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Based on document review, review of medical records, review of policies and procedures and interviews with key personnel at both the transferring and the receiving facilities on September 17, 2010, it was determined that the hospital failed to provide the necessary stabilizing treatment. These findings represent an Immediate Jeopardy to the patients seeking emergency treatment at Calais Regional Hospital.

The evidence is as follows:

1. 42 CFR ?489.24 (e) (1) states that if an individual at a hospital has an emergency medical condition that has not been stabilized, the hospital may not transfer the individual unless the transfer is an appropriate transfer.

2. 42 CFR ?489.24(b) defines stabilized to mean " ...that 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 " ... "


3. 42CFR ?489.24 (e) (2) defines an appropriate transfer as having four requirements. The first requirement at ?489.24 (2) (i) states... the transferring hospital provides medical treatment, within its capacity, that minimizes the risks to the individual ' s health.

4. The American College of Emergency Physician ' s Emergency Medicine, A Comprehensive Study Guide , 6th edition, Judith Tintinalli, Ed., page 1415 & 16 states, " ...after cassation of drinking include tremulousness, nausea, anxiety ...delirium tremors (DT ' s) if left untreated, approximately 5 per cent of patients who withdraw from alcohol will proceed to DT ' s, which usually begin 3 to 5 days after cessation of alcohol. "

5. The Emergency Nurses Association, Sheehy ' s Manual of Emergency Care, 6th edition, Lorene Newberry, Ed., page 452, states under the topic Alcohol Withdrawal, " In chronic alcoholics, withdrawal will begin 6 to 48 hours after a reduction or cessation of ethanol intake. This condition lasts 2 to 7 days. " It further indicated " Severe cases of alcohol withdrawal occur in chronic alcoholics 24 hours to 5 days after cessation or reduction of alcohol consumption ...Delirium tremens (DT) occurs after a severe drop in the amount of ethanol consumed by an alcoholic, usually starting on the third day without alcohol. DT is an acute medical emergency. Untreated, this condition is associated with 10 % to 15 % mortality. "

6. On review of the CRH Patient Care Committee Meeting minutes on September 17, 2010 revealed, that the issue of treating Alcohol Withdrawal patients was discussed on July 29, 2009 and October 28, 2009. The Alcohol Withdrawal Form is complete and the committee reviewed the form and approved it. The form was to be taken to the Medical Staff for approval on September 10, 2009. It was documented under Conclusion/Action " The committee approved the Alcohol Withdrawal Order Set. This form will be utilized as a Standard Order Sheet for admissions and will be adapted to the Emergency Department as well. "

7. The Calais Regional Hospital, " Alcohol Withdrawal Order Set ' stated, " The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-AR) scale is a validated 10 item assessment tool that can be used to qualify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal. "

8. On September 17, 2010, a review of the CRH policy titled 'Guidelines for Medical Screening Exams, Diversions, Admitting and Discharging Patients ' was conducted. It states ... " CRH [Calais Regional Hospital] must provide either: medical examination and such treatments as may be required to stabilize the medical condition if available at CRH or, transfer the individual to another medical facility using appropriate staff and method of transfer to obtain specialized care. "

9. The policy titled 'Guidelines for Medical Screening Exams, Diversions, Admitting and Discharging Patients ' also defined " Emergency Medical Condition as being ' a medical condition manifesting itself by acute symptoms of sufficient severity [ ...or symptoms of substance abuse]. " It further defines " Stabilize " as ' the provision of such medical treatment of the condition as may be necessary to ensure, with reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility ... "

10. On September 17, 2010, a review of the CRH policy titled 'Transfer/Referral of Patient to other Providers ' was conducted. It stated, " The transferring personnel will ensure proper equipment/medications needed to maintain care and provide safe transport of patient are available. "

11. A review of the CRH Hospital Wide Performance Improvement Plan on September 17, 2010 was conducted. It stated as its purpose, " to serve as a guide to assist hospital departments and medical staff to identify opportunities for improvement. " The stated objectives included ... " identifying and meeting the needs of our patients both internal and external ...emphasizing on continuous improvement of areas that significantly affect patient care and outcomes. " Additionally, Appendix C: Department Specific Quality Indicators failed to include transfers.

12. The review of Patient B ' s medical record on September 17, 2010, indicated that he/she arrived in the Emergency Department [ED] of CRH [Calais Regional Hospital] at 12:56 via EMS [Emergency Medical Service] with a chief complaint of ETOH [alcohol] withdrawal and nausea. At 1300, the patient ' s neurological status was documented as alert, oriented times three (3) and drowsy. At 1301, it was documented by nursing that the patient reported heavy use of alcohol, and was currently trying to quit drinking. At 1330, the ED physician documented in his medical screening examination note that Patient B was trying to detox himself/herself over four days and shakes continually and noted vital signs of BP (blood pressure) of 121/74, a O2 (oxygen saturation) of 98%, respirations of 22, and a temperature of 95.5 orally. He also indicated that the patient was oriented to person and place but not time, and his/her " cranials two through 12 are intact " . ...Lungs surprisingly clear heart regular rate and rhythm, no S3/S4 murmur " . The physician also documented no apparent hallucinations or delusions, but does seem to have tremors. It was also documented that Patient B had been accepted in transfer at DECH [Down East Community Hospital] with a diagnosis of alcohol withdrawal .... (Note: this is the only documentation by the ED physician.) At 1337, nursing documented that the physician was in the room to see the patient. In spite of the fact that the patient received Phenergan at 1352, and Thiamin at 1358, there was no further documentation of treatment until 1812 when an IV [intravenous] infusion of D5 0.45% NS at 500 ml/hr [Dextrose, Normal Saline, milliliters/hour] was ordered. At 1845, nursing documented that the patient was sleeping on the stretcher. Then at 1900 nursing documented that the Emergency Department physician was talking with the receiving physician at Down East Community Hospital [DECH] regarding the pending transfer. The IV fluids were discontinued at 1916. The patient then received Ativan 1 mg (milligram), intravenous push, at 1921. At 1935, nursing documented that the patient was shaking intensely on the stretcher, and the patient was uncooperative. In spite of these changes in the patient ' s condition, the IV access was removed at 1940. At 1950, it was documented that the patient was unable to be driven to the receiving hospital via private car. At 2021, the transferring nurse called the report to the receiving nurse. Finally at 2058, it was documented that the patient was " transferred to DECH for Detox " , and the patient ' s condition was documented as " stable. "

13. During a review of Patient B ' s medical record on September 17, 2010, the Consent to Transfer Form stated, " alcoholism detox " as the need for treatment and stated, " I understand that this treatment is not available at Calais Regional Hospital (CRH), so transfer to DECH under the care of [receiving physician] is needed in order that I may receive this necessary treatment. "

14.A review of Medical Record B on September 17, 2010 revealed that only transfer orders written by the physician at 20:15 stated, " Code status full ....maintain oxygen per: 2 @ flow rate...during transport ...tx DECH [receiving physisicn]. "

15. Review of Patient B ' s medical record on September 17, 2010, revealed documentation on the " Consent to Transfer Form " that the benefit to transfer was " care of facility who has detox program " .

16. A review of Patient B ' s medical record was conducted on September 17, 2010, the medical record failed to contain documentation on the ' Consent to Transfer form ' of the patient ' s condition at time of transfer.

17. A review of Patient B ' s ambulance run sheet dated September 13, 2010, regarding the transportation of the patient from CRH to DECH revealed that the patient was having respirations that were " snoring like. " Additionally, there was no documentation that the patient had been maintained on oxygen (as ordered by the physician) during the transport to DECH. The documentation also stated that the patient was still on " the combative side with [his/her] arms flailing around " and was very shaky. It stated that the attendants were unable to obtain any blood pressure readings. Additionally, it stated that the patient ' s skin was cool to the touch. The documentation stated that the attendants were told prior to leaving the hospital that the patient had received Ativan and it did not help.

18. During an interview with the Chief Nursing Officer, at CRH, on September 17, 2010, at 1745, she stated, " For alcohol withdrawal, we use the CIWA [Clinical Institute Withdrawal Assessment for Alcohol] order set for inpatient ...it could be used in the Emergency Department. "

19. During an interview with the Chief Nursing Officer at CRH on September 17, 2010, at 1645, she stated, " we can ' t keep a patient here to detox [detoxification] unless they are here for another reason ... I was told we couldn ' t admit a patient here to detox a patient ... I thought it was a state regulation ... I don ' t think I have a policy ... We are not trying to rehabilitate alcoholics.... We don ' t accept patients for that primary purpose and staff doesn ' t have the expertise.. ... Yeah, we could detox a patient. "

20. During a telephone interview, on September 21, 2010 at 0800, with the Chief Nursing Officer (CNO) at CRH, she stated that she had done further research, regarding their transfer practice, and stated, " CMS [Center for Medicare and Medicaid Services] will not pay for any psych [psychiatric] diagnosis ...they [facility] must hold the patient in the ER [emergency room] until a bed is available secondary to no consulting psychiatrist. ...Straight detox is considered a psychiatric diagnosis by CMS ...they won ' t pay for detox. " 22. During an interview on September 17, 2010 at 17:45 with the CRH CNO, it was stated, " I checked the last four (4) quarters of quality...there is no discussion of EMTALA in quality. "

21. In an interview with the Chief Nursing Officer, at DECH, the receiving facility, on September 17, 2010 at 11:45 a.m. she stated " I don ' t believe they [CRH] admit patients for detox. " She stated we have no detox unit here. She stated we don ' t have special training for alcohol detox, it ' s just included in staff orientation. She continued by stating that the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) Scale was the tool currently in use when detoxing patients.

22. During an interview with the Emergency Department Director at CRH on September 17, 2010, at 1630, he stated, " They don ' t let us detox patients ....not sure who made the edict to not admit detox patients. No, I don ' t have a policy that prohibits the admission of detox patients ...I think it ' s financially driven ....I ' ve been told we can ' t detox patients ...I don ' t know that we couldn ' t detox a patient here. "

23.During an interview with the Emergency Department Medical Director at CRH on September 17, 2010, at 1645, he stated, " The State will not pay hospitals to detox patients, if there is no psychiatrist on staff. I understood the rule to be that we need a psychiatrist on staff. We can only detox patients if they are admitted for another reason. I can not admit a patient for detox because it is a psychiatric patient. " When asked if a detox patient needs a psychiatrist, he stated, " No, not that I know of " . He remarked, " Often times when the patient has no medical problems, and can ' t be admitted, we involve Northeast Crisis. "

24. During an interview with the CRH Emergency Department Medical Director on September 17, 2010, he stated, " I didn ' t order the patient ' s IV to be discontinued. [He/She] was dehydrated. I ordered O2 [oxygen] and I don ' t know why the patient didn ' t get it while being transported. My decision to transfer by ambulance was based on O2 sats [saturation]. " When asked why it took so long for the transfer to occur, the Medical Director stated that it was a very busy day in the Emergency Department including teens in an automobile accident. The Medical Director stated that often the physician will specify which level of ambulance was needed for the transfer. The Medical Director stated that both ambulance services had paramedic level of care available.

25. During another interview with the Emergency Department Medical Director on September 17, 2010 at 18:25, when asked if he had performed any reassessments after treatment, he stated, " No " ... When asked how he would know if the treatments helped and made the patient stable, he replied, " I can ' t assume that. I had been in the room several times...I did not write a note. "

26. During an interview with the CRH Emergency Department Medical Director on September 17, 2010, he stated, " I often specify which level of ambulance [BCLS or ACLS] ....By not specifying, the assumption is the patient will go by Basic. "

27. During an interview with the receiving physician at DECH on September 17, 2010, the physician stated that the ED physician at CRH had called to ask if he would accept a patient in transfer for alcohol detox who had no aspiration, no GI [gastrointestinal] bleed, no pancreatitis and " nothing medically wrong. " Additionally, the receiving physician stated, " At 9 p.m. I had a Blackberry message from the ED physician at CRH. The message stated that the patient had become agitated and had received IV fluids and Ativan and the patient was being transferred. "

28. During the same interview with the receiving physician at DECH on September 17, 2010, the physician stated that a call was received while he was at home in the evening from the receiving nurse. The nurse stated that the patient had coded in ICU [intensive care unit] and subsequently died. Additionally, the physician stated that he had been told that the patient was coming by private vehicle.


29. In the DECH "Discharge Summary" dated September 13, 2010, the Receiving Physician documented, "I did not see this patient. At the time of [his/her] demise, I was called. Appartently [he/she] came through Calais by EMT. [He/She] was cold, cyanotic, blue, apneic, and unresponsive with a straight line and [he/she] died." This document further stated, "It was described by the ER physician that [he/she] was unresponsive and cyanotic by the time [he/she] got into ICU. [He/She] was apparently pulseless, unresponsive, and cyanotic with a straight line. CPR and ACS protocol was attempted but the patient died."

30. In a telephone interview, conducted on September 17, 2010, a staff nurse at DECH stated that at 8:30 p.m. on September 13, 2010, the CRH nurse called her. She stated it was a " scattered report " and that the patient was unkempt and for the last couple of days had tried detoxing at home. The CRH nurse further stated that the patient was very shaky and shaking so badly that the patient would probably hurt himself/herself. The CRH nurse also stated that the patient ' s IV access had been taken out. The staff nurse at DECH asked the CRH nurse to put in another IV. The CRH nurse ended the discussion that the patient had been given Ativan. (Note: There was no documentation that IV access was reestablished.)

31. In a telephone interview, conducted on September 17, 2010, the staff nurse at DECH stated that when the patient arrived to the floor, she remembered thinking that the patient didn ' t " look good " . The DECH nurse continued by stating that when the patient was transferred from the ambulance stretcher to the bed, the blanket came off the patient ' s legs. This nurse stated that the patient ' s legs were mottled, the patient ' s arms were freezing, and the patient ' s ears were purple. Additionally, the nurse stated that the patient gave one big expiratory breath and when the nurse felt for the pulse there was no pulse. The nurse continued by stating that a code was called and that it was unsuccessful.

32. In spite of the predictable progression of Patient B ' s emergency medical condition, Patient B requiring Phenergan and Ativan, and the documentation stating that Patient B had begun " shaking intensely " and become " uncooperative " during the course of his/her lengthy ED visit (approximately eight hours), there is no documentation that demonstrated a reassessment, indicated recognition of the patient ' s deterioration, provided further stabilizing interventions prior to transfer, or the recognized the requirement for transfer via an ACLS/paramedic ambulance.

Based on document review, review of medical records, review of policies and procedures and interviews with key personnel at both the transferring and the receiving facilities on September 17, 2010, it was determined that the hospital failed to stabilize a patient with an emergency medical condition prior to transfer. These findings represent an Immediate Jeopardy to the patients seeking emergency treatment at Calais Regional Hospital.

The evidence is as follows:

1. 42 CFR ?489.24 (e) (1) states that if an individual at a hospital has an emergency medical condition that has not been stabilized, the hospital may not transfer the individual unless the transfer is an appropriate transfer.

2. 42 CFR ?489.24(b) defines stabilized to mean " ...that 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 " ... "


3. 42CFR ?489.24 (e) (2) defines an appropriate transfer as having four requirements. The first requirement at ?489.24 (2) (i) states... the transferring hospital provides medical treatment, within its capacity, that minimizes the risks to the individual ' s health.

4. The American College of Emergency Physician ' s Emergency Medicine, A Comprehensive Study Guide , 6th edition, Judith Tintinalli, Ed., page 1415 & 16 states, " ...after cassation of drinking include tremulousness, nausea, anxiety ...delirium tremors (DT ' s) if left untreated, approximately 5 per cent of patients who withdraw from alcohol will proceed to DT ' s, which usually begin 3 to 5 days after cessation of alcohol. "

5. The Emergency Nurses Association, Sheehy ' s Manual of Emergency Care, 6th edition, Lorene Newberry, Ed., page 452, states under the topic Alcohol Withdrawal, " In chronic alcoholics, withdrawal will begin 6 to 48 hours after a reduction or cessation of ethanol intake. This condition lasts 2 to 7 days. " It further indicated " Severe cases of alcohol withdrawal occur in chronic alcoholics 24 hours to 5 days after cessation or reduction of alcohol consumption ...Delirium tremens (DT) occurs after a severe drop in the amount of ethanol consumed by an alcoholic, usually starting on the third day without alcohol. DT is an acute medical emergency. Untreated, this condition is associated with 10 % to 15 % mortality. "

6. On review of the CRH Patient Care Committee Meeting minutes on September 17, 2010 revealed, that the issue of treating Alcohol Withdrawal patients was discussed on July 29, 2009 and October 28, 2009. The Alcohol Withdrawal Form is complete and the committee reviewed the form and approved it. The form was to be taken to the Medical Staff for approval on September 10, 2009. It was documented under Conclusion/Action " The committee approved the Alcohol Withdrawal Order Set. This form will be utilized as a Standard Order Sheet for admissions and will be adapted to the Emergency Department as well. "

7. The Calais Regional Hospital, " Alcohol Withdrawal Order Set ' stated, " The Clinical Institute Withdrawal Assessment for Alcohol (CIWA-AR) scale is a validated 10 item assessment tool that can be used to qualify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal. "

8. On September 17, 2010, a review of the CRH policy titled 'Guidelines for Medical Screening Exams, Diversions, Admitting and Discharging Patients ' was conducted. It states ... " CRH [Calais Regional Hospital] must provide either: medical examination and such treatments as may be required to stabilize the medical condition if available at CRH or, transfer the individual to another medical facility using appropriate staff and method of transfer to obtain specialized care. "

9. The policy titled 'Guidelines for Medical Screening Exams, Diversions, Admitting and Discharging Patients ' also defined " Emergency Medical Condition as being ' a medical condition manifesting itself by acute symptoms of sufficient severity [ ...or symptoms of substance abuse]. " It further defines " Stabilize " as ' the provision of such medical treatment of the condition as may be necessary to ensure, with reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility ... "

10. On September 17, 2010, a review of the CRH policy titled 'Transfer/Referral of Patient to other Providers ' was conducted. It stated, " The transferring personnel will ensure proper equipment/medications needed to maintain care and provide safe transport of patient are available. "

11. A review of the CRH Hospital Wide Performance Improvement Plan on September 17, 2010 was conducted. It stated as its purpose, " to serve as a guide to assist hospital departments and medical staff to identify opportunities for improvement. " The stated objectives included ... " identifying and meeting the needs of our patients both internal and external ...emphasizing on continuous improvement of areas that significantly affect patient care and outcomes. " Additionally, Appendix C: Department Specific Quality Indicators failed to include transfers.

12. The review of Patient B ' s medical record on September 17, 2010, indicated that he/she arrived in the Emergency Department [ED] of CRH [Calais Regional Hospital] at 12:56 via EMS [Emergency Medical Service] with a chief complaint of ETOH [alcohol] withdrawal and nausea. At 1300, the patient ' s neurological status was documented as alert, oriented times three (3) and drowsy. At 1301, it was documented by nursing that the patient reported heavy use of alcohol, and was currently trying to quit drinking. At 1330, the ED physician documented in his medical screening examination note that Patient B was trying to detox himself/herself over four days and shakes continually and noted vital signs of BP (blood pressure) of 121/74, a O2 (oxygen saturation) of 98%, respirations of 22, and a temperature of 95.5 orally. He also indicated that the patient was oriented to person and place but not time, and his/her " cranials two through 12 are intact " . ...Lungs surprisingly clear heart regular rate and rhythm, no S3/S4 murmur " . The physician also documented no apparent hallucinations or delusions, but does seem to have tremors. It was also documented that Patient B had been accepted in transfer at DECH [Down East Community Hospital] with a diagnosis of alcohol withdrawal .... (Note: this is the only documentation by the ED physician.) At 1337, nursing documented that the physician was in the room to see the patient. In spite of the fact that the patient received Phenergan at 1352, and Thiamin at 1358, there was no further documentation of treatment until 1812 when an IV [intravenous] infusion of D5 0.45% NS at 500 ml/hr [Dextrose, Normal Saline, milliliters/hour] was ordered. At 1845, nursing documented that the patient was sleeping on the stretcher. Then at 1900 nursing documented that the Emergency Department physician was talking with the receiving physician at Down East Community Hospital [DECH] regarding the pending transfer. The IV fluids were discontinued at 1916. The patient then received Ativan 1 mg (milligram), intravenous push, at 1921. At 1935, nursing documented that the patient was shaking intensely on the stretcher, and the patient was uncooperative. In spite of these changes in the patient ' s condition, the IV access was removed at 1940. At 1950, it was documented that the patient was unable to be driven to the receiving hospital via private car. At 2021, the transferring nurse called the report to the receiving nurse. Finally at 2058, it was documented that the patient was " transferred to DECH for Detox " , and the patient ' s condition was documented as " stable. "

13. During a review of Patient B ' s medical record on September 17, 2010, the Consent to Transfer Form stated, " alcoholism detox " as the need for treatment and stated, " I understand that this treatment is not available at Calais Regional Hospital (CRH), so transfer to DECH under the care of [receiving physician] is needed in order that I may receive this necessary treatment. "

14.A review of Medical Record B on September 17, 2010 revealed that only transfer orders written by the physician at 20:15 stated, " Code status full ....maintain oxygen per: 2 @ flow rate...during transport ...tx DECH [receiving physisicn]. "

15. Review of Patient B ' s medical record on September 17, 2010, revealed documentation on the " Consent to Transfer Form " that the benefit to transfer was " care of facility who has detox program " .

16. A review of Patient B ' s medical record was conducted on September 17, 2010, the medical record failed to contain documentation on the ' Consent to Transfer form ' of the patient ' s condition at time of transfer.

17. A review of Patient B ' s ambulance run sheet dated September 13, 2010, regarding the transportation of the patient from CRH to DECH revealed that the patient was having respirations that were " snoring like. " Additionally, there was no documentation that the patient had been maintained on oxygen (as ordered by the physician) during the transport to DECH. The documentation also stated that the patient was still on " the combative side with [his/her] arms flailing around " and was very shaky. It stated that the attendants were unable to obtain any blood pressure readings. Additionally, it stated that the patient ' s skin was cool to the touch. The documentation stated that the attendants were told prior to leaving the hospital that the patient had received Ativan and it did not help.

18. During an interview with the Chief Nursing Officer, at CRH, on September 17, 2010, at 1745, she stated, " For alcohol withdrawal, we use the CIWA [Clinical Institute Withdrawal Assessment for Alcohol] order set for inpatient ...it could be used in the Emergency Department. "

19. During an interview with the Chief Nursing Officer at CRH on September 17, 2010, at 1645, she stated, " we can ' t keep a patient here to detox [detoxification] unless they are here for another reason ... I was told we couldn ' t admit a patient here to detox a patient ... I thought it was a state regulation ... I don ' t think I have a policy ... We are not trying to rehabilitate alcoholics.... We don ' t accept patients for that primary purpose and staff doesn ' t have the expertise.. ... Yeah, we could detox a patient. "

20. During a telephone interview, on September 21, 2010 at 0800, with the Chief Nursing Officer (CNO) at CRH, she stated that she had done further research, regarding their transfer practice, and stated, " CMS [Center for Medicare and Medicaid Services] will not pay for any psych [psychiatric] diagnosis ...they [facility] must hold the patient in the ER [emergency room] until a bed is available secondary to no consulting psychiatrist. ...Straight detox is considered a psychiatric diagnosis by CMS ...they won ' t pay for detox. " 22. During an interview on September 17, 2010 at 17:45 with the CRH CNO, it was stated, " I checked the last four (4) quarters of quality...there is no discussion of EMTALA in quality. "

21. In an interview with the Chief Nursing Officer, at DECH, the receiving facility, on September 17, 2010 at 11:45 a.m. she stated " I don ' t believe they [CRH] admit patients for detox. " She stated we have no detox unit here. She stated we don ' t have special training for alcohol detox, it ' s just included in staff orientation. She continued by stating that the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) Scale was the tool currently in use when detoxing patients.

22. During an interview with the Emergency Department Director at CRH on September 17, 2010, at 1630, he stated, " They don ' t let us detox patients ....not sure who made the edict to not admit detox patients. No, I don ' t have a policy that prohibits the admission of detox patients ...I think it ' s financially driven ....I ' ve been told we can ' t detox patients ...I don ' t know that we couldn ' t detox a patient here. "

23.During an interview with the Emergency Department Medical Director at CRH on September 17, 2010, at 1645, he stated, " The State will not pay hospitals to detox patients, if there is no psychiatrist on staff. I understood the rule to be that we need a psychiatrist on staff. We can only detox patients if they are admitted for another reason. I can not admit a patient for detox because it is a psychiatric patient. " When asked if a detox patient needs a psychiatrist, he stated, " No, not that I know of " . He remarked, " Often times when the patient has no medical problems, and can ' t be admitted, we involve Northeast Crisis. "

24. During an interview with the CRH Emergency Department Medical Director on September 17, 2010, he stated, " I didn ' t order the patient ' s IV to be discontinued. [He/She] was dehydrated. I ordered O2 [oxygen] and I don ' t know why the patient didn ' t get it while being transported. My decision to transfer by ambulance was based on O2 sats [saturation]. " When asked why it took so long for the transfer to occur, the Medical Director stated that it was a very busy day in the Emergency Department including teens in an automobile accident. The Medical Director stated that often the physician will specify which level of ambulance was needed for the transfer. The Medical Director stated that both ambulance services had paramedic level of care available.

25. During another interview with the Emergency Department Medical Director on September 17, 2010 at 18:25, when asked if he had performed any reassessments after treatment, he stated, " No " ... When asked how he would know if the treatments helped and made the patient stable, he replied, " I can ' t assume that. I had been in the room several times...I did not write a note. "

26. During an interview with the CRH Emergency Department Medical Director on September 17, 2010, he stated, " I often specify which level of ambulance [BCLS or ACLS] ....By not specifying, the assumption is the patient will go by Basic. "

27. During an interview with the receiving physician at DECH on September 17, 2010, the physician stated that the ED physician at CRH had called to ask if he would accept a patient in transfer for alcohol detox who had no aspiration, no GI [gastrointestinal] bleed, no pancreatitis and " nothing medically wrong. " Additionally, the receiving physician stated, " At 9 p.m. I had a Blackberry message from the ED physician at CRH. The message stated that the patient had become agitated and had received IV fluids and Ativan and the patient was being transferred. "

28. During the same interview with the receiving physician at DECH on September 17, 2010, the physician stated that a call was received while he was at home in the evening from the receiving nurse. The nurse stated that the patient had coded in ICU [intensive care unit] and subsequently died. Additionally, the physician stated that he had been told that the patient was coming by private vehicle.


29. In the DECH "Discharge Summary" dated September 13, 2010, the Receiving Physician documented, "I did not see this patient. At the time of [his/her] demise, I was called. Appartently [he/she] came through Calais by EMT. [He/She] was cold, cyanotic, blue, apneic, and unresponsive with a straight line and [he/she] died." This document further stated, "It was described by the ER physician that [he/she] was unresponsive and cyanotic by the time [he/she] got into ICU. [He/She] was apparently pulseless, unresponsive, and cyanotic with a straight line. CPR and ACS protocol was attempted but the patient died."

30. In a telephone interview, conducted on September 17, 2010, a staff nurse at DECH stated that at 8:30 p.m. on September 13, 2010, the CRH nurse called her. She stated it was a " scattered report " and that the patient was unkempt and for the last couple of days had tried detoxing at home. The CRH nurse further stated that the patient was very shaky and shaking so badly that the patient would probably hurt himself/herself. The CRH nurse also stated that the patient ' s IV access had been taken out. The staff nurse at DECH asked the CRH nurse to put in another IV. The CRH nurse ended the discussion that the patient had been given Ativan. (Note: There was no documentation that IV access was reestablished.)

31. In a telephone interview, conducted on September 17, 2010, the staff nurse at DECH stated that when the patient arrived to the floor, she remembered thinking that the patient didn ' t " look good " . The DECH nurse continued by stating that when the patient was transferred from the ambulance stretcher to the bed, the blanket came off the patient ' s legs. This nurse stated that the patient ' s legs were mottled, the patient ' s arms were freezing, and the patient ' s ears were purple. Additionally, the nurse stated that the patient gave one big expiratory breath and when the nurse felt for the pulse there was no pulse. The nurse continued by stating that a code was called and that it was unsuccessful.

32. In spite of the predictable progression of Patient B ' s emergency medical condition, Patient B requiring Phenergan and Ativan, and the documentation stating that Patient B had begun " shaking intensely " and become " uncooperative " during the course of his/her lengthy ED visit (approximately eight hours), there is no documentation that demonstrated a reassessment, indicated recognition of the patient ' s deterioration, provided further stabilizing interventions prior to transfer, or the recognized the requirement for transfer via an ACLS/paramedic ambulance.