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St. Francis Hospital - Downtown was not in compliance with the Federal Requirements at 42 CFR 489.24 and related provisions of CFR 489.20 Responsibilities of Medicare Hospitals in Emergency cases.

An EMTALA Investigation Survey was conducted from 03/11/13 to 03/13/13.

1. On the days of the EMTALA Investigation Survey based on interviews, medical record reviews, on-call physician schedules, and physician credentials, emergency room logs, bed census reports, policies and procedures, Medical Staff By-Laws, and Medical Staff Rules and Regulations, the participating hospital's on-call physician (surgeon on-call), when notified by the emergency department physician, refused to come to the hospital to provide treatment necessary to stabilize an individual with an identified emergency medical condition which the participating hospital has the capability and capacity to treat for 1 of 20 patient charts reviewed. (Patient #2) The hospital also failed to ensure that their ED EMTALA policy and procedure, Medical Staff By-Laws or Medical Staff Rules and Regulations defined the responsibility of the on-call physician response time to examine and treat patients with an emergency medical condition, when requested and/or notified by the Emergency Department physician for Patient #2. This deficient practice has the potential to affect other patients who present to the ED. Refer to findings in Tag A 2404.

2. On the days of the EMTALA complaint investigation (SC00022743) based on interviews, medical record reviews, and review of hospital policies and procedures, it was determined that the hospital failed to provide further examination and stabilizing treatment as required that was within the capability and capacity of the staff and the services available at the hospital for one (1) of twenty (20) medical records reviewed (Patient #2). Refer to finding in tag A-2407

3. Based on reviews of medical records, ED logs, policies and procedures and interviews, the facility failed to provide further evaluation and treatment for 2 trauma individuals that required further evaluation and treatment of their emergency medical condition which was within the capability and capacity of the hospital. As this deficient practice resulted in the inappropriate transfer of 2 (PT #1 and PT #2) patient medical records reviewed. Refer to findings in A-2409.

On the days of the EMTALA Investigation Survey based on interviews, medical record reviews, on-call physician schedules, and physician credentials, emergency room logs, bed census reports, policies and procedures, Medical Staff By-Laws Manual, and Medical Staff Rules and Regulations, the participating hospital's on-call physician (surgeon on-call) when notified by the emergency department physician refused to come to the hospital to provide treatment necessary to stabilize an individual with an identified emergency medical condition which the participating hospital has the capability and capacity to treat for 1 of 20 patient charts reviewed (Patient #2). The hospital also failed to ensure that their ED EMTALA policy and procedure, Medical Staff By-Laws or Medical Staff Rules and Regulations defined the responsibility of the on-call physician response time to examine and treat patients with an emergency medical condition, when requested and/or notified by the Emergency Department physician for Patient #2. This deficient practice has the potential to affect other patients who present to the ED.

The findings are:

1. The hospital's Medical Staff By-Laws Manual, revised November 2012, section titled, "2.15 On Call and Interpretation Roster" was reviewed. The manual indicated in part, "2.15.1. There shall be such on-call schedules as the Hospital determines to be necessary to meet the needs of the community after considering the recommendations of the Department Chairs and/or Division Chiefs and the Medical Executive Committee. The appropriate department Chair or Division Chief shall be responsible for designating the physicians who will serve on the on-call schedules. Any disputes or disagreements concerning the on-call schedules shall be submitted to the Medical Executive Committee for review and recommendation to the hospital CEO who will make the final decision concerning appointments of physicians to on-call schedules."
2. The hospital's policy, titled, "Emergency Medical Treatment and Active Labor ACT ("EMTALA") Policy including Triage and Medical Screening Policy Number 01-6017-RM000055, Reviewed date 1/9/2013, was reviewed. The policy indicated in part, "3. Medical Screening Examination ... C. In the event the on-call physician fails to come to the hospital and another physician cannot be reached, the patient will be transferred in accordance with this policy. Prior to the transfer, the Administrator on Call and the Risk Manager will be contacted and informed of the physician's failure to comply and is then noted on the Transfer Certification form. . . 7. Administrative Requirements. . . All On-Call physicians must respond to the treating physicians call in accordance with the timeframe set forth in the hospital's on-call coverage policy or its medical staff bylaws, rules and regulations, whichever is applicable."

3. Patient #2
On 03/12/13 at 1100, a review of the hospital's emergency room log revealed Patient #2 presented to the Hospital A's (St. Francis- Downtown Emergency Department via car on 02/02/13 for a chief complaint of a gunshot wound to the abdomen.

Review of the emergency department note in the patient's chart that was recorded on 02/02/13 at 2252, revealed, "Note time: 02/02/13 2140 Called to ambulance pad reference GSW (Gun Shot Wound). Arrived to find patient seated in rear seat, driver side. Patient alert/oriented though moaning in discomfort. Manual C-spine held and maintained. Rapid trauma assessment shows one wound to groin. C-Collar applied at no-neck setting which fit patient's body size. Patient immobilized to LSB (spinal board) across the back seat with assistance from 4 other crew members. C-Spine maintained throughout event. Patient to ED (emergency department) cot and moved to ED 3. MD(Medical Doctor ED physician)#1 to bedside for assessment."

Review of the nurse notes in the patient's chart revealed the patient was triaged(assessment by ED nurse to determine a patient medical priority needs) on 02/02/13 at 2136 as an urgent acuity level. Vital signs obtained and recorded at 2140 were: pulse-72, respirations-18, SpO2(Oxygen saturation measures the capacity of blood transporting oxygen to other parts of the body) 98%, blood pressure-100/70 mmhg (millimeters mercury), and temperature-97.6 degrees Fahrenheit (F). The nurse recorded that the patient responds to voice commands.

Review of the patient's emergency department notes revealed the ED Physician examined the patient on 02/02/13 at 2146. On 02/02/13 at 2305, the ED Physician recorded, "Note Time: 02/02/13 at 2205 HPI (History and Physical) Comments: PT intoxicated, moaning. Poor hx (history). Shot in L (left) groin while at club. Arrived pov (privately owned vehicle). Pt. unable to move LE (Lower Extremities). Patient is a 29 y.o. (year old) male presenting with a gunshot wound. The history is provided by the patient and a parent. Gunshot Wound The incident occurred less than 1 hour ago. The laceration is located on the abdomen. The laceration is 1 cm (centimeter) in size. The injury mechanism is gunshot wound. Possible foreign bodies present include a bullet. The pain is severe. The pain has been constant since onset. Associated symptoms include numbness and weakness. It is unknown when the patient last had a tetanus shot (a shot given to prevent lockjaw). Past medical history included GSW (Gun Shot Wound) to head and L foot and GERDS(gastroesophageal reflux disease)."

Review of the ED Physician orders included but are not limited to: intravenous(a procedure where a plastic needle is inserted into a vein to deliver intravenous fluids, antibiotics, directly into the blood stream) administration of a sodium chloride (a solution/fluid that hospitals give patient intravenously-also called normal saline) 0.9% - 1,000 milliliter bolus (rapid infusion of intravenous fluids) at 2145 and at 2240; pelvic x-ray which showed "pelvis reveals bullet fragments overlying the head of the right femur without definite fracture demonstrated. Visualized bowel gas pattern is unremarkable"; portable chest x-ray that showed left upper quadrant bullet fragments; complete blood count that showed the patient's hemoglobin(oxygen carrying pigment of red blood cells, serves to convey oxygen to the tissues)was 14.9 (normal range 13.2 - 17.1), Hematocrit (test measures whether patient has too few or too many red blood cells) was 42.7 (normal range 41.1 - 50.3%), and white blood cell count (part of immune system that helps fight infection) of 4.2 (normal range 4.3-11.1); Alcohol serum that showed 156 mg/DL(deciliter); drug screen that showed positive for TH-Cannabinol (inactive component of marijuana); urinalysis; metabolic panel, and type and cross match blood.

Review of the ED Physician provider notes showed, "abdominal: He exhibits distention (enlarged). There is tenderness. There is rebound and guarding. Genitourinary: No blood at urethral meatus, poor tone (reduced muscle strength). Musculoskeletal: No movement of LE (lower extremities), pt (patient) with no sensation (Lack of pain sensation) below umbilicus (navel). Neurological: He is alert. GCS (Glasgow coma scale- measures/assesses level of consciousness) eye subscore is 3. GCS verbal subscore is 4. GCS motor subscore is 5."

Review of the ED Provider Notes in the patient's HPI (History and Physical) section revealed, "Note Time: 02/02/13 at 2205: Differential Diagnosis; Clinical Impression; Plan: Pt (patient) needs to go to OR (operating room). D/w (discussed with) Physician #3 at Hospital B (another acute care hospital). He/she (Physician #3) refused pt stating we should stabilize pt and have them go to the OR(operating room) here (Hospital A). Talked to Physician #2(Hospital A's on - call surgeon) at 2007, and he/she (Physician #2) said the pt should go to Hospital B. Then, D/w(discussed with) Physician #3(Hospital B), and he accepted pt. O neg (negative) blood hung .... " .

Documentation in the section of the ED notes labeled, "Risk of Significant Complications, Morbidity, and/or Mortality:" revealed the ED Physician documented: patient's presenting problems:High
Diagnostic procedures: High, and Management options: High."

Review of the ED nurse note that was documented at 02/02/2013 at 2222 revealed, "Note Time: 02/02/13 2158 Patient is noted to have no sensation below umbilicus. Patient is awake and talking complaining of pain in the groin, one wound is visualized on the left side. Patient has no visible exit wound. Patient has 2 liter of normal saline infusing at present." "Note time: 02/02/13 2222 - Foley (catheter) with bright red blood and blood oozing from the urinary meatus (transport tube from the bladder to which brings urine outside of the body)."

Review of the patient's vital sign complex documentation showed:
"02/02/13 at 2145: pulse - 67, respirations - 25, SpO2- 99%, and blood pressure- 99/60;
02/02/13 at 2147: pulse- 70, respirations- 30, SpO2-100%, blood pressure- 101/60;
02/02/13 2157: pulse-81, respirations-27, SpO2-100%, blood pressure- 134/86;
02/02/13 2209: pulse-83, respirations-! 50, SpO2- 100%, blood pressure-113/73; and
02/02/13 2222: pulse-93, respirations-! 41, SpO2 - 100%, blood pressure ...".

On 03/12/13 at 1500, further review of Patient #2's chart revealed a section, labeled, Transfer Out/EMTALA Report, dated 02/02/13 at 2219, that showed Physician EMTALA documentation that read, "The patient may be at risk for deterioration from or during transport, reason for transfer is listed as for equipment or services not available at this facility, the name of the accepting physician, risks of transfer were lower blood pressure; Cardiac arrest; Death, benefits of transfer were listed as: services (trauma) unavailable, and patient discharge condition at transfer was listed as stable." Review of the Emergency Services Transport form dated 02/02/13 showed a unit of blood infusing wide open. A review of the transfer certification form dated 2/2/2013; at 2219: "Patient Condition the patient condition may be at risk for deterioration from or during the transport ...". Reason for Transfer ... for equipment and or services not available at this facility. On 2/2/2013, the facility had equipment and services available As Evidenced By:
a.)(Services) Review of Hospital A's on-call schedule dated 3/12/13/at 1100 showed Physician #2 was designated as the on-call surgeon from 0800 am Saturday 02/02/13 to 0800 am Monday 02/02/13. On 3/13/13 at 1130, during an interview, the Administrative Director in the Emergency Department verified the physician on-call coverage is from 0800 am on the designated date to 0800 am the next morning. Review of Privileges By Provider Report from Hospital A on 3/13/13 at 1140 revealed Physician #2 had Major Surgery Privileges in Alimentary/abdominal diagnostic/therapeutic treatment for organs/structures of intra-abdominal area, Alimentary/ abdominal diagnostic/therapeutic treatment of organs structures of retroperitoneal areas, Diagnostic/therapeutic procedures utilizing video assisted endoscopy for chest/abdomen/alimentary and Sleeve gastrectomy. St. Francis Downtown had capability (level of care that the personnel of the hospital can provide within the training and scope of their professional licenses. This includes the coverage available through the hospital on-call roster) to provide further evaluation and treatment for Patient #2 on 2/2/2013; b.) (Equipment) Review of Hospital A's bed census availability on 3/13/13 at 1135 revealed that on 2/2/13 an actual bed census of 174 with bed availability of 240. On 2/22013, St. Francis Hospital had capability and capacity (there was physical space, equipment, supplies, and specialized services (on-call surgeon) the hospital provides) to provide further evaluation and treatment for Patient #2 with an emergency medical condition. The facility's EMTALA policy indicated that if an on call physician fails to come to the hospital and another physician could not be reached, this information would be noted on the Transfer Certification form. There was no documented evidence to support that Physician #2's name was noted on Patient #2's chart as "failure to comply. " Further review of the patient's chart revealed the nurse documented on 02/02/13 that the patient was transferred via ambulance at 2245.

4. On 3/12/13 at 1320, the ED Physician stated that he/she had contacted Hospital B before contacting Hospital A's on-call surgeon due to the fact that "we don't have a trauma service here, so I called Hospital B." The ED Physician stated, "Physician #3 at Hospital B didn't want to accept the patient and told me to call our (Hospital A)'s on- call physician (Physician #2) here first. So, when I called Physician #2, he/she said, "I don't do traumas here." Then, I called Physician #3(Hospital B) back and told him what Physician #2 (Hospital A) had said, and that's when Physician #3 accepted the patient transfer." When questioned if Physician #2 presented to Hospital A for an evaluation of the patient's status, the ED Physician, stated, "Physician #2 said he/she wasn't going to take the patient so I called Physician #3 back, and he accepted the patient..."

On 3/12/13 at 1420, Physician #2(Hospital A) revealed, "all traumas go to Hospital B because that was our policy (Hospital A) since I've been here. We've always done it that way. I asked about the patient's vital signs and the heart rate was stable, but the patient couldn't move below the belly button. I felt it would require a general surgeon and a neurosurgeon as well because of what was going on. I felt the patient was stable based on the information provided. He had a neurologic injury and a gunshot that needed exploratory surgery (surgical exploration of abdomen, allows surgeon to examine abdominal organs for individuals who may have sustained an injury to the abdomen, penetrating trauma (e.g., GSW)... I won't be happy, but if I need to take traumas, then I would... ". When questioned if he/she presented to Hospital A to evaluate the patient's status prior to the transfer, Physician #2 stated "No." The facility failed to ensure that the on-call physician (Physician#2-surgeon) met the needs of Patient #2 on 2/2/2013 who had an emergency medical condition that required definitive treatment (surgery).

On 3/12/13 at 1525, Physician #3 (Hospital B) revealed, "The ED Physician (Hospital A) called and said he/she had this patient. I asked the ED Physician if he/she had called their hospital's(Hospital A)on- call physician...they have physicians there who are capable of stabilizing the patient, then sending them on over. The ED Doctor said he/she (Physician #2) probably won't see it, so I said, "you should call him/her first." The ED Physician (Hospital A) called him/her (Physician #2), and the ED Physician said that the on-call physician (Hospital A) wouldn't accept the patient. I said okay, go ahead and send (the patient)....". Physician #3 further stated that he/she "felt like there was no choice but to accept the patient."

During an interview with Staff Member #1 on 3/12/13 at 1635, he/she revealed, "the patient was critically ill and unstable and needed some type of intervention...ED Physician felt he/she (the patient) needed to leave, and that was our main focus... ". When questioned if the hospital's on-call physician ever presented to the hospital to evaluate the patient, Staff Member #1 replied, "the physician did not come to evaluate the patient..."

On 3/13/13 at 0905, during an interview with the Administrative Director Quality/MSS(medical staff services), the Administrative Director revealed, "There is no policy and procedure about on-call physician responsibilities for the hospital. Each physician is required to sign an "Attestation of Coverage Arrangements" agreement in the event the practitioner is unable to fulfill on-call responsibilities. Currently, there is no policy and procedure which defines a response time for an on-call physician..." Review of the hospital's Medical Staff Rules and Regulations and Medical Staff by- Laws Manual verified that the on-call physician response time (telephonically or actual appearance in the ED after being notified) was not clearly defined , i.e., in minutes. The facility failed to enforce their physician on- call policies and physician's EMTALA obligation when on call.

On 3/13/13 from 1450 to 1455, during an interview with the Administrative Director Quality/MSS, the Administrative Director was asked "if an on-call physician refuses to come in or accept a patient, what action does the hospital take and how do you hold that physician accountable? "The Administrative Director revealed, "the Director of Specialty will contact the on-call physician and we start with the Chain of Command-Chief Medical Officer is notified and disciplinary action is taken. The disciplinary process is counseling and if severe enough they get suspension...."

On the days of the EMTALA complaint investigation (SC00022743) based on interviews, medical record reviews, and review of hospital policies and procedures, it was determined that the hospital failed to provide further examination and stabilizing treatment as required that was within the capability and capacity of the staff and the services available at the hospital for one (1) of twenty (20) medical records reviewed. (Patient #2).

The findings are:
Cross Reference to A 2404: The participating hospital's on-call physician refused to come to the hospital when requested by the ED physician to provide treatment necessary to stabilize an individual with an identified emergency medical condition which resulted in the transfer of (Patient #2) to another participating hospital .
Emergency Services policy, reads, "Policy Number: 01-6017-RM000055, Emergency Medical Treatment and Active Labor Act ("EMTALA") Policy including Triage and Medical Screening, Reviewed Date: 1/9/2013, reads ..."4. Treatment and Stabilization - A. All patients determined to have an EMC(Emergency Medical Condition) will have one of the following: (1) treatment within the hospital's capabilities to stabilize the patient's condition."
Emergency Services Policy, 01-7510-ED000000.doc, title, scope of services, Reviewed Date: 09/2011, 09/2012, Revised Date: 01/2013, reads, "3.1 Description of Service -The Emergency Department provides a medical screening examination and appropriate care and treatment on a non-appointment basis to all persons who present to the department with a medical complaint. Qualified physicians/midlevel providers, registered nurses, and an interdisciplinary team provide assessment and treatment."

Review of Hospital A's on-call schedule dated 3/12/13 at 1100 showed Physician #2 was designated as the on-call surgeon from 0800 am Saturday 02/02/13 to 0800 am Monday 02/02/13. On 3/13/13 at 1130, the Administrative Director in the Emergency Department verified the physician on-call coverage is from 0800 am on the designated date to 0800 am the next morning. Review of Privileges By Provider Report from Hospital A on 3/13/13 at 1140 revealed Physician #2 had Major Surgery Privileges in Alimentary/abdominal diagnostic/therapeutic treatment for organs/structures of intra-abdominal area, Alimentary/abdominal diagnostic/therapeutic treatment of organs/structures of retroperitoneal areas, Diagnostic/therapeutic procedures utilizing video assisted endoscopy for chest/abdomen/alimentary and Sleeve gastrectomy. Review of Hospital A's bed census availability on 3/13/13 at 1135 revealed Hospital A had an actual bed census of 174 with bed availability of 240 on 2/2/13. The facility failed to ensure that their policies and procedures were followed as evidenced by failing to ensure that further medical examination and treatment as required to stabilize an identified emergency medical condition for Patient #2 on 2/2/2013, which was within the capability and capacity of the staff and facilities available at the hospital.

Based on reviews of medical records, ED logs, policies and procedures, on-call schedules, bed census, and interviews, the facility failed to provide further evaluation and treatment of 2 trauma individuals that required further evaluation and treatment of their emergency medical condition, which was within the capability and capacity of the hospital. As this deficient practice resulted in the inappropriate transfer of 2 (Patient #1 and Patient #2) patient medical records reviewed.
The findings are:

Emergency services policy

Policy Number: 01-7510-ED000304. Document title: Management of the Adult Patient with Traumatic Emergencies, Effective Date: 03/2004, Reviewed Date: 09/2012, reads in part. . . "Trauma is the leading cause of death in the United States for people in the first four decades of life. Because of the inadequate number of designated trauma centers and the distance from hospitals providing such care, many trauma patients are assessed, stabilized, admitted, or treated in non trauma centers. The care that is expected is to save the patient's life and to immediately treat all associated, life threatening injuries . . . . Criteria for consideration for Early Transfer of Trauma Patient....System Location: Major extremities injuries ... Injury: Fracture or dislocation with loss of distal pulses, open long-bone Fracture, Ischemic extremity."
Emergency Services Policy, 01-7510-ED 000000. doc, title, scope of services, Reviewed Date: 09/2011, 09/2012, Revised Date: 01/2013, reads, 3.5.3 Transfer: Patients may be transferred under the following guidelines: Types of cases listed below in which definitive care cannot be provided should be considered for transfer: Behavioral Health or Chemical Substance Dependent; Patients age 12 and under requiring collection of evidence for suspected rape/sexual abuse; Pediatrics patients needing referral to Pediatric Specialty; Level 1 Trauma patients to designated trauma center except under mass casualty circumstances; and Patients requiring extensive burn treatment".

Patient #1
On 3/12/13 at 1100, a review of Hospital A's physician on-call schedule showed Physician #4 was listed as the on-call surgeon (vascular -surgeon) from after 5:00 p.m. on Friday 09/21/12 to 8 am Saturday 09/22/12 during the time Patient#1 was in Hospital A's Emergency Department.

On 3/13/13 at 1135, a review of Hospital A's bed census availability revealed Hospital A had an actual bed census of 188 with bed availability of 240 on 09/22/13.

On 3/11/13 at 1500, a review of Hospital A's Emergency Department Log revealed Patient #1 presented via ambulation to Hospital A's Emergency Department on 09/22/12 at 5:30 for a chief complaint of Gun Shot Wound to upper left thigh/appears as an entry and exit.

Review of the ED notes dated 09/22/12 at 0533 shows the patient was triaged at with an acuity (triage) of immediate. Review of the ED Notes dated 09/22/12 showed the HPI (History of Present Illness) conducted at 0551 revealed, "Pt walked into front lobby. States he was shot in L (left) leg by 3 pple (people) trying to rob him. Shot at close range by hand gun. No other injury. Patient is a 32 yo male presenting with gunshot wound. The history is provided by the patient.
Gun Shot Wound : The incident occurred less than 1 hour ago. The laceration is 1 cm in size. The injury mechanism is gunshot wound. Foreign body present: no. The pain is moderate. The pain has been constant since onset. Pertinent negatives include no coolness and no discoloration. It is unknown when the patient last had a tetanus shot. . . Physical Exam (examination) Legs: 1. 2 GSW's, oozing blood, 2+ DP/PT (dorsalis pedis(pulse top of foot)/(Posterior tibia (pulse inner ankle) pulses, moving extremity (leg) well. "
Differential Diagnosis; Clinical Impression; Plan Pt with GSW (Gunshot Wound) to thigh. needs vascular eval(evaluation), no bony involvement. D/w trauma surgeon at ...(Hospital B), would prefer to do CT(Computerized Axial Tomography) angio at their facility, ok to transfer. PD (Police Department) at bedside. 6:11 AM."

The ED physician ordered: white blood cell count of 13.9 (normal range 4.3-11.1), HGB (hemoglobin) 13.5 (normal range 13.2-17.1) and HCT (hematocrit) 39.6 (normal range 41.1-50.3), drug screen positive for THC (TH-Cannabinol), Ethyl Alcohol <(less than)3(no alcohol detected), x-ray left femur that showed no fracture, dislocation, or acute bony abnormality...No radiopaque foreign body. Impression: No acute abnormality; Sodium Chloride 0.9% bolus infusion." There was no documentation of wound care in the chart.

On 3/12/13 at 1000, a review of the ED Physician's documentation in the patient's chart in the section labeled, Transfer Out/EMTALA Report, revealed "Reason for Transfer: For equipment or services not available at this facility, trauma surgery." In the section, labeled, risks of transfer, worsening pain, Lower blood pressure; Cardiac Arrest; Death; car accident." Review of the Transfer Certification dated 9/22/2012 at 0605 indicated in part, "Benefits of transfer: Services unavailable, Trauma surgeon to evaluate." The patient's chart showed the patient was transferred on 09/22/12 at 0632. The facility failed to ensure that further evaluation and treatment was provided for Patient #1 on 9/22/2013 as evidenced by the facility had the specialized services (capability on-call vascular surgeon) and equipment( capacity-bed availability, qualified staff availability, and operating room).

Patient #2

Cross Reference to A 2404: The participating hospital's on-call physician
refused to come to the hospital when requested by the ED physician to provide treatment necessary to stabilize an individual with an identified emergency medical condition which resulted in the inappropriate transfer of (Patient #2) to another acute care participating hospital . A review of Hospital A's on-call schedule revealed that from 0800 Saturday 02/02/2013 to 0800 Monday 02/02/2013, Physician #2 was the surgeon on call. Review of Hospital A's bed census availability on 3/13/2013 at 11:35 a.m. revealed that on 02/02/2013, the facility had an actual bed census of 174 with bed availability of 240. On 2/2/0213 St. Francis -Downtown had the capability and capacity to provide further evaluation for this individual.

On 3/13/13 at 1510, ED Physician stated,"my understanding is if it's a trauma patient, then all traumas are transferred to Hospital B. So I didn't call the on-call physician to evaluate the patient. I was told upon hire that all traumas go to Hospital B.... ".

On 3/13/13 from 1620-1630, the Administrative Director Emergency revealed,"there is no policy or procedure stating that traumas are not handled here. Traumas go to Hospital B. EMS (Emergency Medical Services) will not bring any traumas or pediatrics here. Traumas that walk in or are dropped off are seen here..." The facility failed to ensure that their Policy and Procedure, titled, "Management of the Adult Patient with Traumatic Emergencies" was followed as evidenced by failing to appropriately stabilize (Patient #1) and failing to appropriately treat and/or admit Patient #1 and Patient #2, as this resulted in inappropriate transfers of these individuals, (Patient #1) on 2/2/2013 and Patient #2 on 9/22/2012. Additionally, according to this policy, Patient #1 did not meet the criteria for consideration of early transfer as evidenced by: Patient with a major extremity injury (L upper thigh) had an x-ray on 9/22/2012 that revealed, "no fracture, no dislocation or acute bony abnormality; the physical exam revealed 2+ DP/PT pulses and no documentation was noted in the chart that the affected limb was ischemic. This further confirms that Patient #1 could have been appropriately treated and admitted to St. Francis Hospital downtown on 9/22/2012.