HospitalInspections.org

Based on policy review, medical record review and interview, it was determined the hospital failed to ensure the Emergency Department (ED) provided medical screening, stabilization and an appropriate transfer for 1 of 2 (Patient #7) sampled patients transferred from the hospital.

The findings included:

1. Review of Hospital #1's "Emtala" policy revealed "...Patient Transfers Transfer of a Stable Patient to Another Facility After a MSE If necessary treatment cannot be provided at [name of Hospital #1], the patient may be transferred to another facility, after stabilization...Transfer of an Unstable Patient to Another Facility After a MSE If the patient has an EMC that has not been stabilized, [name of Hospital #1] will not transfer the patient unless...The patient (or legal representative), requests, in writing, to be transferred to another medical facility...A physician completes an Authorization and Consent for Patient Transfer form as a certification that the benefits of the transfer exceeds the risk(s). At a minimum, the certificate shall include a summary of the risks and benefits of the transfer...the lack of service availability..."

2. Review of 20 medical records revealed 1 (Patient #7) of the sample was not stabilized prior to transferring and did not receive an appropriate transfer or medical screening.

Refer to findings in deficiency A2404, A-2407 and A-2409.

Based on document review, medical record review and interview, it was determined the facility failed to provide a medical screening examination within their capabilities, in order to determine the cause of the patient's presenting symptoms for 1 of 20 (Patient #7) sampled patients presenting to the DED seeking a medical screening examination



The findings included:

1. Review of the facility's "EMTALA" policy revealed, "...If an EMC [Emergency Medical Condition] exists [name of Hospital #1] will provide appropriate treatment to stabilize the EMC..."

2. Medical record review for Patient #7 revealed on 8/18/14 at 8:51 PM Emergency Medical Services (EMS) arrived at the patient's home to transport patient to the hospital due to complaints of Abdominal Pain.

Review of the 8/18/14 EMS report revealed "...On scene, Pt 59 y/o [year old]...C/C [chief complaint] ABD [abdominal] pain x 30 min [minutes]...radio report, diverted for [Hospital #2's name] to [Hospital #1's name]...Pt en route to [Hospital #1's name]..."

At 8:54 PM, the EMS documented the patient's blood pressure (BP) was 209/126, pulse (P) was 77 and regular, respirations (RR) were 20 and normal and an oxygen saturation (O2 sat) of 97 % (percent) on room air. The patient complained of pain at a level 9, on a scale of 0 - 10, with 10 being the worst pain.

At 9:04 PM EMS documented the pt's BP was 169/114, P 74 and regular, RR 20 and normal and O2 sat was 100 % on room air.

Record review of the "Presentation" note revealed Patient #1 arrived at Hospital #1's Dedicated Emergency Department (DED) on 8/18/14 at 9:22 PM. At 9:22 PM, RN #1 documented "...EMS states 'patient is complaining of right lower quadrant pain'...Acuity: ESI 3 Urgent..."

Review of the 8/18/14 "Triage Assessment" at Hospital #1 revealed at 9:27 PM RN #1 documented the "patient appears...obese, uncomfortable, Behavior is anxious...Pain began 1 hour ago...continuous...Complains of pain right lower quadrant...currently is 10 of 10 on a pain scale...aching, crampy [pain]..."

At 9:36 PM RN #2 documented the patient's abdominal "Pain began suddenly 2 hours ago...is continuous...currently is 10 out of 10...aching, sharp, throbbing...does not radiate..." RN #2 documented the patient "...Appears distressed, obese, uncomfortable, unkempt...PT REPORTS SOB AND IS VERY DIAPHORETIC...bowel sounds present x 4 quads. Abdomen is obese...tender to palpation x 4 quads. Mass noted in right lower quadrant HX OF HERNIA...Skin is diaphoretic..."

Review of the 8/18/14 physicians' documentation revealed Physician #1's physician assistant (PA) documented the MSE was performed at 9:48 PM.
The PA documented at 9:58 PM "...The patient presents with abdominal pain...began/occurred at 20:00 [8:00 PM]...nausea, vomiting ...constant...The symptoms are alleviated by nothing, the symptoms are aggravated by palpation...The patient has not experienced similar symptoms in the past...The patient has a history of hernia repair a few years ago [2011] Since then has had hernia return near scar...tonight at 8 pm he had sudden onset of abdominal pain...hernia would not reduce..." The Review of Systems revealed "...Positive for abdominal pain, nausea, vomiting, diarrhea..."
The PA documented at 9:59 PM the Exam revealed "...Bowel sounds diminished...moderate abdominal tenderness in the supraumbilical..." At 10:00 PM the PA documented, "...will consult surgery..."

At 8/18/14 the patient's "Vital Signs" and "Medications Administered" were as follows:
At 9:28 PM the BP was 144/95, P - 76, RR - 15, temperature - 97.6 and O2 sat was 98 % on room air. The patient's pain was 10/10.
At 9:57 PM the patient was administered 2 milligrams (mg) of Dilaudid for pain and Zofran 4 mg for nausea intravenously (IV).
At 11:12 PM the BP was 115/61, P - 106, RR 13, O2 sat 94% on 2 liters of oxygen per nasal cannula (nc).

Review of the 8/18/14 laboratory tests revealed at 10:03 PM the patient's results were as follows: an elevated white blood count of 14.3 (normal 4.0 - 10.0) and an elevated lactic acid level of 3.0 (normal 0.5 - 2.2).

Review of the physician's note revealed the PA documented on 8/1814 at 10:05 PM "Physician consultation...Surgery..."

Review of the 8/18/14 Abdominal CT scan performed at 11:34 PM revealed, "...Impression: 1. Multiple diverticula seen throughout the colon with mild adjacent fat stranding, suggesting diverticulitis...A small amount of free fluid is seen in the pelvis. 2. Multiple foci of air throughout the abdomen, indicating hollow organ perforation...the quantity of air is out of portion with a perforated diverticulum. 3. Multiple ventral hernias..."

Record review revealed on 8/19/14 at 12:37 AM the patient's vital signs were as follows: BP was 114/75, P - 98, RR - 24, O2 sat 97% on 2 liters of bi-nasal cannula oxygen.

Review of the 8/19/14 physician's orders revealed Physician #1 ordered NACL [Normal Saline]...1000 ml [milliliters] IV at bolus" at 12:39 AM. Physician #1 ordered another "NACL...1000 ml IV at bolus once" at 12:58 AM.
At 12:41 AM RN #2 administered the 1000 ml Normal Saline "Bolus" and Dilaudid 2 mg via the "right femoral" intravenous site.
At 1:21 AM RN #2 administered another 1000 ml of Normal Saline "bolus" and the antibiotic of Zosyn 3.375 grams via Intravenous piggyback (IVPB) in the "left antecubital" intravenous site.

On 8/19/14 at 12:30 AM the PA documented, "...Surgery [surgeon's name] and Surgery resident have seen and evaluated patient, want patient to be transferred to [Hospital #2's name] because his hernia surgery from a few years ago was done by a doctor there.."

Review of the physician documentation revealed Physician #1 documented on 8/19/14 at 12:45 AM, "...Case was discussed with [name of surgery resident] who again restates that [name of surgeon] wants the pt to be transferred to [name of Hospital #2] for final care. I reminded resident that there is not going to be higher level of care because the surgical services can be provided here, he said that he and [name of surgeon] reviewed the ct [CT] scan and they did not see any kind of incarceration. I also mentioned lab results including the lactic acid of 3.0."

Review of the 8/19/14 surgery "Consultation Assessment" revealed the resident surgeon documented at 1:05 AM, "...5 hr history of acute abdominal pain and nausea without emesis...cramping in nature and lower in periumbilical area...he is still passing flatus...patient's primary surgery at [name of hospital #2]...will discuss transfer...will need ex-lap [exploratory laparotomy] soon for hernia repair and possible small bowel resection..."

At 1:10 AM Physician #1 documented, "...Radiology...called me and told me about the new surgical issues on this patient including the large amount of free air in the abdomen compatible with a perforated hollow viscous. I let [name of resident surgeon] talk to radiology...about these new findings. Because of these new issues I told [name of resident surgeon] to call [name of surgeon] again so he can take care of the pt here, however [name of surgeon] declined again to take care of this pt and advised to transfer pt to [name of Hospital #2]..."

At 2:01 AM the PA documented, she discussed the lab results with the patient/support person and the need to transfer per request of the surgeon.

At 2:16 AM Physician #1 documented, "Attestation...I agree with assessment and plan. My impression/plan are documented in this role, which I supervised and corrected."

At 2:22 AM the following changes were documented for the patient's vital signs: BP was 115/61, P - 130, RR - 24, O2 sat 92 % on 2 liters of BN oxygen.

At 2:30 AM Physician #1 documented the resident surgeon "called me to let me know that pt has been accepted by [name of a physician at Hospital #2's DED]...Pt was transferred to [name of hospital #2] and no issues were reported to me during the transfer process."

Review of the 8/19/14 nurse's notes revealed at 2:41 AM RN #2 documented, "...Condition: Stable, Transferred by EMS ground to..." Hospital #2. At 2:45 AM, "...Patient left the ED."

Review of the 8/19/14 EMS report revealed the ground ambulance arrived at Hospital #2 at 2:32 AM. The EMS report revealed the patient's BP per manual cuff was 96/60, P - 133, RR - 30 and labored and the O2 sat was 89%. The EMS report revealed the pt was transferred to Hospital #2 per ambulance.

Medical record review revealed Patient #7 presented to the DED at Hospital #2 on 8/19/14 at 3:07 AM.
Review of the DED Triage form revealed the patient arrived per stretcher with respirations slightly labored. The patient's BP was 103/64, P - 132, RR - 26 and O2 sat - 92%. The patient was triaged as a level 2 semi-emergent. At 3:50 AM the patient's BP was 83/61 and at 4:10 AM the patient's BP was 79/49.
Review of the patient's laboratory results at Hospital #2 were as follows: Carbon Dioxide - 15 (normal 22-32), BUN - 26 (normal 7-18), Creatinine 1.7 (normal 0.6-1.3), glucose 123 (normal 65-99), WBC 7.5 (normal 4.2-10.2), HGB 17.7 (normal 12.8-16.4), HCT 53.4 (normal 38.8-48.1), platelets 308,000 (normal 150-400) and a critical lactic acid level of 7.9 (normal 0.4-2.0).

Review of Hospital #2's ED physician's History and Physical note revealed the patient was administered IV fluids and required a subclavian central line to administer Levophed to sustain the patient's BP. The ED note documented "...Urgent surgical intervention..."

Review of Hospital #2's 8/19/14 "Intensivist Consultation" note revealed the physician documented "...taken for emergency surgery earlier this morning with exploratory laparotomy and resection of distal ileum...he was returned to the intensive care unit, intubated...hypotensive requiring pressors and fluid boluses. He has a significant metabolic acidosis...Respiratory failure...Septic, Shock...Peritonitis secondary to bowel perforation, status resection...Lactic acidosis related to sepsis and bowel perforation...hypokalemia...Coagulopathy..."

Review of Hospital #2's records revealed on 8/21/13 the patient underwent the operative procedure for "Reopening of recent laparotomy...Mobilization of the hepatic flexure with tight hemicolectomy...End-ileostomy..." The patient had bilateral chest tubes inserted related to Respiratory complications and remained in an Intensive Care Unit.

The patient expired at Hospital #2 on 8/29/14 at 3:44 PM related to Septic Shock and Respiratory Failure.

During an interview on 8/27/14 at 1:25 PM the PA at Hospital #1 stated "I understood that he [Patient #7] was stable the whole time..."

During an interview on 8/27/14 at 3:10 PM the resident surgeon at Hospital #1 stated, The patient came into "Level 1 with Abdomen Pain." The medicine physician resident at Hospital #1 was "concerned" the patient had an "incarcerated hernia...Took me about 1 1/2 hours to see pt, so busy with traumas." The patient's hernia was unable to reduce easily." The resident surgeon at Hospital #1 was asked if the patient was in distress. The resident surgeon stated the CT scan showed an "area of free air not a surgical abdomen." The patient wanted to go to Hospital #2 and wasn't an acute abdomen at the time, so he was transferred. There was no documentation the patient wanted to be transferred to Hospital #2.

During a telephone interview on 8/27/14 at 3:40 PM RN #1 at Hospital #1 stated "We got a call bringing patient with Right Upper Quadrant pain. I was only in and out" he was not my patient. "The PA [physician's assistant] was the first to see the patient after triage." The "other RN [RN #2] said the patient was very diaphoretic" and had a lot of pain. The patient's EKG and vital signs were stable. The patient got up to go to the bathroom, had a lot of pain and increased heart rate with exertion. His heart rate decreased after rest and pain medications. The patient "just wanted help."

During a telephone interview on 8/27/14 at 1:50 PM RN #2 at Hospital #1 stated she was in orientation at the time of this incident. RN #2 stated, "I remember the whole thing. I took...primary" nurse role in his care. He came by EMS and "didn't look good." He was "diaphoretic" and I had to wipe the sweat off him in order to place the EKG leads on him. The resident surgeon and surgeon came to see the patient sometime between 12 and 2 AM. RN #2 stated, "I didn't tell [Physician #1's name] about the heart rate increase because it came down with rest." RN #2 stated "[Physician #1's name] said the patient needs surgery" and we transferred him to Hospital #2.

During an interview, in the conference room on 8/28/14 at 9:05 AM the surgeon at Hospital #1 stated the patient's physician had been following him at Hospital #2. The surgeon stated the patient's "bowels probably perforated." The surgeon stated he talked with the patient about 1:00 AM on 8/19/14. The surgeon stated he was "overseeing" the resident surgeon. The surgeon stated the patient "only had localized pain and not diffuse at that time [1:00 AM]." The surgeon stated he "felt like he was stable at the time I saw him."

During an interview on 8/28/14 at 11:00 AM Physician #1 at Hospital #1 was asked about the series of events with Patient #1. The physician stated "The nurse asked me to go see him [patient]. I went to see the patient and couldn't reduce [the hernia], was very tender. He was about 400 pounds and wouldn't reduce." "The resident [surgeon] called me and said they weren't doing anything with the patient", no acute surgical intervention at this point. Physician #1 stated "I saw the patient 3 times, once for the MSE, around 12:30 AM and at 2:05 AM I closed the chart." The physician was asked how the patients' vital signs are monitored. Physician #1 stated the patients' vital signs and blood pressure can be monitored from the computer screens in passing.

The facility failed to provide a medical screening examination that was appropriate to the individual's complaints that would recognize the gravity of the patient's condition, sepsis in the setting of a perforated viscous prior to transfer and as a result the patient was unstable. The facility had a surgical team that was capable of performing surgery.

Based on document review, medical record review and interview, it was determined the facility failed to provide evidence of stabilizing treatment within the capability of the hospital for 1 of 2 (Patient #7) patients reviewed for transfers.

The findings included:

1. Review of the facility's "EMTALA" policy revealed, "...If an EMC [Emergency Medical Condition] exists [name of Hospital #1] will provide appropriate treatment to stabilize the EMC..."

2. Medical record review for Patient #7 revealed on 8/18/14 at 8:51 PM Emergency Medical Services (EMS) arrived at the patient's home to transport patient to the hospital due to complaints of Abdominal Pain.

Review of the 8/18/14 EMS report revealed "...On scene Pt 59 y/o [year old]...C/C [chief complaint] ABD [abdominal] pain x 30 min [minutes]...radio report, diverted for [Hospital #2's name] to [Hospital #1's name]...Pt en route to [Hospital #1's name]..."

At 8:54 PM the EMS documented the patient's blood pressure (BP) was 209/126, pulse (P) was 77 and regular, respirations (RR) were 20 and normal and an oxygen saturation (O2 sat) of 97 % (percent) on room air. The patient complained of pain at a level 9, on a scale of 0 - 10, with 10 being the worst pain.

At 9:04 PM EMS documented the pt's BP was 169/114, P 74 and regular, RR 20 and normal and O2 sat was 100 % on room air.

Record review of the "Presentation" note revealed Patient #1 arrived at Hospital #1's Dedicated Emergency Department (DED) on 8/18/14 at 9:22 PM. At 9:22 PM, RN #1 documented "...EMS states 'patient is complaining of right lower quadrant pain'...Acuity: ESI 3 Urgent..."

Review of the 8/18/14 "Triage Assessment" at Hospital #1 revealed at 9:27 PM RN #1 documented the "patient appears...obese, uncomfortable, Behavior is anxious...Pain began 1 hour ago...continuous...Complains of pain right lower quadrant...currently is 10 of 10 on a pain scale...aching, crampy [pain]..."

At 9:36 PM RN #2 documented the patient's abdominal "Pain began suddenly 2 hours ago...is continuous...currently is 10 out of 10...aching, sharp, throbbing...does not radiate..." RN #2 documented the patient "...Appears distressed, obese, uncomfortable, unkempt...PT REPORTS SOB AND IS VERY DIAPHORETIC...bowel sounds present x 4 quads. Abdomen is obese...tender to palpation x 4 quads. Mass noted in right lower quadrant HX OF HERNIA...Skin is diaphoretic..."

Review of the 8/18/14 physicians' documentation revealed Physician #1's physician assistant (PA) documented the MSE was performed at 9:48 PM.
The PA documented at 9:58 PM "...The patient presents with abdominal pain...began/occurred at 20:00 [8:00 PM]...nausea, vomiting ...constant...The symptoms are alleviated by nothing, the symptoms are aggravated by palpation...The patient has not experienced similar symptoms in the past...The patient has a history of hernia repair a few years ago [2011] Since then has had hernia return near scar...tonight at 8 pm he had sudden onset of abdominal pain...hernia would not reduce..." The Review of Systems revealed "...Positive for abdominal pain, nausea, vomiting, diarrhea..."
The PA documented at 9:59 PM the Exam revealed "...Bowel sounds diminished...moderate abdominal tenderness in the supraumbilical..." At 10:00 PM the PA documented, "...will consult surgery..."

At 8/18/14 the patient's "Vital Signs" and "Medications Administered" were as follows:
At 9:28 PM the BP was 144/95, P - 76, RR - 15, temperature - 97.6 and O2 sat was 98 % on room air. The patient's pain was 10/10.
At 9:57 PM the patient was administered 2 milligrams (mg) of Dilaudid for pain and Zofran 4 mg for nausea intravenously (IV).
At 11:12 PM the BP was 115/61, P - 106, RR 13, O2 sat 94% on 2 liters of oxygen per nasal cannula (nc).

Review of the 8/18/14 laboratory tests revealed at 10:03 PM the patient's results were as follows: an elevated white blood count of 14.3 (normal 4.0 - 10.0) and an elevated lactic acid level of 3.0 (normal 0.5 - 2.2).

Review of the physician's note revealed the PA documented on 8/1814 at 10:05 PM "Physician consultation...Surgery..."

Review of the 8/18/14 Abdominal CT scan performed at 11:34 PM revealed, "...Impression: 1. Multiple diverticula seen throughout the colon with mild adjacent fat stranding, suggesting diverticulitis...A small amount of free fluid is seen in the pelvis. 2. Multiple foci of air throughout the abdomen, indicating hollow organ perforation...the quantity of air is out of portion with a perforated diverticulum. 3. Multiple ventral hernias..."

Record review revealed on 8/19/14 at 12:37 AM the patient's vital signs were as follows: BP was 114/75, P - 98, RR - 24, O2 sat 97% on 2 liters of bi-nasal cannula oxygen.

Review of the 8/19/14 physician's orders revealed Physician #1 ordered NACL [Normal Saline]...1000 ml [milliliters] IV at bolus" at 12:39 AM. Physician #1 ordered another "NACL...1000 ml IV at bolus once" at 12:58 AM.
At 12:41 AM RN #2 administered the 1000 ml Normal Saline "Bolus" and Dilaudid 2 mg via the "right femoral" intravenous site.
At 1:21 AM RN #2 administered another 1000 ml of Normal Saline "bolus" and the antibiotic of Zosyn 3.375 grams via Intravenous piggyback (IVPB) in the "left antecubital" intravenous site.

On 8/19/14 at 12:30 AM the PA documented, "...Surgery [surgeon's name] and Surgery resident have seen and evaluated patient, want patient to be transferred to [Hospital #2's name] because his hernia surgery from a few years ago was done by a doctor there.."

Review of the physician documentation revealed Physician #1 documented on 8/19/14 at 12:45 AM, "...Case was discussed with [name of surgery resident] who again restates that [name of surgeon] want the pt to be transferred to [name of Hospital #2] for final care. I reminded resident that there is not going to be higher level of care because the surgical services can be provided here, he said that he and [name of surgeon] reviewed the ct [CT] scan and they did not see any kind of incarceration. I also mentioned lab results including the lactic acid of 3.0."

Review of the 8/19/14 surgery "Consultation Assessment" revealed the resident surgeon documented at 1:05 AM, "...5 hr history of acute abdominal pain and nausea without emesis...cramping in nature and lower in periumbilical area...he is still passing flatus...patient's primary surgery at [name of hospital #2]...will discuss transfer...will need ex-lap [exploratory laparotomy] soon for hernia repair and possible small bowel resection..."

At 1:10 AM Physician #1 documented, "...Radiology...called me and told me about the new surgical issues on this patient including the large amount of free air in the abdomen compatible with a perforated hollow viscous. I let [name of resident surgeon] talk to radiology...about these new findings. Because of these new issues I told [name of resident surgeon] to call [name of surgeon] again so he can take care of the pt here, however [name of surgeon] declined again to take care of this pt and advised to transfer pt to [name of Hospital #2]..."

At 2:01 AM the PA documented, she discussed the lab results with the patient/support person and the need to transfer per request of the surgeon.

At 2:16 AM Physician #1 documented, "Attestation...I agree with assessment and plan. My impression/plan are documented in this role, which I supervised and corrected."

At 2:22 AM the following changes were documented for the patient's vital signs: BP was 115/61, P - 130, RR - 24, O2 sat 92 % on 2 liters of BN oxygen.

At 2:30 AM Physician #1 documented the resident surgeon "called me to let me know that pt has been accepted by [name of a physician at Hospital #2's DED]...Pt was transferred to [name of hospital #2] and no issues were reported to me during the transfer process."

Review of the 8/19/14 nurse's notes revealed at 2:41 AM RN #2 documented, "...Condition: stable Transferred by EMS ground to..." Hospital #2. At 2:45 AM, "...Patient left the ED."

Review of the 8/19/14 EMS report revealed the ground ambulance arrived at Hospital #2 at 2:32 AM. The EMS report revealed the patient's BP per manual cuff was 96/60, P - 133, RR - 30 and labored and the O2 sat was 89%. The EMS report revealed the pt was transferred to Hospital #2 per ambulance.

Medical record review revealed Patient #7 presented to the DED at Hospital #2 on 8/19/14 at 3:07 AM.
Review of the DED Triage form revealed the patient arrived per stretcher with respirations slightly labored. The patient's BP was 103/64, P - 132, RR - 26 and O2 sat - 92%. The patient was triaged as a level 2 semi-emergent. At 3:50 AM the patient's BP was 83/61 and at 4:10 AM the patient's BP was 79/49.
Review of the patient's laboratory results at Hospital #2 were as follows: Carbon Dioxide - 15 (normal 22-32), BUN - 26 (normal 7-18), Creatinine 1.7 (normal 0.6-1.3), glucose 123 (normal 65-99), WBC 7.5 (normal 4.2-10.2), HGB 17.7 (normal 12.8-16.4), HCT 53.4 (normal 38.8-48.1), platelets 308,000 (normal 150-400) and a critical lactic acid level of 7.9 (normal 0.4-2.0).

Review of Hospital #2's ED physician's History and Physical note revealed the patient was administered IV fluids and required a subclavian central line to administer Levophed to sustain the patient's BP. The ED note documented "...Urgent surgical intervention..."

Review of Hospital #2's 8/19/14 "Intensivist Consultation" note revealed the physician documented "...taken for emergency surgery earlier this morning with exploratory laparotomy and resection of distal ileum...he was returned to the intensive care unit, intubated...hypotensive requiring pressors and fluid boluses. He has a significant metabolic acidosis...Respiratory failure...Septic Shock...Peritonitis secondary to bowel perforation, status resection...Lactic acidosis related to sepsis and bowel perforation...hypokalemia...Coagulopathy..."

Review of Hospital #2's records revealed on 8/21/13 the patient underwent the operative procedure for "Reopening of recent laparotomy...Mobilization of the hepatic flexure with tight hemicolectomy...End-ileostomy..." The patient had bilateral chest tubes inserted related to Respiratory complications and remained in an Intensive Care Unit.

The patient expired at Hospital #2 on 8/29/14 at 3:44 PM related to Septic Shock and Respiratory Failure.

During an interview on 8/27/14 at 1:25 PM the PA at Hospital #1 stated "I understood that he [Patient #7] was stable the whole time..."

During an interview on 8/27/14 at 3:10 PM the resident surgeon at Hospital #1 stated, The patient came into "Level 1 with Abdomen pain." The medicine physician resident at Hospital #1 was "concerned" the patient had an "incarcerated hernia...Took me about 1 1/2 hours to see pt, so busy with traumas." The patient's hernia was unable to reduce easily." The resident surgeon at Hospital #1 was asked if the patient was in distress. The resident surgeon stated the CT scan showed an "area of free air not a surgical abdomen." The patient wanted to go to Hospital #2 and wasn't an acute abdomen at the time, so he was transferred. There was no documentation the patient wanted to be transferred to Hospital #2.

During a telephone interview on 8/27/14 at 3:40 PM RN #1 at Hospital #1 stated "We got a call bringing patient with Right Upper Quadrant pain. I was only in and out" he was not my patient. "The PA [physician's assistant] was the first to see the patient after triage." The "other RN [RN #2] said the patient was very diaphoretic" and had a lot of pain. The patient's EKG and vital signs were stable. The patient got up to go to the bathroom, had a lot of pain and increased heart rate with exertion. His heart rate decreased after rest and pain medications. The patient "just wanted help."

During a telephone interview on 8/27/14 at 1:50 PM RN #2 at Hospital #1 stated she was in orientation at the time of this incident. RN #2 stated, "I remember the whole thing. I took...primary" nurse role in his care. He came by EMS and "didn't look good." He was "diaphoretic" and I had to wipe the sweat off him in order to place the EKG leads on him. The resident surgeon and surgeon came to see the patient sometime between 12 and 2 AM. RN #2 stated, "I didn't tell [Physician #1's name] about the heart rate increase because it came down with rest." RN #2 stated "[Physician #1's name] said the patient needs surgery" and we transferred him to Hospital #2.

During an interview, in the conference room on 8/28/14 at 9:05 AM the surgeon at Hospital #1 stated the patient's physician had been following him at Hospital #2. The surgeon stated the patient's "bowels probably perforated." The surgeon stated he talked with the patient about 1:00 AM on 8/19/14. The surgeon stated he was "overseeing" the resident surgeon. The surgeon stated the patient "only had localized pain and not diffuse at that time [1:00 AM]." The surgeon stated he "felt like he was stable at the time I saw him."

During an interview on 8/28/14 at 11:00 AM Physician #1 at Hospital #1 was asked about the series of events with Patient #1. The physician stated "The nurse asked me to go see him [patient]. I went to see the patient and couldn't reduce [the hernia], was very tender. He was about 400 pounds and wouldn't reduce." "The resident [surgeon] called me and said they weren't doing anything with the patient", no acute surgical intervention at this point. Physician #1 stated "I saw the patient 3 times, once for the MSE, around 12:30 AM and at 2:05 AM I closed the chart." The physician was asked how the patients' vital signs are monitored. Physician #1 stated the patients' vital signs and blood pressure can be monitored from the computer screens in passing.

The facility failed to provide stabilizing treatment that was appropriate to the individual's complaints that would recognize the gravity of the patient's condition, sepsis in the setting of a perforated viscous prior to transfer and as a result the patient was unstable. The facility had a surgical team that was capable of performing surgery.

Based on document review, record review and interview, it was determined the hospital failed to provide an appropriate transfer for 1 of 2 (Patient #7) sampled patients who presented to the Dedicated Emergency Department (DED) and were transferred to another facility.

The findings included:

1. Review of Hospital #1's "Emtala" policy revealed "...Patient Transfers Transfer of a Stable Patient to Another Facility After a MSE If necessary treatment cannot be provided at [name of Hospital #1], the patient may be transferred to another facility, after stabilization...Transfer of an Unstable Patient to Another Facility After a MSE If the patient has an EMC that has not been stabilized, [name of Hospital #1] will not transfer the patient unless...The patient (or legal representative), requests, in writing, to be transferred to another medical facility...A physician completes an Authorization and Consent for Patient Transfer form as a certification that the benefits of the transfer exceeds the risk(s). At a minimum, the certificate shall include a summary of the risks and benefits of the transfer...the lack of service availability..."

2. Medical record review for Patient #7 revealed on 8/18/14 at 8:51 PM Emergency Medical Services (EMS) arrived at the patient's home to transport the patient to the hospital for complaints of Abdominal pain and the patient was transported via ground ambulance. The EMS report documented the patient was a 59 year old male with the chief complaint of abdominal pain with an onset of 30 minutes.

The EMS report revealed at 8:54 PM the patient's blood pressure (BP) was 209/126, pulse (P) was 77 and regular, respirations (RR) were normal at 20 and an oxygen saturation (O2 sat) of 97 % (percent) on room air. The patient complained of pain at a level 9, on a scale of 0 - 10, with 10 being the worst pain. At 9:04 PM the pt's BP was 169/114, P 74 and regular, RR 20 and O2 sat was 100 % on room air.

Record review of Hospital #1's 8/18/14 "Presentation" note revealed the patient presented to the DED at 9:22 PM.

Review of Hospital #1's 8/18/14 "Triage Assessment" note revealed at 9:27 PM RN #1 documented the patient appears "obese, uncomfortable...anxious...Pain began 1 hour ago...continuous...Complains of pain right lower quadrant...currently is 10 of 10 on a pain scale...aching, crampy [pain]..."

Review of Hospital #1's 8/18/14 nurses note revealed RN #2 documented at 9:36 PM the patient's abdominal pain began 2 hours previously and was a 10 out of 10. The pain was documented to be "...is continuous...aching, sharp, throbbing...does not radiate..." RN #2 documented the patient "...Appears distressed, obese, uncomfortable, unkempt...PT REPORTS SOB AND IS VERY DIAPHORETIC...bowel sounds present x 4 quads. Abdomen is obese...tender to palpation x 4 quads. Mass noted in right lower quadrant HX [history] OF HERNIA...Skin is diaphoretic..."

Review of Hospital #1's 8/18/14 physicians' documentation note revealed Physician #1's physician assistant (PA) documented the MSE was performed at 9:48 PM. The PA documented at 9:58 PM "...The patient presents with abdominal pain...nausea, vomiting...constant...The symptoms are alleviated by nothing...symptoms are aggravated by palpation...sudden onset of abdominal pain...hernia would not reduce..." The ROS revealed "...Positive for abdominal pain, nausea, vomiting, diarrhea..." At 9:59 PM the PA documented an exam revealed "...Bowel sounds diminished...moderate abdominal tenderness in the supraumbilical..." At 10:00 PM the PA documented, "...will consult surgery..."

Record review revealed on 8/18/14 the patient's "Vital Signs" and "Medications Administered" were as follows:
At 9:28 PM the BP was 144/95, P - 76, RR - 15, temperature - 97.6 and O2 sat was 98 % on room air. The patient's pain was 10/10.
At 9:57 PM the patient was administered 2 milligrams (mg) of Dilaudid for pain and Zofran 4 mg for nausea via intravenous push.
At 11:12 PM the BP had dropped to 115/61, the P had increased to 106, RR 13, O2 sat 94% on 2 liters of oxygen per nasal cannula (nc). The patient's pain was 5/10.

Review of the patient's 8/18/14 laboratory tests, completed at 10:03 PM, revealed: white blood count - 14.3 (normal 4.0 - 10.0) and lactic acid 3.0 (normal 0.5 - 2.2).

Review of the 8/18/14 Abdominal CT scan performed at 11:34 PM revealed, "...Impression: 1. Multiple diverticula seen throughout the colon with mild adjacent fat stranding, suggesting diverticulitis...A small amount of free fluid is seen in the pelvis. 2. Multiple foci of air throughout the abdomen, indicating hollow organ perforation...the quantity of air is out of portion with a perforated diverticulum. 3. Multiple ventral hernias..."

Record review revealed on 8/19/14 the patient's "Vital Signs" and "Medications Administered" were as follows:
At 12:37 AM the BP was 114/75, P - 98, RR - 24, O2 sat 97% on 2 liters of BN oxygen.
At 12:41 AM RN #2 documented the patient was administered Dilaudid 2 mg intravenous push (IVP) for pain. RN #2 documented the patient was administered a 1000 ml Normal Saline "Bolus" in the "right femoral" intravenous (IV) site.
At 1:21 AM RN #2 documented the patient was administered the antibiotic of Zosyn 3.375 grams via Intravenous piggyback (IVPB). RN #2 documented the patient was administered another 1000 ml of Normal Saline IV "bolus" in the "left antecubital" IV site.

Record review revealed on 8/19/14 at 12:30 AM the PA at Hospital #1 documented the surgeon and resident surgeon at Hospital #1 evaluated the patient and want the patient to be transferred to Hospital #2 "because his hernia surgery from a few years ago was done by a doctor there."

Record review revealed on 8/19/14 at 12:45 AM Physician #1 at Hospital #1 documented he paged the resident surgeon to discuss the case. Physician #1 documented the resident surgeon stated again that the surgeon wants "the pt to be transferred...reminded resident that there is not going to be higher level of care because the surgical services can be provided here [Hospital #1]." The resident surgeon informed Physician #1 that the surgeon reviewed the computerized tomography (CT) scan and they did not see any kind of incarceration. Physician #1 informed the resident surgeon of the elevated lactic acid results of 3.0.

Record review revealed on 8/19/14 at 2:00 AM Physician #1 advised the resident surgeon to transfer the patient.

Review of the 8/19/14 Hospital's #1"Authorization and Consent for Patient Transfer" form, signed by Physician #1, revealed the patient's diagnosis was Perforated Viscous and Diverticulitis.
The patient's condition was listed as "Stable/Stabilized (means that no material deterioration is likely, within reasonable medical probability, to result from or occur during the transfer of the patient)...."
The "Reason for Transfer" was documented as "The patient is stable and being transferred to another facility because they require services that this facility does not provide."
The transfer form was checked that the patient had been informed of the risks and benefits of the transfer. There was no documentation or a summary what the risks versus benefits were and it was not clear that the benefits outweighed the risks because the patient was already septic with a declining clinical status prior to transfer.
At 2:16 AM Physician #1 documented, "Attestation...I agree with assessment and plan. My impression/plan are documented in this role, which I supervised and corrected."

Record review revealed at 2:22 AM RN #2 at Hospital #1 documented the patient's BP had dropped to 115/61, the P had increased to 130, RR were elevated to 24 and the O2 sat was 92 % on 2 liters of BN oxygen.

Record review revealed RN #2 documented the patient left the DED at 2:45 AM.

Review of the EMS report arrived at Hospital #1 at 2:32 AM to transport the patient. The report revealed the patient's BP had dropped to 96/60, P was 133, RR were 30 and labored and the O2 sat had dropped to 89%, while assessing the patient at Hospital #1 and before transporting the patient to Hospital #2.

Review of Hospital #2's records revealed the patient arrived at 3:07 AM. The patient's breathing was labored. The patient's BP was low at 103/61, pulse was elevated at 132, respirations 26 and O2 sat at 92%.

Review of the patient's laboratory results at Hospital #2 were abnormal as follows: Carbon Dioxide - 15 (normal 22-32), BUN - 26 (normal 7-18), Creatinine 1.7 (normal 0.6-1.3), glucose 123 (normal 65-99), WBC 7.5 (normal 4.2-10.2), HGB 17.7 (normal 12.8-16.4), HCT 53.4 (normal 38.8-48.1), platelets 308,000 (normal 150-400) and a critical lactic acid level of 7.9 (normal 0.4-2.0).

The ED physician at Hospital #2 administered intravenous fluids and inserted a central venous line to administer Levophed to keep the patient's BP from dropping further. A surgeon was consulted for "urgent surgical intervention."

The patient underwent "emergency surgery" at Hospital #2 for an exploratory laparotomy and resection of the distal ileum on 8/19/14 at 7:45 AM and was admitted to an Intensive Care Unit. The patient was intubated, on the ventilator and continued to require medications to prevent the BP from dropping. An 8/19/14 physician consult note documented "...hypotensive requiring pressors and fluid boluses. He has a significant metabolic acidosis...Respiratory failure...Septic Shock...Peritonitis secondary to bowel perforation, status resection...Lactic acidosis related to sepsis and bowel perforation...Presumptive hypokalemia...Coagulopathy..."

The patient underwent an additional surgery at Hospital #2 on 8/21/14 for "Reopening of recent laparotomy" and had bilateral chest tubes inserted related to respiratory complications.

The patient expired at Hospital #2 on 8/29/14 at 3:44 PM related to Septic Shock and Respiratory Failure.

During an interview on 8/27/14 at 1:25 PM the PA at Hospital #1 stated "...[the name of the surgeon] saw the patient and left. Left the resident [resident surgeon] in the ED. The resident said [the surgeon's name] wanted the patient transported to [name of Hospital #2]..."

During an interview on 8/27/14 at 3:10 PM the resident surgeon at Hospital #1 stated, The patient came into "Level 1 with Abdomen pain." The medicine physician resident was "concerned" the patient had an "incarcerated hernia...Took me about 1 1/2 hours to see pt, so busy with traumas." The patient's hernia was unable to reduce easily." The labs and images were back and the attending surgeon applied more pressure to try and reduce the hernia. The resident surgeon stated the patient had originally wanted to go to [name of Hospital #2] but he was diverted due to a "high off load time" for EMS. "I talked to the ED [name of physician at Hospital #2], he accepted...I called then he [ED physician at Hospital #2] called me back over in CCA [Trauma Assessment Area] area." The resident surgeon was asked if the patient was in distress. The resident surgeon stated the CT scan showed an "area of free air not a surgical abdomen." The resident surgeon stated the patient had originally wanted to go to Hospital #2, wasn't an acute abdomen at the time, therefore, he was transferred. There was no documentation the patient wanted to be transferred to Hospital #2.

During a telephone interview on 8/27/14 at 3:40 PM RN #1 at Hospital #1 stated "We got a call bringing patient with Right Upper Quadrant pain. I was only in and out" he was not my patient. RN #1 stated the patient's EKG (electrocardiogram) and vital signs were stable. The patient got up to go to the bathroom, had a lot of pain and increased heart rate with exertion. His heart rate decreased after rest and pain medications. The surgeon came to see the patient and that he had wanted to go to Hospital #2, but they were on diversion. The surgeon "had flat dry tone" and asked the patient why he came here instead of going to Hospital #2. RN #1 stated the patient "just wanted help."

During a telephone interview on 8/27/14 at 1:50 PM RN #2 at Hospital #1 stated "I remember the whole thing. I took...primary" nurse role in his care. He came by EMS and "didn't look good." He was "diaphoretic" and I had to wipe the sweat off him in order to place the EKG leads on him. The resident surgeon and surgeon came to see the patient sometime between 12 and 2 AM. When he got up to the bathroom, his heart rate went up and came back down with rest. RN #2 stated the surgeon was "rude to the patient" and mad because they brought him here. RN #2 stated she spoke with the nurse at Hospital #2 about transferring the patient.

At 1:10 AM, the radiologist called about the surgical issues on the patient including the large amount of free air in the abdomen compatible with a perforated hollow viscus. Physician #1 declined again to take the patient to surgery and advised to transfer the patient.

RN #2 stated, "I didn't tell [Physician #1's name] about the heart rate increase" because it came down with rest. RN #2 stated "Physician #1's name] said the patient needs surgery" and we transferred him to Hospital #2.

During an interview, in the conference room, on 8/28/14 at 9:05 AM the surgeon at Hospital #1 stated the patient's physician had been following him at Hospital #2. The surgeon stated the patient's "bowels probably perforated." The surgeon stated he talked with the patient about 1:00 AM on 8/19/14. The surgeon stated the patient said he had rather be taken care of at Hospital #2, "because they were familiar with him." The surgeon stated he was "overseeing" the resident surgeon. The surgeon stated the patient "only had localized pain and not diffuse at that time [1:00 AM]." The surgeon stated he "felt like he was stable at the time I saw him." The surgeon was asked if there was a refusal or inability to perform the patient's surgery. The surgeon stated that all surgery services are always available here at Hospital #1. There was no documentation the patient requested the transfer.

During an interview on 8/28/14 at 11:00 AM Physician #1 at Hospital #1 was asked about the series of events with Patient #1. Physician #1 was informed that some staff stated the patient requested the transfer, the medical record revealed the patient was transferred because "they require services this facility does not provide" and because the surgeon requested the transfer. Physician #1 was asked about the patient's transfer as the record reflected the surgeon requested the transfer and some of the interviews reflected the patient requested the transfer. Physician #1 stated "It's kind of confusing, I have to agree with you." The paperwork did not reflect that the patient requested the transfer nor did it indicate that the patient was offered surgery at Hospital #1.

The physician stated "The nurse asked me to go see him [patient]. I went to see the patient and couldn't reduce [the hernia], was very tender. He was about 400 pounds and would reduce." Physician #1 stated the PA told him the surgeon wanted the patient transferred to Hospital #2. The physician was asked how the patients' vital signs are monitored. Physician #1 stated patients' vital signs and blood pressure can be monitored from the computer screens in passing. "The resident [surgeon] called me and said they weren't doing anything with the patient", no acute surgical intervention at this point. Physician #1 stated "I saw the patient 3 times, once for the MSE, around 12:30 AM and at 2:05 AM I closed the chart." Physician #1 stated he was not informed of the elevated pulse and low blood pressures.

Physician #1 also stated that he did not document on the transfer form that the services could not be provided here at Hospital #1. There was evidence that Hospital #1 had the capability and the surgical team capable of performing the surgery. The transfer form stated that the patient was transferred because "they require services that this facility does not provide". The certification states that the benefits of transfer exceed the risks of transfer, which does not appear to be the case as the patient was septic with a declining clinical status prior to transfer. Physician #1 was reminded and agreed that he did sign the information documented on the transfer form.

While preparing the patient for transport, the EMS report revealed the patient's change in status as follows: the BP per manual cuff was 96/50, P-133 and RR-30 and labored and the O2 SAT was 89%. The patient was transferred and left the DED on 08/19/2014 at 2:45 AM.

Review of Hospital's 2's ED physician history and physical note revealed the patient received IV fluids, required a subclavian central line, started Levophed to sustain the patient's BP and consulted General Surgery. The patient was taken for emergency surgery and then admitted to the ICU, intubated, continued to receive pressors to prevent the patient's blood pressure from dropping. The patient was diagnosed with Respiratory Failure, Septic Shock, Peritonitis secondary to bowel perforation, Lactic acidosis related to sepsis and bowel perforation.

The patient underwent another surgical procedure on 08/21/2014 and had bilateral chest tubes inserted related to Respiratory complications and remained in the ICU. The patient expired on 08/29/2014 at 3:44 PM related to Septic Shock and Respiratory Failure.