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Based on review of the facility's Medical Staff Bylaws and Rules and Regulations, facility policies and procedures, staff and physician interviews, on -call schedules,and credential files, it was determined that the facility failed to ensure compliance with CFR 489.24, for one (1) patient (#2) of twenty (20) sampled medical records.

FINDINGS:


Cross refer to A2407 as it relates to failure of the facility to provide appropriate stabilizing treatment.


Cross refer to A2409 as it relates to failure of the facility to ensure that the transfer of patient #2 was an appropriate transfer.

Based on review of the facility's policies and procedures, Medical Staff Bylaws and Rules and Regulations, medical records, on-call schedules, physician credential files, and physician and nurse interviews, it was determined that the facility failed to provide within its capabilities of the staff, facilities available at the hospital for further medical examination and treatment as required to stabilize the medical condition for one (1) individual (#2) of twenty (20) sampled patients.

FINDINGS WERE:

Review of the medical record (#2) revealed that the patient was a 58 years old female who had a history of cancer as a child, and high blood pressure. The patient presented to the emergency department (ED) of Piedmont New Hospital (Hospital A) on 12/13/2015, and was first seen by the ED physician (Physician #1) at 2:23 p.m. Patient #2 was being worked up for endometrial cancer (cancer of the lining of the uterus) and had had a dilation and curettage (D&C-a procedure to remove tissue from inside of the uterus for diagnosis or treatment of certain uterine conditions) two (2) days previously at another facility (Hospital B). The patient stated that since that time, she has had left sided pleuritic chest pain (chest pain that worsens when you breathe, cough or sneeze) and abdominal pain. The patient denied having fever, but felt like she was going to pass out. The patient denied other complaints.

The medical record further noted that multiple lab work was obtained and revealed that the patient's white blood count (an elevation would reveal an infectious process) was within normal limits, but her lactic acid and bleeding and clotting time were elevated (possible indication of sepsis, a severe infection). The physical examination by the ED physician (Physician #1) noted that the patient's abdomen was diffusely firm with hypoactive (not functioning normally) bowel sounds.

Review of the nursing assessments in the medical record by Registered Nurses (RN # 4 and RN# 9) revealed that at 2:30 p.m. and 2:45 p.m. on 12/13/2015, the patient arrived at the ED of Hospital A. The patient was diaphoretic (sweating), pale, cold and guarding her abdomen. The patient was assisted from the car to a stretcher and was crying out in pain. Registered Nurse (RN #9) noted that the patient's lower abdomen was firm and painful to touch. The patient's husband stated that the patient awakened that morning with unbearable pain, and that the pain level was 20 on a scale of 1-10 (pain scale goes from 0-10 with 10 being the most severe). The nurse (RN #4) noted that the patient's breathing was labored due to the pain.

An acute abdominal series with chest x-ray was ordered and findings revealed a large amount of intraperitoneal (in the abdominal cavity) air under the right diaphragm. Impression: findings suggesting bowel perforation. This report was called to the emergency department and the radiologist personally gave the report to the ED physician at 3:00 p.m.

During a phone interview with the radiologist (Physician #3) on 01/12/16 at 2:55 p.m. in the Conference Room, the radiologist confirmed that he/she was on-call for the ED on 12/13/15. The radiologist acknowledged that he/she remembered reading the patient's x-ray and noting free air under the diaphragm. The radiologist stated he/she personally called the results to the ED physician. When asked if the radiologist normally calls in all x-ray results, the radiologist stated that he/she only calls personally when there is a significant finding. The radiologist stated he/she would always call a physician with a finding of free air as that finding indicates a possible bowel perforation. When asked if a bowel perforation would be considered a medical emergency, the radiologist indicated it would.

Review of the consult sheet revealed that at 3:27 p.m., the ED physician (Physician #1) consulted the general surgeon (Physician #2) on call at Hospital A and that this general surgeon recommended that Hospital B accept the patient to fix the perforation that was caused by the patient's D&C performed at Hospital B.

At 4:10 p.m., the ED physician spoke with the surgeon on call at Hospital B and this surgeon recommended that physician #2 evaluate the patient in the ED and determine if the patient was able to be transferred.

The ED physician noted that the on-call surgeon evaluated the patient and this surgeon stated that the patient was stable for transfer to Hospital B since the patient and his/her family had called Hospital B earlier that day and did not get an answer and decided to come to the ED at Hospital A. The on-call surgeon (Physician #2) spoke with the surgeon on call for Hospital B and they agreed that the patient would be transferred. A bed for the patient was requested from Hospital B and Hospital A staff were told at that time that the Hospital B staff were in a meeting. The ED physician noted that the risk manager from Hospital B called and spoke with the on call surgeon. Hospital B accepted the patient and requested that the patient be air flighted to their facility immediately.

Review of the surgeon's (Physician #2) Consult Sheet in the medical record revealed that he/she noted that the accepting physician from Hospital B made a request that Physician #2 examine the patient to evaluate the patient for stability prior to transfer. The surgeon noted that the patient was resting in bed, alert and oriented and in mild distress. The patient did not have a temperature and her blood pressure was 143/66 (normal was 130/90), pulse was 120 (normal is 60-100) and oxygen saturation was 93% on nasal oxygen (normal 95% to 100%). The surgeon (Physician #2) noted that the patient's abdomen was flat, non-distended and that the patient was tender in the lower quadrants (bottom half of the abdomen). Physician #2 noted that her/his findings were discussed with ED physician #1 and Hospital B's on call surgeon and that a mutual agreement to transfer the patient was reached.

ED physician #1 noted that the patient was in critical condition and that intravenous fluids and antibiotics were ordered as life saving interventions. The patient was transferred to Hospital B in critical condition. The total time that the patient remained in Hospital A's ED was three (3) hours and forty-seven (47) minutes. The patient was air-lifted to Hospital B and expired the following day.



The Medical Record fro Patient #2 from Hospital B was reviewed. The discharge summary dated 12//13/2015 revealed in part, "CAUSE OF DEATH: Septic shock with multiorgan failure. Diagnosis at Death: 1. A bowel perforation with peritonitis. 2. Septic Shock with multiorgan failure. 3. Acute Respiratory failure with ARDS (Adult Respiratory Distress Syndrome) on...Ventilator. 4. Aspiration Pneumonia...History of Present illness : This is 58 year-old ...who underwent hysteroscopy and dilated...on 12/11/2015...and discharged home. She presented to the emergency department at Piedmont, Newton Campus with severe abdominal pain. She was air lifted to Hospital B where she was in acute respiratory distress and intubated on arrival. She was subsequently taken to OR (Operating Room) ... she was found to have a bowel perforation and resection and colostomy was done. Postoperatively, she was hypoxemic despite 100 percent FIO2,...on ventilator. ..Broad spectrum antibiotics were started...Through the day, she was unresponsive on ventilator. Her urine has been progressively decreased in volume...She was seen by the General Surgeon...ID (Infectious Disease ) consult was done ...renal service was consulted. Her clinical condition deteriorated through the day with worsening hemodynamics... Her renal function also deteriorated...family members also made her a DNR (Do Not Resuscitate) based on her previously expressed wishes. Despite aggressive supportive care, she expired at 1745 (5:45 p.m.) hours."


During an interview with the ED physician (#1) on 01/13/16 at 10:15 a.m. in the Conference Room, the physician confirmed that he/she was working on 12/13/15 and remembered treating the patient. The physician revealed that the patient presented to the ED via private vehicle and was quickly placed in a room and placed on a monitor. The physician indicated the patient was able to give a personal account of her complaints and was able to convey that she had a dilation and curettage (D&C-a procedure to remove tissue from inside the uterus) two days previously at Hospital B.

The physician recounted that the patient appeared to be in extreme pain and was tachycardic (a rapid heart rate) on admission to the ED. The physician continued by stating that a visual inspection of the patient's abdomen revealed indications of previous abdominal surgeries, and the abdomen was noted to be firm and rigid on palpation (the process of using one's hands to examine the body). The physician stated he/she then ordered IV fluids, labs (including sepsis protocol), and an acute abdominal series (common set of abdominal x-rays used to evaluate the abdomen).

Physician #1 stated he/she received a call from the radiologist (Physician #3) indicating that free air was noted on the x-ray. When asked what the physician's impression was from the x-ray result, the physician indicated he/she suspected a bowel perforation. The physician explained that he/she then contacted, and had a conversation with, the on-call regarding the patient. The physician stated that the OB/GYN (obstetrician-gynecologist, specialists whose focus is women's health) requested that the on-call surgeon be called, in case there was bowel involvement if and when they took the patient to the operating room.

At that point, the physician stated he/she called the on-call general surgeon (#2) and conveyed what the OB/GYN had recommended and the results of the x-ray. The ED physician stated that the surgeon recommended that the patient return to Hospital B as he/she felt the patient was experiencing a complication from the surgery the patient had at Hospital B. The surgeon also recommended holding off on a Cat Scan (CT) in light of the possible transfer. When asked if requesting a transfer for a patient would be a normal course of action from a surgeon, the ED physician indicated it was.

Physician #1 stated that he/she then called and spoke with the on-call surgeon at Hospital B and explained what the surgeon (Physician #2) had recommended and relayed the patient's x-ray and available lab results. The on-call surgeon at Hospital B stated he/she would be willing to take the patient, but requested that the on-call surgeon at Hospital A evaluate the patient to determine if the patient was stable for transfer. The ED physician added that the on-call surgeon at Hospital B provided his/her cell phone so that he/she could be contacted with greater ease.

The ED physician indicated that he/she then called the surgeon (Physician #2) at Hospital A and explained what was discussed and gave him/her the surgeon from Hospital B's cell phone number so that they could exchange and discuss the patient's information directly. The ED physician stated that the surgeon (Physician #2) indicated that she would come into the ED to evaluate the patient shortly. Per the ED physician, the surgeon (Physician #2) examined the patient and stated the patient was stable for transfer, and the transfer was accepted by Hospital B.

When the ED (Physician #1) was asked if he/she was in agreement with the course of treatment and plan to transfer, the physician stated he/she did not agree. The physician stated the patient's creatinine level was high (an elevated creatinine level signifies impaired kidney function) so a CT with IV contrast could not be performed (the contrast is secreted through the urine and if kidney function is impaired, IV contrast is contraindicated). The ED physician stated he/she felt that the patient needed to go to surgery at Hospital A due to the finding of free air and the presence of the rigidity of the abdomen. The ED physician stated he/she felt the patient had a bowel perforation and should not be transferred. The ED physician stated he/she expressed to the surgeon (Physician #2) that transporting the patient might be a violation of EMTALA. The physician added that the risk management at Hospital B had also spoken with surgeon (Physician #2) about EMTALA guidelines as well. The physician stated that the surgeon did not believe this situation was EMTALA related. When asked if the Physician #1 had ever had EMTALA training, he/she stated it is given annually through their group and Hospital A had given the course in the past two (2) weeks.

During an interview with the General Surgeon (Physician #2) on 01/12/15 at 1:15 p.m. in the Conference Room, the surgeon confirmed that he/she was on call and remembered the situation that occurred on 12/13/15. The surgeon stated that on 12/13/15 he/she received a call at home at approximately 2:30 p.m. in the afternoon from one of the Emergency Department (ED) physicians (Physician #1). The surgeon stated the ED physician explained that a patient had presented to the ED complaining of severe abdominal pain after having had a surgical procedure at Hospital B the previous Friday. The surgeon confirmed that he/she remembered suggesting to the ED physician that if the patient were stable, the patient should be transferred to Hospital B as this appeared to be a complication of the surgery performed at Hospital B.

The surgeon stated that he/she received another call from the ED physician shortly thereafter in which the ED physician explained that a surgeon at Hospital B was willing to take the patient if a surgical consult was done prior to transfer to determine if the patient was stable for transfer. The surgeon stated he/she advised the ED physician that he/she would be in the ED in about twenty (20) minutes to evaluate the patient.

The surgeon stated when he/she first saw the patient in the ED the patient was in a monitored bed with family at the bedside. The surgeon stated the patient was unsure of the surgical procedure she had had at Hospital B and indicated it might have been for endometrial cancer. The surgeon stated he/she explained to the patient that he/she was there to evaluate her for transfer to Hospital B. The surgeon stated the patient did appear to be in pain and was obviously uncomfortable. The surgeon stated the patient was tachycardic (had an abnormally fast heart rate) at that time but the patient's vital signs were within normal limits.

The surgeon stated the patient appeared stable, and elaborated further by stating the patient's white count (a test that measures the number of white blood cells in the blood. A higher level number of white cells indicates a possible infection as white blood cells help the body fight infection) was within normal limits and the abdomen (stomach) was not rigid. The surgeon stated that the patient had had an x-ray prior to her exam and that the x-ray indicated that free air was noted. The surgeon explained that he/she believed the free air was a result of the surgery, but stated he/she was unsure at that time if the free air was from a bowel perforation or from insufflation (the introduction of a flow of gas into a body cavity) that occurred during the patient's surgery. The surgeon stated that since the patient was unable to explain what kind of abdominal surgery she had, it was difficult to determine why there was free air noted on the x-ray.

When asked why a computerized axial tomography (CT) scan (a special x-ray that can produce cross-sectional images of the body) was not ordered for the patient, the surgeon stated it was not ordered because the patient was stable and had an accepting surgeon at Hospital B. The surgeon continued and stated that a CT with contrast (an agent or medium used to improve the visibility on internal body structures) can be given intravenously (IV-into the vein or orally) and would have taken anywhere from two (2) to four (4) hours to complete. When asked if the patient's condition changed at all while she was in the ED, the surgeon stated he/she did not see the patient again before the patient was transferred.

When asked why surgeon #2 felt the patient should be transferred from Hospital A to Hospital B, the surgeon stated that the patient was stable, and that because the patient had had surgery two days prior at Hospital B, the surgeon felt there would be a better continuity of care if the patient was transferred.

The surgeon explained that he/she was qualified to repair a bowel perforation, and when asked if surgery is available on an emergency basis at Hospital A, the surgeon stated it was. The surgeon stated the operating room (OR) is staffed for scheduled surgeries and has on-call staff on a twenty-four (24) basis for emergencies.


When asked how long it would take to get an OR if the surgeon required one, the surgeon stated forty-five (45) minutes to one (1) hour. The facility failed to ensure that on 12/13/2015 Patient was provided stabilizing treatment which was within the capabilities of the staff (on-call surgeon, and Operating Room staff) and facilities (Operating Room suites) for further medical examination and treatment as required to stabilize an emergency medical condition.


The surgeon (Physician #2) acknowledged that he/she had not had EMTALA (Emergency Medical Transfer and Labor Act) training during the course of his/her thirty-four (34) year career, but added he/she had had EMTALA training in the last two (2) weeks at Hospital A.

During an interview with a staff General Surgeon at Hospital A (#5) on 01/12/16 at 1:40 p.m. in the Conference Room, the surgeon stated he/she had been with Hospital A for thirty-one (31) years and had been a practicing general surgeon for thirty-one (31) years. The surgeon stated he/she had reviewed the case and was familiar with the incident that occurred with the patient on 12/13/15. The surgeon stated his/her impression after reading the x-ray results, which indicated free air, was that the patient had a bowel perforation or that there was air from insufflation present from the previous surgical procedure.

The surgeon stated that if he/she would have been the consulting surgeon, the preference would have been for the patient to be transferred to Hospital B, but the surgeon stated that in this case, that might not have been possible due to the possible bowel perforation. The surgeon indicated that a CT with oral contrast might have indicated if there was a leak in the bowel, but the surgeon stated with the presence of free air noted on the x-ray, he/she would have felt more compelled to go straight to surgery and do an exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined) and make any surgical repairs at that time.

The surgeon stated he/she would consider a bowel perforation a medical emergency requiring prompt surgical intervention. When asked if the surgeon had ever attended or taken EMTALA training, the surgeon stated he/she believed he/she has had it at some point in the past but acknowledged that his/her understanding of EMTALA was limited.

Review of the facility Medical Staff By-Laws and Medical Staff Rules and Regulations adopted in 1985 and revised October 2012 revealed at " Section 7-Emergency Department" that all physician members of the active staff would be required to participate in emergency room coverage unless exempted by the Executive Committee. Separate "on-call" lists would be maintained and distributed for the Medical Staff Department. Those physicians need not remain in hospital but should be available within thirty (30) minutes if needed.

Review of the facility's policy entitled "Transfer Activities in Accordance with EMTALA Requirements, Policy number 5068, last reviewed 04/2014, noted in part, "Stabilized or to Stabilize A With respect to an emergency medical condition: That no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of an individual from the hospital; or To provide such medical treatment of the condition as necessary to assure, within reasonable probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the hospital...Within the capability - of the emergency department or of the Hospital means those capabilities which the hospital is required to have as a condition of its Emergency Department license, including on-call physicians and specialists and ancillary services routinely available to the Emergency Department.
Review of the facility's on-call lists revealed that surgeon (#2) was on call on 12/13/2015 when patient #2 presented to the hospital's ED. On-call lists for the previous three (3) months were reviewed and were being maintained for the specialists available at this facility. There were no other requirements listed in the Bylaws or facility policies which addressed additional requirements for the on-call physician. The facility's Bylaws and Policies and Procedure failed to address the duties and responsibilities of the on-call physician as it related to the evaluation, treatment and stabilization of an individual with an emergency medical condition.


Review of the four (4) of four (4) credential files (#s 1, 2, 3 and 7) revealed that physician #2 (on-call surgeon) was credentialed to perform abscess drainage, amputation, appendectomy, biopsy, colonoscopy, colostomy, cholecystectomy, hernia repair, ileostomy, laceration repair, apparition laparoscopy, bowel resection, bowel perforation repair and exploratory laparotomy.

As the facility provided surgical services, as patient #2 was unstable and surgeon #2 was credentialed to perform surgical procedures, it was determined that the on-call surgeon failed to provide stabilizing treatment/services for Patient #2 on 12/13/2015 that were within the resources available to the hospital.

Based on review of facility's policies and procedures, Medical Staff Bylaws and Rules and Regulations, medical records, on-call schedules, physician credential files, and physician and nurse interviews, it was determined that the facility inappropriately transferred an individual by failing to ensure that the surgeon that was call provided surgical treatment that was within the capacity of the hospital to minimize the risk of the individual health for one (1) individual (#2) of twenty (20) sampled patients.


FINDINGS:

Review of the medical record (#2) revealed that the patient was a 58 years old female who had a history of high blood pressure and cancer as a child. The patient presented to the ED of Hospital A and was first seen by the emergency department physician (#1) at 2:23 p.m. Patient #2 was being worked up for endometrial cancer (cancer of the lining of the uterus) and had had a dilation and curettage (D&C)(a procedure to remove tissue from inside of the uterus for diagnosis or treatment of certain uterine conditions) two (2) days previously at another facility (Hospital B). The patient stated that since that time, she has had left sided pleuritic chest pain (chest pain that worsens when you breathe, cough or sneeze) and abdominal pain. The patient denied having fever but felt like she was going to pass out. The patient denied other complaints.

The medical record further noted that multiple lab work was obtained and revealed that the patient's white blood count (an elevation would reveal an infectious process) was within normal limits, but her lactic acid and bleeding and clotting time were elevated (could be indicative of sepsis (a severe infection). The physical examination by the ED physician (#1) noted that the patient's abdomen was diffusely firm with hypoactive (not functioning normally) bowel sounds.

Review of the medical record nursing assessments of Registered Nurses's (#s 9 and 4) revealed that at 2:30 p.m. and 2:45 p.m. on 12/13/2015, the patient arrived to Hospital A's ED. The patient was diaphoretic (sweating), pale and cold and guarding her abdomen. The patient was assisted from the car to a stretcher and was crying out in pain. Registered Nurse (#9) noted that the patient's lower abdomen was firm and painful to touch. The patient's husband stated that the patient awakened that morning with unbearable pain, and that the pain level was 20/10 (pain scale goes from 0-10 with 10 being the most severe). The nurse (#4) noted that the patient's breathing was labored due to the pain.

An acute abdominal series with chest x-ray was ordered and findings revealed a large amount of intraperitoneal (in the abdominal cavity) air under the right diaphragm. Impression: findings suggesting bowel perforation. This report was called to the emergency department and the radiologist personally gave the report to the Emergency Department (ED) physician at 3:00 p.m.

During an interview with the radiologist (#3) on 01/12/16 at 2:55 p.m. in the Conference Room via phone call, the radiologist confirmed that he/she was on-call for the ED on 12/13/15. The radiologist acknowledged that he/she remembered reading the patient's x-ray and noting free air under the diaphragm. The radiologist stated he/she personally called the results to the ED physician. When asked if the radiologist normally calls in all x-ray results, the radiologist stated that he/she only calls personally when there is a significant finding. The radiologist stated he/she would always call a physician with a finding of free air as that finding indicates a possible bowel perforation. When asked if a bowel perforation would be considered a medical emergency, the radiologist indicated it would.

Review of the Consult sheet revealed that at 3:27 p.m., the ED physician (#1) consulted the general surgeon on call at Hospital A (#2) and that this general surgeon (#2) recommended that Hospital B accept the patient to fix the perforation that was caused by the patient's D&C performed at Hospital B.

At 4:10 p.m., the ED physician (#1) spoke with the surgeon on call at Hospital B and this surgeon recommended that physician #2 evaluate the patient in the ED and determine if the patient was able to be transferred.

The ED physician (#1) noted that the on-call surgeon (#2) evaluated the patient and this surgeon (#2) stated that the patient was stable for transfer to Hospital B since the patient and her family had called Hospital B earlier that day and did not get an answer and decided to come to the ED at Hospital A. The on-call surgeon (#2) spoke with the surgeon on call for Hospital B and they agreed that the patient would be transferred. A bed for the patient was requested from Hospital B and Hospital A staff were told that the Hospital B staff were in a meeting. The ED physician (#1) noted that the risk manager from Hospital B called and spoke with the on call surgeon (#2). Hospital B accepted the patient and requested that the patient be air flighted to their facility immediately.

Review of Surgeon #2's Consult Sheet in the medical record revealed that the on-call surgeon (#2) noted that the accepting physician from Hospital B made a request that she/he examine the patient to evaluate the patient for stability prior to transfer. The surgeon noted that the patient was resting in bed, alert and oriented and in mild distress. The patient did not have a temperature and her blood pressure was 143/66 (normal was 130/90), pulse was 120 (normal is 60-100) and oxygen saturation was 93% on nasal oxygen (normal 95% to 100%). The surgeon (#2) noted that the patient's abdomen was flat, nondistended and that the patient was tender in the lower quadrants (bottom half of the abdomen). The surgeon (#2) noted that her/his findings were discussed with ED physician #1 and Hospital B's on call surgeon and that a mutual agreement to transfer the patient was reached.

ED physician #1 noted that the patient was in critical condition and that intravenous fluids and antibiotics were ordered as life saving interventions. The patient was transferred to Hospital B in critical condition. The total time that the patient remained in Hospital A's ED was three (3) hours and forty-seven (47) minutes prior to transfer to Hospital B. The patient was air-lifted to Hospital B and expired the following day.


During an interview with the ED physician (#1) on 01/13/16 at 10:15 a.m. in the Conference Room, the physician confirmed that he/she was working on 12/13/15 and remembered treating the patient. The physician revealed that the patient presented to the ED via private vehicle and was quickly placed in a room and placed on a monitor. The physician indicated the patient was able to give a personal account of her complaints and was able to convey that she had a dilation and curettage (D&C) (a procedure to remove tissue from inside the uterus) two days previously at Hospital B.

The physician recounted that the patient appeared to be in extreme pain and was tachycardic (a rapid heart rate) on admission to the ED. The physician continued by stating that a visual inspection of the patient's abdomen revealed indications of previous abdominal surgeries, and the abdomen was noted to be firm and rigid on palpation (the process of using one's hands to examine the body). The physician stated he/she then ordered IV fluids, labs (including sepsis protocol), and an acute abdominal series (common set of abdominal x-rays used to evaluate the abdomen).

Physician #1 stated he/she received a call from the radiologist (#3) indicating that free air was noted on the x-ray. When asked what the physician's impression was from the x-ray result, the physician indicated he/she suspected a bowel perforation. The physician explained that he/she then contacted, and had a conversation with, the on-call OB/GYN regarding the patient. The physician stated the OB/GYN requested that the on-call surgeon be called in case there was bowel involvement if and when they took the patient to the operating room.

At that point, the physician stated he/she called the on-call general surgeon (#2) and conveyed what the OB/GYN had recommended and the results of the x-ray. The ED physician stated that the surgeon (#2) recommended that the patient return to Hospital B as he/she felt the patient was experiencing a complication from the surgery the patient had at Hospital B. The surgeon also recommended holding off on a Cat Scan (CT) in light of the possible transfer. When asked if requesting a transfer for a patient would be a normal course of action from a surgeon, the ED physician indicated it was.

The physician #1 stated he/she then called and spoke with the on-call surgeon at Hospital B and explained what the surgeon (#2) had recommended and relayed the patient's x-ray and available lab results. The on-call surgeon at Hospital B stated he/she would be willing to take the patient, but requested the on-call surgeon at Hospital A evaluate the patient to determine if the patient was stable for transfer. The ED physician added that the on-call surgeon at Hospital B provided his/her cell phone so that he/she could be contacted with more ease.

The ED physician indicated that he/she then called the surgeon (#2) at Hospital A and explained what was discussed and gave him/her the surgeon from Hospital B's cell phone number so that they could exchange and discuss the patient's information directly. The ED physician stated that the surgeon (#2) indicated she would come into the ED to evaluate the patient shortly. Per the ED physician, the surgeon (#2) examined the patient and stated the patient was stable for transfer, and the transfer was accepted by Hospital B.

When the ED physician #1 was asked if he/she was in agreement with the course of treatment and plan to transfer, the physician stated she did not agree. The physician stated the patient's creatinine level was high (an elevated creatinine level signifies impaired kidney function) so a CT with IV contrast could not be performed (the contrast is secreted through the urine and if kidney function is impaired, IV contrast is contraindicated). The ED physician stated he/she felt that the patient needed to go to surgery at Hospital A due to the finding of free air and the presence of the rigidity of the abdomen. The ED physician stated he/she felt the patient had a bowel perforation and should not be transferred. The ED physician stated she expressed to the surgeon (#2) that transporting the patient might be a violation of EMTALA. The physician added that the risk management at Hospital B had also spoken with surgeon (#2) about EMTALA guidelines as well. The physician stated that the surgeon (#2) did not believe this situation was EMTALA related. When asked if the physician (#1) had ever had EMTALA training, he/she stated it is given annually through their group and Hospital A had given the course in the past two (2) weeks.

During an interview with General Surgeon (#2) on 01/12/15 at 1:15 p.m. in the Conference Room, the surgeon confirmed that he/she was on call and remembered the situation that occurred on 12/13/15. The surgeon stated that on 12/13/15 he/she received a call at home at approximately 2:30 p.m. in the afternoon from one of the Emergency Department (ED) physicians (#1). The surgeon stated the ED physician explained that a patient had presented to the ED complaining of severe abdominal pain after having had a surgical procedure at Hospital B the previous Friday. The surgeon confirmed that he/she remembered suggesting to the ED physician that if the patient were stable, the patient should be transferred to Hospital B as this appeared to be a complication of the surgery performed at Hospital B.

The surgeon stated that he/she received another call from the ED physician shortly thereafter in which the ED physician explained that a surgeon at Hospital B was willing to take the patient if a surgical consult was done prior to transfer to determine if the patient was stable for transfer. The surgeon stated he/she advised the ED physician that he/she would be in the ED in about twenty (20) minutes to evaluate the patient.

The surgeon stated when he/she first saw the patient in the ED the patient was in a monitored bed with family at the bedside. The surgeon stated the patient was unsure of the surgical procedure she had had at Hospital B and indicated it might have been for endometrial cancer. The surgeon stated he/she explained to the patient that he/she was there to evaluate her for transfer to Hospital B. The surgeon stated the patient did appear to be in pain and was obviously uncomfortable. The surgeon stated the patient was tachycardic (had an abnormally fast heart rate) at that time but the patients vital signs were within normal limits.

The surgeon stated the patient appeared stable, and elaborated further by stating the patient's white count (a test that measures the number of white blood cells in the blood. A higher level number of white cells indicates a possible infection as white blood cells help the body fight infection) was within normal limits and the abdomen (stomach) was not rigid. The surgeon stated that the patient had had an x-ray prior to her exam and that the x-ray indicated that free air was noted. The surgeon explained that he/she believed the free air was a result of the surgery, but stated he/she was unsure at that time if the free air was from a bowel perforation or from insufflation (the introduction of a flow of gas into a body cavity) that occurred during the patient's surgery. The surgeon stated that since the patient was unable to explain what kind of abdominal surgery she had, it was difficult to determine why there was free air noted on the x-ray.

When asked why a computerized axial tomography (CT) scan (a special x-ray that can produce cross-sectional images of the body) was not ordered for the patient, the surgeon stated it was not ordered because the patient was stable and had an accepting surgeon at Hospital B. The surgeon continued and stated that a CT with contrast (an agent or medium used to improve the visibility on internal body structures). The contrast can be given intravenously (IV) (into the vein) or orally) would have taken anywhere from two (2) to four (4) hours to complete. When asked if the patient's condition changed at all while she was in the ED, the surgeon stated he/she did not see the patient again before the patient was transferred.

When asked why surgeon #2 felt the patient should be transferred from Hospital A to Hospital B, the surgeon stated that the patient was stable, and that because the patient had had surgery two days prior at Hospital B, the surgeon felt there would be a better continuity of care if the patient was transferred.

The surgeon explained that he/she was qualified to repair a bowel perforation, and when asked if surgery is available on an emergency basis at Hospital A, the surgeon stated it was. The surgeon stated the operating room (OR) is staffed for scheduled surgeries and has on-call staff on a twenty-four (24) basis for emergencies. When asked how long it would take to get an OR if the surgeon required one, the surgeon stated forty-five (45) minutes to one (1) hour. The surgeon acknowledged that he/she had not had EMTALA (Emergency Medical Transfer and Labor Act) training during the course of his/her thirty-four (34) year career, but added he/she had had EMTALA training in the last two (2) weeks at Hospital A.

During an interview with a staff General Surgeon at Hospital A (#5) on 01/12/16 at 1:40 p.m. in the Conference Room, the surgeon stated he/she had been with Hospital A for thirty-one (31) years and had been a practicing general surgeon for thirty-one (31) years. The surgeon stated he/she had reviewed the case and was familiar with the incident that occurred with the patient on 12/13/15. The surgeon stated his/her impression after reading the x-ray results, which indicated free air, was that the patient had a bowel perforation or that there was air from insufflation present from the previous surgical procedure.

The surgeon stated that if he/she would have been the consulting surgeon, the preference would have been for the patient to be transferred to Hospital B, but the surgeon stated that in this case, that might not have been possible due to the possible bowel perforation. The surgeon indicated that a CT with oral contrast might have indicated if there was a leak in the bowel, but the surgeon stated with the presence of free air noted on the x-ray, he/she would have felt more compelled to go straight to surgery and do an exploratory laparotomy (a surgical operation where the abdomen is opened and the abdominal organs examined) and make any surgical repairs at that time.

The surgeon stated he/she would consider a bowel perforation a medical emergency requiring prompt surgical intervention. When asked if the surgeon had ever attended or taken EMTALA training, the surgeon stated he/she believed he/she has had it at some point in the past but acknowledged that his/her understanding of EMTALA was limited.

During an interview with ED Registered Nurse (RN) (#6) on 01/12/16 at 2:05 p.m. in the Conference Room, the RN indicated he/she had been an ED nurse for the past fifteen (15) years. The RN confirmed that he/she was working as the charge nurse on the seven (7) a.m. to seven (7) p.m. shift on 12/13/15 and remembered the patient. The RN stated he/she recalled that the ED Patient Representative working the desk alerted him/her that two of ED nurses were bringing in a patient by stretcher that had arrived via private vehicle. The RN stated the two (2) nurses reported that the patient was a recent post-op patient and was complaining of chest pain.

The RN stated he/she immediately began making arrangements to move a current patient from a treatment room in preparation of placing this patient in that room, as it was close to the nurse's station. The RN stated when he/she entered the room after the patient was situated on the bed, he/she noted the nurses had started an IV (a device used to allow fluid to flow directly into a patient's vein), were drawing labs, and placing the patient on a monitor. The RN stated the patient appeared gray, diaphoretic (sweating heavily) and anxious. The RN added that he/she noted the patient to be clutching her chest. The RN continued by stating that he/she then contacted the lab to make sure that all tests were reported to the ED STAT (urgent or rush).

The RN indicated that a portable chest x-ray was ordered as well as a CT with IV contrast. The RN stated the sepsis protocol was initiated (a set of laboratory tests that help determine if a patient is septic (the presence in tissues of harmful bacteria and their toxin, typically through infection of a wound) and cardiac testing was also ordered. The RN stated that he/she stepped away at that point to check on the rest of the department.

The RN explained that /he/she later heard the ED physician (#1) stating that free air was noted on the x-ray and the RN was asked to call the on-call OB/GYN (obstetrics and gynecology) and general surgeon in case of bowel involvement. The RN stated that after he/she heard the ED physician speaking with the surgeon (#2), he/she heard the ED physician speaking with the on-call surgeon at Hospital B. The RN stated he/she did not see the surgeon (#2) examine the patient but did remember seeing the surgeon at the nurse's station speaking with the ED physician (#1) at approximately 5:05 p.m.

The RN stated that while he/she was at the nurse's station he/she received a call from the Risk Management (RM) at Hospital B. The RN continued by stating that RM was concerned that the patient was not receiving the necessary treatment considering the patient's symptoms. The RN stated at that point he/she gave the call to the surgeon (#2) to handle. The RN stated he/she overheard the surgeon stating that the patient was stable enough for transfer. The RN continued by stating he/she received a call from Hospital B with a room assignment and accepting physician. The RN indicated that the accepting physician requested the transfer be done as soon as possible. The RN continued by stating air transport was called at Hospital B's request, and report was then called to Hospital B. The RN stated the last time that he/she saw the patient, the patient had received pain medication and seemed more comfortable.

When the RN was asked if he/she had ever received EMTALA training, the RN stated he/she did remember having some EMTALA training in the past that had been offered at Hospital A, and he/she added that she had received EMTALA training from Hospital A two weeks ago.

During an interview with the Administrator (#8) on 01/13/16 at 9:30 a.m. in the Conference Room, the Administrator stated he/she was very sorry about the outcome of the patient. The Administrator continued by stating that the facility (Hospital A) failed the patient and added that he/she was embarrassed that their facility did not handle the situation appropriately. The Administrator acknowledged that the patient should not have been transferred from Hospital A.

During an interview with the ED Medical Director (#8), Medical Doctor (MD) on 01/13/16 at 10/35 a.m. in the Conference Room, the MD acknowledged he/she is the supervisor for the ER physicians and Allied Health Practitioners. The MD stated all of his/her staff receive annual re-education and training, which is inclusive of EMTALA training. The MD stated the training is offered online and his/her staff also just completed additional EMTALA training through Hospital A.

During an interview with the ED Registered Nurse (RN), (#4) on 01/13/16 at 11:10 a.m. in the Conference Room, the RN stated he/she had been a Licensed Practical Nurse (LPN) for twenty-six (26) years and an RN for the past six (6) months. The RN stated he/she has been working at Hospital A for the last six (6) months. The RN acknowledged he/she was working on 12/13/15 on the seven (7) a.m. to seven (7) p.m. shift, and the RN remembered caring for the patient on that date. The RN stated he/she recalled some nurses bringing in a patient that had arrived by private vehicle and was asked to move an existing patient from one of the treatment rooms in preparation of receiving this patient.

The RN stated when he/she assessed the incoming patient the patient appeared to be in pain. The RN stated the patient's blood pressure was slightly elevated and that the patient was tachycardic. The RN stated the patient's husband was answering many of the questions for the patient as the patient was in extreme pain, and it was difficult for her to answer the questions. The RN added that he/she remembered encouraging the patient to try and slow her respirations (breathing) down. The RN added that the patient had had a number of labs and tests ordered, which were being done as he/she was getting the patient's information.

The RN acknowledged that a portable x-ray was done and remembered the patient crying out in pain when being positioned. The RN stated the charge nurse (#6) came into the patient's room and informed him/her that free air was noted on the patient's x-ray. The RN stated he/she felt the patient was in serious condition and was aware the patient had had a D&C at Hospital B two days prior to coming into the ED.

The RN stated he/she had no recollection of seeing any of the physicians or surgeons examining the patient. The RN stated he/she was told the patient had been seen by the on-call surgeon (#2) and was cleared for transport. The RN stated he/she then began working on the transfer paper work. The RN continued by stating that all of the ED nurses help with transfer paper work and that the patient's transfer paper work was completed by the charge nurse (#6). The RN stated the patient's vital were within normal limits, and the patient had improved since first presenting to the ED.

The RN acknowledged that Hospital B had wanted a CT with contrast done on the patient, but the RN stated the patient's creatinine was elevated and and IV contrast could not be used. The RN indicated he/she was unsure of what Hospital A's full capabilities were in regard to caring for this patient. The RN stated he/she could not remember whether or not he/she had had EMTALA training during her orientation six (6) months ago. The RN stated he/she did have EMTALA training two (2) weeks ago at Hospital A.

Review of the facility Medical Staff By-Laws and Medical Staff Rules and Regulations adopted in 1985 and revised October 2012 revealed at " Section 7-Emergency Department" that all physician members of the active staff would be required to participate in emergency room coverage unless exempted by the Executive Committee. Separate "on-call" lists would be maintained and distributed for the Medical Staff Department. Those physicians need not remain in hospital but should be available within thirty (30) minutes if needed.

Review of the facility policy entitled " Interhospital Transfers (Facility to Facility), " number 11-11:166, revised 09/01/2015 revealed that the policy noted that hospitals may appropriately transfer a patient to another facility if 1) that person (or someone acting on that person's behalf), after being informed of the risks associated with the transfer and of the hospital's obligation to provide treatment, requests the transfer; or 2) a physician (or qualified medical person if a physician is physically unavailable but has provided consultation) certified that the benefits of the transfer outweigh the risks.

2. Stabilize meant, with respect to an emergency medical condition, to provide such medical treatment of the condition as may be necessary to assure, within 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, or with respect to an EMC (of a pregnant woman who is having contractions) to deliver.

3. Capacity is defined as the ability of the hospital to accommodate the individual.

PROCEDURE
1. When the level of care of any patient is deemed beyond the scope of services at the facility, the attending physician is responsible for arranging the transfer to an appropriate facility.
2. The facility, also referred to as the transferring hospital, will provide the necessary medical treatment within the capacity of the institution prior to transferring the patient to another facility.
Review of the facility's policy entitled "Transfer Activities in Accordance with EMTALA Requirements, Policy number 5068, last reviewed 04/2014, noted that the policy applied only to transfers of patients out of the ED, and not to transfers of the facility's inpatients to other hospitals. When the emergency medical condition of an ED patient cannot be stabilized with the capability and capacity available to the hospital's ED, or when an ED patient with an unstabilized EMC requests a transfer to another facility, the hospital will arrange for the patient an EMTALA appropriate transfer, as defined in this policy. Transfer forms must be completed on all patients transferred to other facilities.
Review of the facility's on-call lists revealed that surgeon (#2) was on call on the day in question. On-call lists for the previous three (3) months were reviewed and were being maintained for the specialists available at this facility. There were no other requirements listed in the Bylaws or facility policies which addressed additional requirements for the on-call physician. The facility's Bylaws and Policies and Procedure failed to address the duties and responsibilities of the on-call physician as it related to the evaluation, treatment and stabilization of an individual with an emergency medical condition.

Review of the four (4) of four (4) credential files (#s 1, 2, 3 and 7) and two (2) of two (2) personnel files (#s 4 and 6) revealed that physician #2 (on-call surgeon) was credentialed to perform abscess drainage, amputation, appendectomy, biopsy, colonoscopy, colostomy, cholecystectomy, hernia repair, ileostomy, laceration repair, apparition laparoscopy, bowel resection, bowel perforation repair and exploratory laparotomy. There were no problems identified in the review of the personnel and credentialed files.

Review of the Interhospital Transfer Form revealed that the reason noted for the transfer of patient #2 was "Lack of Needed Services." On-call physician #2 was credentialed to perform the patient's surgery, and the hospital had the capacity and capability. As the facility provided surgical services, as patient #2 was unstable and surgeon #2 was credentialed to perform surgical procedures, it was determined that the on-call surgeon failed to provide services within the resources available to the hospital. As this resulted in an inappropriate transfer of Patient #2 on 12/13/2015.