was a true bowel obstruction, due to the patient's normal white blood cell count and a heart rate of 56. The on-call bariatric surgeon at Facility B was called.
9:04 PM - The on-call bariatric surgeon at Facility B was consulted and determined he would be able to accept patient, but there were currently no beds available at Facility B. It was determined the patient's presentation would be discussed with the on-call bariatric surgeon at Facility A.
9:12 PM - The patient's case was discussed with Facility A's on-call for bariatric surgery and he recommended the patient be transferred to Facility B, where the patient's initial bariatric surgery was performed. Facility B's transfer center informed Facility B they were able to accept the patient on transfer and arranged the transfer.
10:30 PM - The patient's transfer in progress to Facility B. The diagnoses included Obstructed Internal Hernia and Small Bowel Obstruction.

Medical record review showed no documentation the on-call bariatric surgeon at Facility A evaluated the patient during the admission on 8/31/2024. There were no additional diagnostics performed to ascertain an ischemic injury (lack of blood supply) or to rule out Sepsis.

Medical record review of an Admission History and Physical from Facility B, dated 9/1/2024 at 3:00 AM, showed the patient had a previous Laparoscopic Gastric Bypass in June 2023. About 14 hours prior to arrival, the patient had a sudden onset of left-sided abdominal pain. He presented to Facility A on 8/31/2024, where he was diagnosed with a Closed Loop Bowel Obstruction in the jejunojejunostomy (surgical procedure) region. A request for transfer was made. On arrival, the patient continued to have pain which was stated as 8-9 out of 10 to the left side. His physical examination showed bloating, positive for abdominal pain, nausea, and dry heaves. His abdomen was nondistended, he had guarding and tenderness with positive rebound tenderness. His CT of the abdomen showed evidence of a Closed Loop Bowel Obstruction, likely related to an Internal Hernia around the jejunojejunostomy region. A discussion with the patient showed "...my recommendation to proceed immediately to the operating room, as was planned prior to his transfer. We discussed the plan for an exploratory laparoscopy. However, I did tell him that given the degree of incarceration that this is likely to be present and the potential for ischemic bowel there is a likelihood that we would need to convert to an open laparotomy. We discussed some of the other etiologies for bowl obstruction such as adhesions. We discussed the potential need for bowel resection. We discussed how nonoperative management was essentially not an option at this point. Patient expressed his understanding and agreement to proceed to the operating room..."

Medical record review of an operative report, dated 9/1/2024 at 3:36 PM, showed an exploratory laparoscopy with segmental small bowel resection and anastomosis was performed. The patient was admitted to Facility B.

During an interview on 10/15/2024 at 2:45 PM, the ED Nurse Manager stated the patient presented to the ED on 8/31/2024 with back and abdominal pain. The ED Physician had spoken with General Surgery regarding the patient, and it was felt related to the patient's normal WBC and low pulse, there was questions if the patient had a true bowel obstruction. The ED physician spoke with the on-call Bariatric Surgeon at Facility B who stated he would accept the patient but there were no inpatient beds. The on-call surgeon suggested speaking with Facility A's on-call bariatric surgeon and the patient not be transferred. The ED Physician spoke with Facility A's on-call Bariatric Surgeon who felt since the patient had the gastric bypass at Facility B, it would be best for the patient to transfer to Facility B.

During an interview on 10/15/2024 at 3:30 PM, ED Physician #1 and ED Medical Director, stated the patient presented with abdominal pain, nausea and vomiting on 8/31/2024. The patient had a previous gastric bypass June 2023. A CT of the abdomen and pelvis was completed which showed a closed loop bowel obstruction. She had spoken with Facility A's on-call General Surgeon and there were some questions related the patient's WBC was not elevated and the patient's heart rate was in the 50's. She had called the Facility B's on-call bariatric surgeon who stated he would accept the patient but there were no beds. The on-call surgeon at Facility B asked for the on-call Bariatric Surgeon at Facility A to be called for possible surgical intervention and the patient not be transferred. She called Facility A's Bariatric Surgeon, who stated if at all possible, the patient should be transferred to Facility B related to previous gastric bypass surgery in the past.

During a telephone interview on 10/16/2024 at 8:00 AM, Facility A's General Surgeon stated the ED physician had called him regarding the patient. The patient's CT showed a possible small bowel obstruction. He had a previous gastric bypass at EMC. The patient's WBC was normal and the patient did not present with sepsis.

During a telephone interview on 10/16/2024 at 1:01 PM, Facility's A's Bariatric Surgeon #1, stated he was on-call for 8/31/2024. The ED Physician called and the patient's presentation and diagnostic findings were discussed. He had spoken with the on-call Bariatric Surgeon at Facility B on the phone regarding the patient's diagnostic findings who felt the patient could be kept at Facility A. The discussions included most surgeons would like to evaluate and treat their own patients, patients could be admitted to the pre-operative unit for evaluation and then taken to surgery. He stated "...he did not like my suggestions and was not happy. He did not think the patient needed transfer related to there were no beds. I told him the patient could be a transfer from ED to ED and he could see the patient in the ED if the beds were the issue. There was an agreement for the transfer to [Facility B] as the patient would probably need surgical intervention..." He confirmed he did not evaluate the patient in the ED on 8/31/2024.

During a telephone interview on 10/16/2024 at 4:40 PM, the complainant stated the patient was transferred from Facility A to Facility B on 9/1/2024. The Risk Manager from Facility A had confirmed Facility A had capacity and availability to perform the surgery. The Bariatric Surgeons from both facilities had spoken on the phone on 8/31/2024. After discussion, there was an agreement for the transfer to Erlanger. The Bariatric Surgeon at Facility B felt the patient did not need transfer and the patient could have been managed at Facility A.

During a telephone interview on 10/21/2024 at 10:00 AM, Bariatric Surgeon #2 the patient was in a facility who had the capacity to treat and admit the patient. He had questioned why the procedure could not be performed at Facility A. He had spoken with the ED Physician who stated the patient had a small bowel obstruction. The ED Physician had talked with the surgeon who thought the patient needed transfer related to previous surgery at Facility B. He had spoken with the on-call bariatric provider at Facility A and informed the surgeon the facility did not open beds and the patient could be treated at [Facility A] and not transferred. Bariatric Surgeon #2 stated "...[named Bariatric Surgeon #1] told me he had often had patients transferred and he would see the patient in the ED or in the preoperative area. I told him I was not refusing the patient, but I felt the patient could be treated there and not transferred..." The patient arrived at Facility B on 9/1/2024 and was taken to surgery for an exploratory laparotomy. The patient was admitted and discharged home on 9/3/2024.

Based on review of facility policy, review of on-call schedules, medical record review, and interviews, the facility inappropriately transferred 1 patient (#15) who presented to the Emergency Department (ED) with complaints of abdominal pain of 22 ED records reviewed. The facility had the capability and capacity to treat Patient #15, but transferred instead.

The findings include:

Review of facility policy, "Emergency Medical Treatment and Active Labor (EMTALA Guidelines," revised 5/2024, showed "...the hospital will not transfer patients who are potentially unstable as long as the hospital has capacity and capabilities to provide stabilizing treatment to the patient..."

Review of the on-call schedules for Facility A showed on 8/31/2024, the facility had on-call surgeons for Bariatrics and General Surgery.

Review of the hospital census for 8/31/2024, showed the facility had the capacity to admit. The facility had 284 staffed beds with 249 of those beds designated for acute care. The facility-wide census was as follows on 8/31/2024:
7:00 AM: 226 patients
7:00 PM: 213 patients

Medical record review of an ED Nursing Triage record, dated 8/31/2024 at 6:27 PM, showed Patient #15 presented with abdominal cramping, stabbing pain into his back and left side. The pain started two hours prior to arrival. The patient was triaged with an Emergency Severity Index (ESI) of a 2, indicating emergent needs.

Medical record review of an ED Physician's Record, dated 8/31/2024 at 9:24 PM, showed the patient had intermittent cramping and pain over the past week. The patient presented with an acute onset of abdominal pain with radiation to his left flank approximately two hours prior to arrival with nausea and vomiting. The patient's abdomen was mildly distended with diffuse tenderness, which was worse to the left side. Diagnostic testing was ordered and completed to include the following: Complete Blood Count (CBC), Comprehensive Metabolic Panel (CMP), Lipase, and a Computed Tomography (CT) of the abdomen and pelvis. The patient's CT scan of the abdomen and pelvis showed a Small Bowel Obstruction.

Medical record review of the ED Physician's notes, dated 8/31/2024, showed the following:
8:35 PM - The case was discussed with Facility A's on-call general surgery. The on-call bariatric surgeon at Facility B was called.
9:04 PM - The on-call bariatric surgeon at Facility B was consulted and determined he would be able to accept the patient, but there were currently no beds available at Facility B. It was determined the patient's presentation would be discussed with the on-call bariatric surgeon at facility A.
9:12 PM - The patient's case was discussed with Facility A's on-call for bariatric surgery who recommended the patient be transferred to Facility B, where the patient had his bariatric surgery.
10:30 PM - It was determined the patient would be transferred to Facility B. The diagnoses included Obstructed Internal Hernia and Small Bowel Obstruction.

Medical record review showed no documentation the bariatric on-call surgeon at Facility A evaluated the patient.

Medical record review of an Admission History and Physical from Facility B, dated 9/1/2024 at 3:00 AM, showed the patient had a previous Laparoscopic Gastric Bypass in June 2023. About 14 hours prior to arrival, the patient had a sudden onset of left-sided abdominal pain. He presented to (Facility A) on 8/31/2024, and was diagnosed with a Closed Loop Bowel Obstruction in the jejunojejunostomy (surgical procedure) region. A request for transfer was made for the patient. On arrival, the patient continued to have pain which was stated as 8-9 out of 10 to the left side. His CT of the abdomen showed evidence of a Closed Loop Bowel Obstruction, likely related to an Internal Hernia around the jejunojejunostomy region. The patient was taken to the operating room where an Exploratory Laparoscopy with Segmental Small Bowel Resection and Anastomosis was performed. The patient was admitted to Facility B.

During an interview on 10/15/2024 at 2:45 PM, the ED Nurse Manager stated the patient presented to the ED on 8/31/2024 with back and abdominal pain. The ED Physician had spoken with General Surgery regarding the patient, and it was felt related to the patient's normal WBC and low pulse, there was questions if the patient had a true bowel obstruction. The ED physician spoke with the on-call Bariatric Surgeon at Facility B who stated he would accept the patient but there were no inpatient beds. The on-call surgeon suggested speaking with Facility A's on-call bariatric surgeon and the patient not be transferred. The ED Physician spoke with Facility A's on-call Bariatric Surgeon who felt since the patient had the gastric bypass at Facility B, it would be best for the patient to transfer to Facility B.

During an interview on 10/15/2024 at 3:30 PM, ED Physician #1 and ED Medical Director, stated the patient presented with abdominal pain, nausea and vomiting on 8/31/2024. The patient had a previous gastric bypass June 2023. A CT of the abdomen and pelvis was completed which showed a closed loop bowel obstruction. She had spoken with Facility A's on-call General Surgeon and there were some questions related the patient's WBC was not elevated and the patient's heart rate was in the 50's. She had called the Facility B's on-call bariatric surgeon who stated he would accept the patient but there were no beds. The on-call surgeon at Facility B asked for the on-call Bariatric Surgeon at Facility A to be called for possible surgical intervention and the patient not be transferred. She called Facility A's Bariatric Surgeon, who stated if at all possible the patient should be transferred to Facility B related to previous gastric bypass surgery in the past.

During a telephone interview on 10/16/2024 at 8:00 AM, Facility A's General Surgeon stated the ED physician had called him regarding the patient. The patient's CT showed a possible small bowel obstruction. He had a previous gastric bypass at EMC. He did not evaluate the patient during his admission on 8/31/2024.

During a telephone interview on 10/16/2024 at 1:01 PM, Facility's A's Bariatric Surgeon #1, stated he was on-call for 8/31/2024. The ED Physician called and the patient's presentation and diagnostic findings were discussed. He had spoken with the on-call Bariatric Surgeon at Facility B on the phone regarding the patient's diagnostic findings who felt the patient could be kept at Facility A. The discussions included most surgeons would like to evaluate and treat their own patients, patients could be admitted to the pre-operative unit for evaluation and then taken to surgery. He stated "...he did not like my suggestions and was not happy. He did not think the patient needed transfer related to there were no beds. I told him the patient could be a transfer from ED to ED and he could see the patient in the ED if the beds were the issue. There was an agreement for the transfer to [Facility B] as the patient would probably need surgical intervention..." He confirmed he did not evaluate the patient in the ED on 8/31/2024.

During a telephone interview on 10/16/2024 at 4:40 PM, the complainant stated the patient was transferred from Facility A to Facility B on 9/1/2024. The Risk Manager from Facility A had confirmed Facility A had capacity and availability to perform the surgery. The Bariatric Surgeons from both facilities had spoken on the phone on 8/31/2024. The Bariatric Surgeon at Facility B felt the patient did not need transfer and the patient could have been managed at Facility A.

During a telephone interview on 10/21/2024 at 10:00 AM, Bariatric Surgeon #2 the patient was in a facility who had the capacity to treat and admit the patient. He had questioned why the procedure could not be performed at Facility A. He had spoken with the ED Physician who stated the patient had a small bowel obstruction. The ED Physician had talked with the surgeon who thought the patient needed transfer related to previous surgery at Facility B. He had spoken with the on-call bariatric provider at Facility A and informed the surgeon the facility did not open beds and the patient could be treated at [Facility A] and not transferred. The patient arrived at Facility B on 9/1/2024 and was taken to surgery for an exploratory laparotomy.