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Based on record review, staff and provider interviews, review of the facility Medical Staff Rules and Regulation and the Emergency Treatment and Labor Act (EMTALA) policies, the facility failed to ensure their Medical Staff Rules and Regulation and their EMTALA policy followed the EMTALA regulations regarding providing necessary stabilizing treatment of an Emergency Medical Condition (EMC) within their capabilities prior to a transfer. One of 21 sampled patients (Patient 1) did not receive a surgical consult or surgical intervention prior to transfer despite the facilities capability, placing the patient's health at risk at the time of the transfer. The total sample size was 21. The hospital's Director of Quality and Compliance was notified at 1:40 pm on 2/17/17 that immediate jeopardy conditions existed (IJ). Patient # 21 presented to the ED with severe abdominal pain and laboratory and imaging testing demonstrated the patient had a small bowel obstruction with possible mesenteric ischemia. Despite its capabilities, which included an on-call surgeon and gynecologist, the hospital inappropriately transferred patient # 1. While patient # 21 was in the ED, the ED physician contacted the on-call surgeon twice. The on-call surgeon requested the ED physician transfer the patient to another hospital unnecessarily delaying stabilizing treatment of the patient's emergency medical condition. The hospital's failure to stabilize a patient's emergency medical condition within its capabilities and capacity could lead to serious complications including death of any patient with an unstable emergency medical condition.

Findings are:

A. Review of facility document titled "Medical Staff Rules and Regulations" revised February 2016 under the section titled "Emergency Treatment and Stabilization" states that "Persons with emergency medical conditions will be treated within the capability of the Hospital's dedicated emergency department (ED) and their condition stabilized, OR the person will be transferred to another facility in accordance with Hospital policy."

This document does not support the EMTALA regulations due to the regulation states that the hospital shall provide medical treatment within it's capability that minimizes the risks to the individuals health.

B. Review of facility policy titled "EMTALA-Patient Screening, Treatment and Transfer Requirements Under Emergency Medical Treatment and Active Labor Act" dated 3-19-15 states, "An individual in an unstable EMC may be transferred only by an "appropriate transfer" as that term is defined by EMTALA, requiring: a) THE HOSPITAL SHALL PROVIDE MEDICAL TREATMENT WITHIN IT CAPABILITY THAT MINIMIZES THE RISKS TO THE INDIVIDUAL'S HEALTH and, in the case of a woman in labor, the health of the unborn child."

C. Review of the hospital's Medicare Database Worksheet verified by the hospital quality coordinator on 2/1/17 revealed the hospital's capabilities include a dedicated Emergency Department, non-surgical cardiac and medical/surgical ICU, inpatient and outpatient surgical services and obstetric services.

D. An interview on 2/1/17 at 1:30 PM, with ED MD-A the physician attending to Patient 1 in the ED on 1/14/17, confirmed that the patient had an EMC at the time of discharge. ED MD-A stated, "I felt that the patient was stable due to having placed an IV (intravenous), a NG (naso-gastric tube -used to decompress the stomach) and provided treatment including lab, xrays and medication. I did believe that at the time of transfer the patient (Patient 1) required possible immediate surgical intervention due to the scan showed possible small bowel obstruction and possible signs of peritonitis (inflammation of the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs)." ED MD-A did identify that the hospital has a general surgeon's on call, and I did visit with (On Call MD-B the general surgeon on call on 1/14/17) on the phone about the case twice that evening at 6:10 PM and 8:05 PM. "I reviewed the numbers (lab values received), the scan report, and the history of Patient 1 having had surgery in November of 2016 at (Hospital B-65 miles away) for abdominal sacral colpopexy (An abdominal surgery which mesh is stitched into the top of the vagina and attached to a strong ligament overlying the sacrum (tail bone) to correct a prolapse of the pelvic organs.) On Call MD-B told me that it is the advice of the American College of General Surgeons, that for 90 days after surgery, the surgeon is responsible for complications from that surgery and On Call MD-B thought that was the case." ED MD-A did call the surgeon (OB/GYN MD-C an Obstetrics and Gynecology [OB/GYN] Specialist) at Hospital B that was on call for the surgeon that performed the November 2016 surgery. ED MD-A stated, "(OB/GYN MD-C) stated that (she) assisted with Patient 1's case in November. OB/GYN MD-C stated that they do not do surgery for bowel obstruction, that would be referred to their general surgeon (On Call MD-D) at Hospital B." ED MD-A stated, "I then called (On Call MD-D the general surgeon at Hospital B) and On Call MD-D accepted the patient for a transfer." The patient was then transferred to Hospital B via ambulance.

Patient 1 presented to the ED with complaints of severe abdominal pain. The ED MD-A did call the general surgeon on call (On Call MD-B) twice while Patient 1 was in the ED. On Call MD-B did not come to the ED to examine the patient prior to being transferred.

E. An interview on 2/2/17 at 10:30 AM, with On Call MD-B the general surgeon on call on 1/14/17, confirmed that (ED MD-A) did call twice to review the case, including the test results and (Patient 1's) history of just having surgery in November 2016. "I did not come in and see (Patient 1), I told ED MD-A that as a surgeon that it is our oath through the American College of Surgery that if you did the 1st surgery, that surgeon usually follows up with any complications within 90 days of the surgery. That way they know exactly what they did, including the placement of the mesh and where they anchored it in this case." On Call MD-B stated that he had assisted in this type of surgery here in the past but did not do this patients surgery. "It is something we can do at this hospital but would need one of the OB/GYN specialist here to assist me. I felt that it would be better for the continuity of care for this patient to return to the original surgeon. (ED MD-A) reviewed the test, lab and scan results with me and that there was a NG tube placed, IV medication for comfort and nausea, from that information I felt the patient would be stable to be transferred to (Hospital B)."

F. Review of Patient 1's medical record revealed in the nurses notes that the patient presented to the ED on 1/14/17 at 3:55 PM with a complaint of intermittent severe abdominal pain with nausea and vomiting. Was seen here Friday (1/13/17) early AM for these symptoms.

ED MD-A's note revealed, Patient complains of continued abdominal pain with intermittent episodes of vomiting. Patient was evaluated in emergency room shortly after midnight on 1/13/17. Patient had negative exam and negative plain films. Patient had nonspecific bowel gas pattern. The patient was given Zofran (medicine for nausea and vomiting) and had improvement of the pain symptoms. (Patient 1) reported that the pain would return after she had been without vomiting for a period of time. Pain persisted throughout the day and patient presented to the ED for evaluation. Denied shortness of breath, chest pain or urinary frequency. "The patient reported that (gender) had an abdominal sacral colpopexy in November performed by (OB/GYN MD-C's partner). Patient reports had mesh placed along the sacrum. Patient was having pelvic prolapse symptoms prior to the surgery. Patient has not had any complications with the surgery to this point."

ED MD-A's physical exam identified that Patient 1's abdomen was soft, hypoactive bowel sounds (slow bowel sounds), moderate diffuse tenderness with increased tenderness in the periumbilical (the belly button area) and suprapubic (the front bone of the pelvis) region more in midline. Positive rebound tenderness (pain upon removal of pressure in the abdomen). Positive guarding (tensing of abdominal wall muscles to guard the abdomen). Positive heeltap by report. (the jarring to the heel causes abdominal pain). Pain does not localize to the right lower quadrant."

ED MD-A ordered the following tests:
-insertion of an IV
-IV zofran for nausea
-CBC-a complete blood count to evaluate the overall health of patient including anemia, infection, leukemia. RESULTS: WBC (white blood count-shows infection) 14.7 High [3.5-10.5]
-CMP-a comprehensive metabolic profile used to measure glucose/sugar level, electrolytes, kidney and liver function. RESULTS: Glucose 169 High [65-100]; Potassium 3.4 Low [3.5-5.5]
-CRP-a c-reactive protein level used to check for inflammation in the body. RESULTS: 0.3 Normal [0.2-0.8]
-Lactic Acid/Lactate- a test that can identify possible severe infection (sepsis). RESULTS: 0.84 low [0.90-1.70]
-Lipase-a test to look at the lipase enzyme that can identify possible issues with the pancreas. RESULTS: 111 Normal [70-300]
-Urinalysis-essentially negative
-CT Abdomen/pelvis-a scan of the abdomen and pelvis area. RESULTS: Impression: 1)small bowel obstruction. Internal hernia and/or closed-loop obstruction not excluded. (a protrusion of an internal organ into the abdominal cavity); 2) Thick walled small bowel loops in the left lower quadrant, could relate to infection/inflammation or ischemic bowel (dead piece of bowel); 3) Mesenteric edema (fluid in the fold of tissue that attaches organs to the body wall) and interloop ascities (fluid) adjacent to the obstructed bowel loops.; 4) Abdominal and pelvic ascities.

ED MD-A's Medical Decision Making Note at 8:25 PM identified: That on exam the patient has findings consistent with peritonitis (inflammation of the membrane peritoneum, that lines the inner abdominal wall and covers the organs in you abdomen). She had rebound tenderness and point tenderness. CT scan revealed evidence of small bowel obstruction. There are thickened areas within the small intestine suggestive of possible ischemia. I spoke with (On Call MD-B) and had an NG tube placed. (On Call MD-B) requested patient be transferred to (Hospital B) for continuity of care. I spoke with the on-call physician OB/GYN MD-C at (Hospital B). (OB/GYN MD-C) requested I contact the on-call General surgeon (On Call MD-D) at Hospital B. I did speak with (On Call MD-D) and he has accepted patient in transfer. I again did speak with (On Call -B) to see if patient would require surgery prior to transfer. (On Call -B) reports patient is stable for transfer to (Hospital B). Lactic acid is normal. NG output has been 240 cc (cubic centimeters) of fluid. Patient has had 2 separate doses of IV morphine prior to transfer. Final diagnosis: Small Bowel obstruction status post abdominal sacral colpopexy November 2016."

G. Review of the completed Transfer Consent/Certification form dated 1/14/17 at 8:43 PM identified the following:
-The patient is stable so that, within reasonable medical probability, no deterioration of patient's condition is likely to result from the transfer.
-Reason for transfer (benefits)- Appropriate facility not available at (this hospital name).; Specialized physician/diagnostic services required.; Patient is not in active labor with imminent delivery/specialized OB care needed.; Expected benefits of treatment at another facility outweigh risks of transfer.
-Risk of transfer- Deterioration in condition: risk of increased pain, risk of ischemic bowel, risk of perforation (a hole open up in the bowel) and transportation risk.

When inquired of ED MD-A why, Continuity of care was not identified as a benefit, ED MD-A indicated that the surgeon that accepted the patient was a general surgeon (On Call MD-D) and not the surgeons (OB/GYN MD-C and partner) that performed the previous surgery. Therefore didn't feel that the continuity of care was not indicated to be identified.

H. An interview with ED Med Director MD-E identified as the ED medical director, on 2/2/17 at 11:30 AM stated, Patient 1 had an EMC during the ED stay that required treatment. "The patient needed stabilizing treatment and care." When asked if the patient was appropriate for transfer or treatment here, ED Med Director MD-E replied, "We could have provided the treatment here, we have the capability." When asked if Patient 1 would have been a high anesthesia risk. ED Med Director MD-E stated, "I think a lower risk patient from anesthesia point of view, no history of cardiac, renal or pulmonary disease and not obese." "In my opinion with the NG tube, IV fluids and pain management, I feel that (Patient 1) was stable for the transfer." When inquired of the risk of the transfer. ED Med Director MD-E indicated that "perforation could occur, not highly likely or Hypotension (low blood pressure) if turns septic (systemic infection), not highly likely in the 60-70 minutes it takes to get there (Hospital B).

I. Review of the privileges of the general surgeon and the OB/Gyn physicians revealed:
-On Call MD-B had privileges to repair rectocele, enterocele, cystocele, or pelvic prolapse.
-The 3 OB/GYN physicians (OB/GYN MD-F, OB/GYN MD-G and OB/GYN MD-H) on staff had privileges for rectocele, enterocele, cystocele, pelvic prolapse repair.

Review of the Physician on-call list revealed that On Call MD-B and OB/GYN MD-H were on call. There was a surgical team and anesthesia services on call. Review of the Surgical Log identified that there was no surgery being performed on 1/14/17 from 3:55 PM to 8:56 PM while at the hospital to prevent the hospital from surgical intervention within its capabilities.

J. Review of the ICU bed availability revealed that thefacility has 9 ICU beds and they had a census of 6 in ICU on 1/14/17.

Review of the surgical case mix from 7/1/16-12/31/16 revealed that there were 4 cases of exploratory laporotomy (surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease) with resections (surgical removal of a piece of bowel that is blocked or diseased) performed.

Review of the surgical case mix from 7/1/16-12/31/16 revealed that there were 23 total surgical cases performed by this hospitals general surgeons for the diagnoses of 1) unspecified small bowel obstruction; 2) small bowel obstruction with adhesions; 3) unspecified ileus [a painful obstruction of the intestine]; 4) post operative ileus; 5) paralytic ileus [a painful obstruction of the intestine].

This surgical mix identifies that the facility had the capability to treat Patient 1, therefore not requiring a transfer to (Hospital B).

I. Review of Patient 1's information from the receiving hospital (Hospital B) medical record revealed:
-Patient 1 was admitted 1/14/17 at 22:34 (10:34 PM) for direct admission to the surgical floor.
-Pre operative History and Physical dated 1/14/17 at 23:18 (11:18 PM) by On Call MD-D stated, "I think clearly this patient does need to go to the OR (surgery). Recommended proceeding with exploratory laparotomy."
-Per the Anesthesia Record, Patient 1 arrived in the surgery suite at 2340 (11:40 PM) on 1/14/17 for the exploratory laparotomy.

The On Call MD-D was a general surgeon that prepared Patient 1 for surgery within 1 hour of arrival to Hospital B. Review of the sending hospital (Hospital A) surgical case mix identifies that Hospital A had the capability to treat Patient 1, therefore Patient 1 would not have required a transfer to (Hospital B) for stabilization of the EMC.

Based on record review, review of the facility Emergency Treatment and Labor Act (EMTALA) policies, staff and provider interviews the facility failed to provide 1 (Patient 1) of 21 sampled patients an appropriate transfer due to this facility had the capability of providing the potentially necessary surgery needed to treat Patient 1's Emergency Medical Condition (EMC). Patient 1's Medical Screening Exam (MSE) identified an EMC requiring potential surgical intervention. The facility had a general surgeon and obstetrics/gynecology, anesthesia staff on call, a surgical team available and Intensive Care Beds (ICU) available, and yet the patient was not seen by a surgeon and transferred placing the patients health at risk at the time of the transfer. The total sample size was 21.

Findings are:

A. Review of facility document titled "Medical Staff Rules and Regulations" revised February 2016 under the section titled "Emergency Treatment and Stabilization" states that "Persons with emergency medical conditions will be treated within the capability of the Hospital's dedicated emergency department (ED) and their condition stabilized, or the person will be transferred to another facility in accordance with Hospital policy."

B. Review of facility policy titled "EMTALA-Patient Screening, Treatment and Transfer Requirements Under Emergency Medical Treatment and Active Labor Act" dated 3-19-15 states, "An individual in an unstable EMC may be transferred only by an "appropriate transfer" as that term is defined by EMTALA, requiring: a)The Hospital shall provide medical treatment within its capability that minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child."

C. Review of the hospital's Medicare Database Worksheet verified by the hospital quality coordinator on 2/1/17 revealed the hospital's capabilities include a dedicated Emergency Department, non-surgical cardiac and medical/surgical ICU, inpatient and outpatient surgical services and obstetric services.

D. An interview on 2/1/17 at 1:30 PM, with ED MD-A the physician attending to Patient 1 in the ED on 1/14/17, confirmed that the patient had an EMC at the time of discharge. ED MD-A stated, "I felt that the patient was stable due to having placed an IV (intravenous), a NG (naso-gastric tube -used to decompress the stomach) and provided treatment including lab, xrays and medication. I did believe that at the time of transfer the patient (Patient 1) required possible immediate surgical intervention due to the scan showed possible small bowel obstruction and possible signs of peritonitis (inflammation of the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs)." ED MD-A did identify that the hospital has a general surgeon's on call, and I did visit with (On Call MD-B the general surgeon on call on 1/14/17) on the phone about the case twice that evening at 6:10 PM and 8:05 PM. "I reviewed the numbers (lab values received), the scan report, and the history of Patient 1 having had surgery in November of 2016 at (Hospital B-65 miles away) for abdominal sacral colpopexy (An abdominal surgery which mesh is stitched into the top of the vagina and attached to a strong ligament overlying the sacrum (tail bone) to correct a prolapse of the pelvic organs.) On Call MD-B told me that it is the advice of the American College of General Surgeons, that for 90 days after surgery, the surgeon is responsible for complications from that surgery and On Call MD-B thought that was the case." ED MD-A did call the surgeon (OB/GYN MD-C an Obstetrics and Gynecology [OB/GYN] Specialist) at Hospital B that was on call for the surgeon that performed the November 2016 surgery. ED MD-A stated, "(OB/GYN MD-C) stated that (she) assisted with Patient 1's case in November. OB/GYN MD-C stated that they do not do surgery for bowel obstruction, that would be referred to their general surgeon (On Call MD-D) at Hospital B." ED MD-A stated, "I then called (On Call MD-D the general surgeon at Hospital B) and On Call MD-D accepted the patient for a transfer." The patient was then transferred to Hospital B via ambulance.

E. An interview on 2/2/17 at 10:30 AM, with On Call MD-B the general surgeon on call on 1/14/17, confirmed that (ED MD-A) did call twice to review the case, including the test results and (Patient 1's) history of just having surgery in November 2016. "I did not come in and see (Patient 1), I told ED MD-A that as a surgeon that it is our oath through the American College of Surgery that if you did the 1st surgery, that surgeon usually follows up with any complications within 90 days of the surgery. That way they know exactly what they did, including the placement of the mesh and where they anchored it in this case." On Call MD-B stated that he had assisted in this type of surgery here in the past but did not do this patients surgery. "It is something we can do at this hospital but would need one of the OB/GYN specialist here to assist me. I felt that it would be better for the continuity of care for this patient to return to the original surgeon. (ED MD-A) reviewed the test, lab and scan results with me and that there was a NG tube placed, IV medication for comfort and nausea, from that information I felt the patient would be stable to be transferred to (Hospital B)."

F. Review of Patient 1's medical record revealed in the nurses notes that the patient presented to the ED on 1/14/17 at 3:55 PM with a complaint of intermittent severe abdominal pain with nausea and vomiting. Was seen here Friday (1/13/17) early AM for these symptoms.

ED MD-A's note revealed, Patient complains of continued abdominal pain with intermittent episodes of vomiting. Patient was evaluated in emergency room shortly after midnight on 1/13/17. Patient had negative exam and negative plain films. Patient had nonspecific bowel gas pattern. The patient was given Zofran (medicine for nausea and vomiting) and had improvement of the pain symptoms. (Patient 1) reported that the pain would return after she had been without vomiting for a period of time. Pain persisted throughout the day and patient presented to the ED for evaluation. Denied shortness of breath, chest pain or urinary frequency. "The patient reported that (gender) had an abdominal sacral colpopexy in November performed by (OB/GYN MD-C's partner). Patient reports had mesh placed along the sacrum. Patient was having pelvic prolapse symptoms prior to the surgery. Patient has not had any complications with the surgery to this point."

ED MD-A's physical exam identified that Patient 1's abdomen was soft, hypoactive bowel sounds (slow bowel sounds), moderate diffuse tenderness with increased tenderness in the periumbilical (the belly button area) and suprapubic (the front bone of the pelvis) region more in midline. Positive rebound tenderness (pain upon removal of pressure in the abdomen). Positive guarding (tensing of abdominal wall muscles to guard the abdomen). Positive heeltap by report. (the jarring to the heel causes abdominal pain). Pain does not localize to the right lower quadrant."

ED MD-A ordered the following tests:
-insertion of an IV
-IV zofran for nausea
-CBC-a complete blood count to evaluate the overall health of patient including anemia, infection, leukemia. RESULTS: WBC (white blood count-shows infection) 14.7 High [3.5-10.5]
-CMP-a comprehensive metabolic profile used to measure glucose/sugar level, electrolytes, kidney and liver function. RESULTS: Glucose 169 High [65-100]; Potassium 3.4 Low [3.5-5.5]
-CRP-a c-reactive protein level used to check for inflammation in the body. RESULTS: 0.3 Normal [0.2-0.8]
-Lactic Acid/Lactate- a test that can identify possible severe infection (sepsis). RESULTS: 0.84 low [0.90-1.70]
-Lipase-a test to look at the lipase enzyme that can identify possible issues with the pancreas. RESULTS: 111 Normal [70-300]
-Urinalysis-essentially negative
-CT Abdomen/pelvis-a scan of the abdomen and pelvis area. RESULTS: Impression: 1)small bowel obstruction. Internal hernia and/or closed-loop obstruction not excluded. (a protrusion of an internal organ into the abdominal cavity); 2) Thick walled small bowel loops in the left lower quadrant, could relate to infection/inflammation or ischemic bowel (dead piece of bowel); 3) Mesenteric edema (fluid in the fold of tissue that attaches organs to the body wall) and interloop ascities (fluid) adjacent to the obstructed bowel loops.; 4) Abdominal and pelvic ascities.

ED MD-A's Medical Decision Making Note at 8:25 PM identified: That on exam the patient has findings consistent with peritonitis (inflammation of the membrane peritoneum, that lines the inner abdominal wall and covers the organs in you abdomen). She had rebound tenderness and point tenderness. CT scan revealed evidence of small bowel obstruction. There are thickened areas within the small intestine suggestive of possible ischemia. I spoke with (On Call MD-B) and had an NG tube placed. (On Call MD-B) requested patient be transferred to (Hospital B) for continuity of care. I spoke with the on-call physician OB/GYN MD-C at (Hospital B). (OB/GYN MD-C) requested I contact the on-call General surgeon (On Call MD-D) at Hospital B. I did speak with (On Call MD-D) and he has accepted patient in transfer. I again did speak with (On Call -B) to see if patient would require surgery prior to transfer. (On Call -B) reports patient is stable for transfer to (Hospital B). Lactic acid is normal. NG output has been 240 cc (cubic centimeters) of fluid. Patient has had 2 separate doses of IV morphine prior to transfer. Final diagnosis: Small Bowel obstruction status post abdominal sacral colpopexy November 2016."

G. Review of the completed Transfer Consent/Certification form dated 1/14/17 at 8:43 PM identified the following:
-The patient is stable so that, within reasonable medical probability, no deterioration of patient's condition is likely to result from the transfer.
-Reason for transfer (benefits)- Appropriate facility not available at (this hospital name).; Specialized physician/diagnostic services required.; Patient is not in active labor with imminent delivery/specialized OB care needed.; Expected benefits of treatment at another facility outweigh risks of transfer.
-Risk of transfer- Deterioration in condition: risk of increased pain, risk of ischemic bowel, risk of perforation (a hole open up in the bowel) and transportation risk.

When inquired of ED MD-A why, Continuity of care was not identified as a benefit, ED MD-A indicated that the surgeon that accepted the patient was a general surgeon (On Call MD-D) and not the surgeons (OB/GYN MD-C and partner) that performed the previous surgery. Therefore didn't feel that the continuity of care was not indicated to be identified.

H. An interview with ED Med Director MD-E identified as the ED medical director, on 2/2/17 at 11:30 AM stated, Patient 1 had an EMC during the ED stay that required treatment. "The patient needed stabilizing treatment and care." When asked if the patient was appropriate for transfer or treatment here, ED Med Director MD-E replied, "We could have provided the treatment here, we have the capability." When asked if Patient 1 would have been a high anesthesia risk. ED Med Director MD-E stated, "I think a lower risk patient from anesthesia point of view, no history of cardiac, renal or pulmonary disease and not obese." "In my opinion with the NG tube, IV fluids and pain management, I feel that (Patient 1) was stable for the transfer." When inquired of the risk of the transfer. ED Med Director MD-E indicated that "perforation could occur, not highly likely or Hypotension (low blood pressure) if turns septic (systemic infection), not highly likely in the 60-70 minutes it takes to get there (Hospital B).

I. Review of the privileges of the general surgeon and the OB/Gyn physicians revealed:
-On Call MD-B had privileges to repair rectocele, enterocele, cystocele, or pelvic prolapse.
-The 3 OB/GYN physicians (OB/GYN MD-F, OB/GYN MD-G and OB/GYN MD-H) on staff had privileges for rectocele, enterocele, cystocele, pelvic prolapse repair.

Review of the Physician on-call list revealed that On Call MD-B and OB/GYN MD-H were on call. There was a surgical team and anesthesia services on call. Review of the Surgical Log identified that there was no surgery being performed on 1/14/17 from 3:55 PM to 8:56 PM while at the hospital to prevent the hospital from surgical intervention within its capabilities.

J. Review of the ICU bed availability revealed that thefacility has 9 ICU beds and they had a census of 6 in ICU on 1/14/17.

Review of the surgical case mix from 7/1/16-12/31/16 revealed that there were 4 cases of exploratory laporotomy (surgical operation where the abdomen is opened and the abdominal organs examined for injury or disease) with resections (surgical removal of a piece of bowel that is blocked or diseased) performed.

Review of the surgical case mix from 7/1/16-12/31/16 revealed that there were 23 total surgical cases performed by this hospitals general surgeons for the diagnoses of 1) unspecified small bowel obstruction; 2) small bowel obstruction with adhesions; 3) unspecified ileus [a painful obstruction of the intestine]; 4) post operative ileus; 5) paralytic ileus [a painful obstruction of the intestine].

This surgical mix identifies that the facility had the capability to treat Patient 1, therefore not requiring a transfer to (Hospital B).

I. Review of Patient 1's information from the receiving hospital (Hospital B) medical record revealed:
-Patient 1 was admitted 1/14/17 at 22:34 (10:34 PM) for direct admission to the surgical floor.
-Pre operative History and Physical dated 1/14/17 at 23:18 (11:18 PM) by On Call MD-D stated, "I think clearly this patient does need to go to the OR (surgery). Recommended proceeding with exploratory laparotomy."
-Per the Anesthesia Record, Patient 1 arrived in the surgery suite at 2340 (11:40 PM) on 1/14/17 for the exploratory laparotomy.

The On Call MD-D was a general surgeon that prepared Patient 1 for surgery within 1 hour of arrival to Hospital B. Review of the sending hospital (Hospital A) surgical case mix identifies that Hospital A had the capability and capacity to treat Patient 1, therefore Patient 1 would not have required a transfer to (Hospital B) for stabilization of the EMC.