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Based on interview and record review, the facility failed to comply with the provisions in 42 CFR 489.20 and 42 CFR 489.24, when the facility's policies and procedures were not implemented, for one of 22 sample patients (Patient 22). Patient 22 was not stabilized before the patient was transferred from the Emergency Department (ED) to an outpatient clinic in another county.

This failure had the potential to result in delay in treatment and may compromise the patient's condition.

Based on interview and record review, the hospital failed to ensure an accurate central log (a list of patients who came to the Emergency Department [ED]) of each individual who came to the ED was maintained, when the mode of transportation of the patients who came to the ED was not documented for multiple days.

This failure resulted in incomplete information for patients seen in the ED.

Findings:

On May 28, 2025, at 9:45 a.m., a review of the ED log was conducted. The review indicated the facility did not enter the mode of transportation for each patient who came to the ED from March 19, 2025, through May 21, 2025 (64 days).

On May 28, 2025, at 9:49 a.m., an interview with the Chief Quality Officer (CQO) was conducted. The CQO stated it was important to keep an accurate ED central log. The CQO stated the upgrade to the facility's electronic medical record system must have caused the issue. The CQO stated the ED central log should have been complete and it was not.

A facility policy and procedure titled, "EMTALA-CENTRAL LOG POLICY," dated April 2023, was reviewed. The document indicated, "...The logs must contain at a minimum, the name of the individual, the date, time and means of the individual's arrival, the individual age, the individual's sex, the individual's record number, the nature of the individual's complaint, the individual's disposition, the individual's time of departure..."

Based on interview and record review, the facility failed to ensure a patient was stabilized before the patient was transferred from the Emergency Department (ED) to an outpatient clinic in another county, for one of 22 sample patients (Patient 22).

This failure could have caused the Patient 22's condition to further decline and had the potential to cause harm and/or death to the patient.

Findings:

On May 29, 2025, at 11:13 a.m., a concurrent interview and review of Patient 22's record were conducted with Registered Nurse (RN) 1.

A facility document titled, "Triage [a system for prioritizing patients for treatment]," dated March 31, 2025, at 7:22 a.m., was reviewed. The document indicated Patient 22 was seen at the facility for a chief complaint of abnormal laboratory (lab) results. The document indicated, "...Acuity [severity of patient's illness]: 3 - Urgent...Vitals and Measurements...31-Mar-2025 [March 31, 2025] 07:25 [7:25 a.m.]...Temp [temperature]: 97 F [Fahrenheit, unit of measurement, normal is 97.7 - 99.0] (Forehead)...Resp [respiration, normal is 12-20 breaths per minute]:16...HR[heart rate, normal is 60-100 beats per minute (bpm)]: 86...BP [blood pressure, normal is 120/80] 1: 90/45..."

A facility document titled, "Assessment Type: Daily," dated March 31, 2025, 7:24 a.m., authored by Case Manager (CM) 1 was reviewed. The document indicated, "...Spoke with [name of Facility A Clinic Staff 1] at [Name of outpatient Facility A's telephone number] to confirm pt's [Patient 22] outpatient appointment. Per [Name of Internal Medicine Physician 1] to transfer pt from ER to her appointment in [Name of Facility A] Per [Facility Clinic Staff 1], pt has appointment on 4-1-25 [April 1, 2025] W [with] [Name of physician scheduled to see patient at the outpatient clinic], for pt to be there at 0945 [9:45 a.m.] for a 1045am [10:45 a.m.] procedure. Procedure will be done at [Name of Facility A] med [medical] ctr. [center] Comp. [Comprehensive] Digestive Disease Center, [address of outpatient clinic]. Pre procedure instructions received [name of Facility A Clinic Staff 1]. ALS [Advanced Life Support (lifesaving protocols, interventions airway management and cardiac monitoring] transport arranged w/ [Name of person who works at transportation company] for a 5am [5 a.m.] ETA [estimated time of arrival]...will call return transport back to [Name of facility] arranged w/ [Name of employee who works at transportation company]..."

A facility document titled, "Emergency Department Record," dated March 31, 2025, at 7:27 a.m., was reviewed. The document indicated, "...female presents to the ER [Emergency Room, ED] via [by way of] EMS [Emergency Medical Services, ambulance service] for evaluation of abnormal lab values [results]. Patient [Patient 22] reported to have a gallbladder surgery and was found to have a doubled white count [WBC, white blood cells, a component of the blood with high levels signifying possible infection, normal range is between 3.6-11.2] at [name of skilled nursing facility]...Past surgical history: Cholecystectomy [a surgery to remove the gallbladder], Biliary Stent Placement [a thin hollow tube inserted into the bile duct to keep it open]...Physical Examination...Abdomen...Purulent [with pus drainage from JP [Jackson-Pratt drain, a medical device used to drain fluid] drain...WBC 15.8...1232 [12: 32 p.m.] Patient will be admitted to Telemetry [unit where the patient will receive continuous remote monitoring of the heart rate and rhythm]...1257 [12:57 p.m.] [Name of Surgeon 1]...General Surgery, called back and states to try to send patients [sic] to [name of Facility A] instead...1330 [1:30 p.m.] [name of Facility A] unable to accept patient for transfer but patient can follow upas [sic] she has an appointment...1340 [1:40 p.m.]...Patient is appearing septic [a serious medical condition that occurs when body responds to an infection]. Heart rate is 115bpm with blood pressure at 89/49. Will give vanco [vancomycin, a medication to treat infections] and more fluids [fluids administered through the vein]...Disposition Time...12:32 [12:32 p.m.]...Condition: Critical...Diagnosis: Acute Intraabdominal Abscesses [collection of pus in the abdomen]..."

A facility document titled, "Vitals," dated March 31, 2025, at 7:50 a.m., through April 1, 2025, at 6:06 a.m., was reviewed. The document indicated Patient 22's vital signs (HR, Resp, Temp, and BP) on the following dates and times:

- on March 31, 2025, at 7:50 a.m., Temp 98.2 F...HR 86...Resp 14...BP 105/52;
- on March 31, 2025, at 10 a.m., Temp 98.4 F...HR 94...Resp 14...BP 110/58;
- on March 31, 2025, at 12 p.m., Temp 98.2 F...HR 102...Resp 16...BP 125/52;
- on March 31, 2025, at 2 p.m., Temp 98.4 F...HR 108...Resp 16...BP 109/51;
- on March 31, 2025, at 8 p.m., Temp 96 F...HR 114...Resp 20...BP 100/51;
- on March 31, 2025, at 10 p.m., Temp 97.8 F...HR 116...Resp 22 ...BP 103/42;
- on April 1, 2025, at 2 a.m., Temp 98 F...HR 102...Resp 19...BP 97/50;
- on April 1, 2025, at 4 a.m., Temp 98.1...HR 104...Resp 21...BP 100/48; and
- on April 1, 2024, at 6:06 a.m., Temp 98 F...HR 92 ...Resp 18...BP 123/42.

A facility document titled, "Order Entry," dated March 31, 2025, at 12:35 p.m., was reviewed. The document indicated, "...Admit to Inpatient Telemetry...Instructions...Intrabdominal Abscesses s/p [status post, after] recent Cholecystectomy under [Name of Internal Medicine Physician 1]...Reason/Indication: Epigastric pain..."

A facility document titled, "Order Entry," dated March 31, 2025, at 12:39 p.m., was reviewed. The document indicated, "...Admit To Inpatient - Telemetry...Discontinued..." (Four minutes after the initial admission order was given)

A facility document titled, "TRANSFER SUMMARY AND CERTIFICATION," dated March 31, 2025, at 4:54 p.m., authored by [Internal Medicine Physician] 1, was reviewed. The document indicated, "...Patient has been stabilized such that within medical probability, no material deterioration of the patient's condition or the condition of the unborn child(ren) is likely to result from transfer...Time of Transfer...0606 [6:06 a.m.]...Vital Signs...BP 124/62; HR 92; RR 18; O2 sat 99; Temp 98.0...TRANSFER REQUIREMENTS...The receiving facility [Name of Facility A Digestive Disease Center] has available space and qualified personnel for treatment as acknowledged by [Facility A Clinic Staff 1]...The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by...[Name of physician scheduled to see patient at the outpatient clinic]...Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer as follows...Physician's record; Lab Results; Diagnostics; EKG...The physician has determined that appropriate means of transportation for transfer which includes qualified personnel and transportation equipment as required...CCT [Critical Care Transport]...Provider Certification...Signature of Physician: [signed by Internal Medicine Physician 1]..."

A facility document titled, "Assessment Type, Daily," dated March 31, 2025, at 5:15 p.m., authored by RN 2 was reviewed. The document indicated, "...[Name of ED Physician] at bedside, assessing pt [Patient 22], Dr. [doctor] stated tht [sic, that] the pt appears septic. MD does nto [sic, not] want to call a cde [sic, code] sepsis [serious medical condition that occurs when body responds to an infection], he requested luids [sic, fluids] and antibiotics [medications to treat infections], pt is having a procedure tomorrow at [Name of Facility A], pt neds [sic, needs] to be at the appointment to have her stent [tiny tube placed in a hollow structure of the body] removed as it is cauing [sic, causing] an infection in her abdomen. MD made aware of pts low pbp [sic, blood pressure], he requested fluids until her bp improves. 2 [two] L [liters, unit of measurement] in so far..."

A facility document titled, "Order Entry," dated March 31, 2025, at 6:09 p.m., was reviewed. The document indicated, "...Discharge to Home...Instructions...Intraabdominal pain/ abscess...to [Name of Facility A] gi [gastrointestinal, pertaining to the stomach and intestines] lab..."

A facility document titled, "Assessment Type Daily," dated March 31, 2025, at 8 pm., was reviewed. The document indicated, "...patient had cholecystectomy 2 weeks ago then another surgery for stents placement, patient was discharged to [name of skilled nursing facility], patient had a JP to low right quadrant [an area o f the abdomen] with green discharge...bloodpressure [sic, blood pressure ] low withSBP [sic] [systolic blood pressure, top number in blood pressure reading that represents pressure in the artery when heart beats, normal is 120] in 90's...at this time patient is pending transport to [Name of Facility A] for surgery to remove stents. NPO [nothing by mouth] after midnight..."

A facility document titled, "Assessment Type Daily," dated April 1, 2025, at 6:06 a.m., was reviewed. The document indicated, "...patient departed ED with medical transport, on monitor, with vanoc [sic, vancomycin] running at 125ml/hr [milliliter per hour, unit of measurement]...patient transferred to [Name of Facility A]..."

There was no documented evidence the Internal Medicine Physician evaluated or assessed Patient 22.

There was no documented evidence Patient 22 was assessed in accordance with the facility's sepsis protocol. There was not documented evidence a Code Sepsis was called for Patient 22.

On May 29, 2025, at 11:47 a.m., a concurrent interview and review of Patient 22's record were conducted with RN 1. RN 1 stated the SIRS [systemic inflammatory response syndrome, a group of symptoms resulting from an inflammatory response in body] criteria [criteria for evaluating for sepsis] was not followed. RN 1 stated Patient 22 met the SIRS criteria due to increased heart rate, increased WBCs, and having a cholecystectomy two weeks ago. He further stated the sepsis protocol [set of guidelines designed to help healthcare providers to quickly identify and treat sepsis] should have been called.

On May 29, 2025, at 12:02 p.m., a concurrent interview and review of Patient 22's record were conducted with RN 2. RN 2 stated a code sepsis should have been called because Patient 22's heart rate was 108, the blood pressure was low at 109/51, and the patient's JP drain had light green drainage which would have been the source of sepsis. RN 2 further stated a code sepsis was not called even though the patient met criteria.

On May 29, 2025, at 1:27 p.m., a concurrent interview and record review were conducted with CM 1. CM 1 stated she was told to transfer Patient 22 to an appointment that had been previously made before her hospitalization. CM 1 stated, "I did not give anyone report at the facility because the patient was going to an appointment." She stated, "I set up transportation the day before." CM 1 further stated there was no transfer order in the chart and there was an order to the patient to her home. CM 1 stated, as far as I knew, the patient was transferred to an outpatient appointment and was not transported to their home.

On May 29, 2025, at 2:20 p.m., a concurrent interview and review of Patient 22's record were conducted with ED Physician 1. ED Physician 1 stated, due to the patient's blood pressure, Patient 22 could have met the sepsis criteria. ED physician 1 stated he did not order a lactic acid test (blood test to determine that cells are not getting enough oxygen due to serious infection because he felt Patient 22 was probably not septic. After reading his ED notes which indicated, "Patient is appearing septic...Condition: Critical...," ED Physician 1 stated, "If it's there then I wrote it." ED Physician 1 stated he spoke with Internal Medicine Physician 1 and the general surgeon on call who both agreed Patient 22 needed to be transferred to [name of Facility A] to have the infected stent removed. ED Physician 1 stated a direct transfer to [name of Facility 2] was attempted but there were no beds available, and he was told [name of Facility 2] was closed to transfers. ED physician 1 stated Patient 22 was too sick to go back to a skilled nursing facility.

The facility policy and procedure (P&P) titled, "VITAL SIGNS-STANDARD OF CARE," dated September 2024, was reviewed. The policy indicated, "...Vital signs should be obtained on all patients ESI level 3 [three], 4 [four], and 5 [five], upon triage. Vital Signs should be repeated per patient condition and per interventions to assess response or at least every 2 hours..."

A facility P&P titled, "ADULT SEPSIS SCREENING AND PHYSICIAN APPROVED NURSING SEPSIS," dated May 2024, was reviewed. The policy indicated, "...This health system protocol applies to Registered Nurses (RNs) only and include the Emergency Department (ED) and inpatient populations >18 years of age...Systemic Inflammatory Response Syndrome (SIRS) = two (2) or more of the following....Temperature above 100.9F or less than 96.8 °F...Heart rate greater than 90 beats/min...Respiration rate is greater than 20 breaths/min or PaCO2 less than 32mmHg...WBC greater than 12,000 cells/mm3 or less than 4,000 cells/mm3, or greater than 10% bands...Sepsis = Two (2) or more SIRS criteria plus a suspected or confirmed infection...SEPSIS TEAM MEMBERS & RESPONSIBILITIES...Registered Nurse caring for the patient....Initiate code sepsis when sepsis, severe sepsis, or septic shock is recognized...Initiate and maintain the sepsis protocol as outlined under procedure ...Completing the Sepsis Worksheet and forwarding to appropriate department Leader when complete...Emergency Department Physician...Team Lead for ED code sepsis...Must work collaboratively with Charge Nurse & Registered Nurse...Must oversee completion of Sepsis Worksheet and confirm with print name..."

A facility P&P titled, "EMTALA - DEFINITION AND GENERAL REQUIRMENTS," dated April 2023, was reviewed. The policy indicated, "...To require, in conjunction with state-specific policies, that an acute care or specific hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to ant individual, including every infant who id born alive, at any stage of development, who comes to the emergency Department and request such examination, as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder...Appropriate transfer occurs when...the transferring hospital provides medical treatment within its capacity that minimizes the risks of the individual's health and, in the case of a woman in labor, the health and safety of the unborn child...the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...the transferring hospitals sends to the receiving hospital all medical records...related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual's EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer...the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual...Emergency Medical Treatment and Labor Act ("EMTALA") refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. §§ 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with EMCs or women in labor. It is also referred to as the "anti-dumping" statute and COBRA...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...Exception applicable to inpatient...If a hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC, the hospital has satisfied its responsibilities with respect to the individual under EMTALA...The hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer..."

Based on interview and record review, the facility failed to ensure medical examination and/or treatment were provided in accordance with the facility's policies and procedures, for one of 22 sample patients (Patient 22), when Patient 22 was not stabilized before the patient was transferred from the Emergency Department (ED) to an outpatient clinic in another county.

Findings:

On May 29, 2025, at 11:13 a.m., a concurrent interview and review of Patient 22's record were conducted with Registered Nurse (RN) 1.

A facility document titled, "Triage [a system for prioritizing patients for treatment]," dated March 31, 2025, at 7:22 a.m., was reviewed. The document indicated Patient 22 was seen at the facility for a chief complaint of abnormal laboratory (lab) results. The document indicated, "...Acuity [severity of patient's illness]: 3 - Urgent...Vitals and Measurements...31-Mar-2025 [March 31, 2025] 07:25 [7:25 a.m.]...Temp [temperature]: 97 F [Fahrenheit, unit of measurement, normal is 97.7 - 99.0] (Forehead)...Resp [respiration, normal is 12-20 breaths per minute]:16...HR[heart rate, normal is 60-100 beats per minute (bpm)]: 86...BP [blood pressure, normal is 120/80] 1: 90/45..."

A facility document titled, "Assessment Type: Daily," dated March 31, 2025, 7:24 a.m., authored by Case Manager (CM) 1 was reviewed. The document indicated, "...Spoke with [name of Facility A Clinic Staff 1] at [Name of outpatient Facility A's telephone number] to confirm pt's [Patient 22] outpatient appointment. Per [Name of Internal Medicine Physician 1] to transfer pt from ER to her appointment in [Name of Facility A] Per [Facility Clinic Staff 1], pt has appointment on 4-1-25 [April 1, 2025] W [with] [Name of physician scheduled to see patient at the outpatient clinic], for pt to be there at 0945 [9:45 a.m.] for a 1045am [10:45 a.m.] procedure. Procedure will be done at [Name of Facility A] med [medical] ctr. [center] Comp. [Comprehensive] Digestive Disease Center, [address of outpatient clinic]. Pre procedure instructions received [name of Facility A Clinic Staff 1]. ALS [Advanced Life Support (lifesaving protocols, interventions airway management and cardiac monitoring] transport arranged w/ [Name of person who works at transportation company] for a 5am [5 a.m.] ETA [estimated time of arrival]...will call return transport back to [Name of facility] arranged w/ [Name of employee who works at transportation company]..."

A facility document titled, "Emergency Department Record," dated March 31, 2025, at 7:27 a.m., was reviewed. The document indicated, "...female presents to the ER [Emergency Room, ED] via [by way of] EMS [Emergency Medical Services, ambulance service] for evaluation of abnormal lab values [results]. Patient [Patient 22] reported to have a gallbladder surgery and was found to have a doubled white count [WBC, white blood cells, a component of the blood with high levels signifying possible infection, normal range is between 3.6-11.2] at [name of skilled nursing facility]...Past surgical history: Cholecystectomy [a surgery to remove the gallbladder], Biliary Stent Placement [a thin hollow tube inserted into the bile duct to keep it open]...Physical Examination...Abdomen...Purulent [with pus drainage from JP [Jackson-Pratt drain, a medical device used to drain fluid] drain...WBC 15.8...1232 [12: 32 p.m.] Patient will be admitted to Telemetry [unit where the patient will receive continuous remote monitoring of the heart rate and rhythm]...1257 [12:57 p.m.] [Name of Surgeon 1]...General Surgery, called back and states to try to send patients [sic] to [name of Facility A] instead...1330 [1:30 p.m.] [name of Facility A] unable to accept patient for transfer but patient can follow upas [sic] she has an appointment...1340 [1:40 p.m.]...Patient is appearing septic [a serious medical condition that occurs when body responds to an infection]. Heart rate is 115bpm with blood pressure at 89/49. Will give vanco [vancomycin, a medication to treat infections] and more fluids [fluids administered through the vein]...Disposition Time...12:32 [12:32 p.m.]...Condition: Critical...Diagnosis: Acute Intraabdominal Abscesses [collection of pus in the abdomen]..."

A facility document titled, "Vitals," dated March 31, 2025, at 7:50 a.m., through April 1, 2025, at 6:06 a.m., was reviewed. The document indicated Patient 22's vital signs (HR, Resp, Temp, and BP) on the following dates and times:

- on March 31, 2025, at 7:50 a.m., Temp 98.2 F...HR 86...Resp 14...BP 105/52;
- on March 31, 2025, at 10 a.m., Temp 98.4 F...HR 94...Resp 14...BP 110/58;
- on March 31, 2025, at 12 p.m., Temp 98.2 F...HR 102...Resp 16...BP 125/52;
- on March 31, 2025, at 2 p.m., Temp 98.4 F...HR 108...Resp 16...BP 109/51;
- on March 31, 2025, at 8 p.m., Temp 96 F...HR 114...Resp 20...BP 100/51;
- on March 31, 2025, at 10 p.m., Temp 97.8 F...HR 116...Resp 22 ...BP 103/42;
- on April 1, 2025, at 2 a.m., Temp 98 F...HR 102...Resp 19...BP 97/50;
- on April 1, 2025, at 4 a.m., Temp 98.1...HR 104...Resp 21...BP 100/48; and
- on April 1, 2024, at 6:06 a.m., Temp 98 F...HR 92 ...Resp 18...BP 123/42.

A facility document titled, "Order Entry," dated March 31, 2025, at 12:35 p.m., was reviewed. The document indicated, "...Admit to Inpatient Telemetry...Instructions...Intrabdominal Abscesses s/p [status post, after] recent Cholecystectomy under [Name of Internal Medicine Physician 1]...Reason/Indication: Epigastric pain..."

A facility document titled, "Order Entry," dated March 31, 2025, at 12:39 p.m., was reviewed. The document indicated, "...Admit To Inpatient - Telemetry...Discontinued..." (Four minutes after the initial admission order was given)

A facility document titled, "TRANSFER SUMMARY AND CERTIFICATION," dated March 31, 2025, at 4:54 p.m., authored by [Internal Medicine Physician] 1, was reviewed. The document indicated, "...Patient has been stabilized such that within medical probability, no material deterioration of the patient's condition or the condition of the unborn child(ren) is likely to result from transfer...Time of Transfer...0606 [6:06 a.m.]...Vital Signs...BP 124/62; HR 92; RR 18; O2 sat 99; Temp 98.0...TRANSFER REQUIREMENTS...The receiving facility [Name of Facility A Digestive Disease Center] has available space and qualified personnel for treatment as acknowledged by [Facility A Clinic Staff 1]...The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by...[Name of physician scheduled to see patient at the outpatient clinic]...Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer as follows...Physician's record; Lab Results; Diagnostics; EKG...The physician has determined that appropriate means of transportation for transfer which includes qualified personnel and transportation equipment as required...CCT [Critical Care Transport]...Provider Certification...Signature of Physician: [signed by Internal Medicine Physician 1]..."

A facility document titled, "Assessment Type, Daily," dated March 31, 2025, at 5:15 p.m., authored by RN 2 was reviewed. The document indicated, "...[Name of ED Physician] at bedside, assessing pt [Patient 22], Dr. [doctor] stated tht [sic, that] the pt appears septic. MD does nto [sic, not] want to call a cde [sic, code] sepsis [serious medical condition that occurs when body responds to an infection], he requested luids [sic, fluids] and antibiotics [medications to treat infections], pt is having a procedure tomorrow at [Name of Facility A], pt neds [sic, needs] to be at the appointment to have her stent [tiny tube placed in a hollow structure of the body] removed as it is cauing [sic, causing] an infection in her abdomen. MD made aware of pts low pbp [sic, blood pressure], he requested fluids until her bp improves. 2 [two] L [liters, unit of measurement] in so far..."

A facility document titled, "Order Entry," dated March 31, 2025, at 6:09 p.m., was reviewed. The document indicated, "...Discharge to Home...Instructions...Intraabdominal pain/ abscess...to [Name of Facility A] gi [gastrointestinal, pertaining to the stomach and intestines] lab..."

A facility document titled, "Assessment Type Daily," dated March 31, 2025, at 8 pm., was reviewed. The document indicated, "...patient had cholecystectomy 2 weeks ago then another surgery for stents placement, patient was discharged to [name of skilled nursing facility], patient had a JP to low right quadrant [an area o f the abdomen] with green discharge...bloodpressure [sic, blood pressure ] low withSBP [sic] [systolic blood pressure, top number in blood pressure reading that represents pressure in the artery when heart beats, normal is 120] in 90's...at this time patient is pending transport to [Name of Facility A] for surgery to remove stents. NPO [nothing by mouth] after midnight..."

A facility document titled, "Assessment Type Daily," dated April 1, 2025, at 6:06 a.m., was reviewed. The document indicated, "...patient departed ED with medical transport, on monitor, with vanoc [sic, vancomycin] running at 125ml/hr [milliliter per hour, unit of measurement]...patient transferred to [Name of Facility A]..."

There was no documented evidence the Internal Medicine Physician evaluated or assessed Patient 22.

There was no documented evidence Patient 22 was assessed in accordance with the facility's sepsis protocol. There was not documented evidence a Code Sepsis was called for Patient 22.

On May 29, 2025, at 11:47 a.m., a concurrent interview and review of Patient 22's record were conducted with RN 1. RN 1 stated the SIRS [systemic inflammatory response syndrome, a group of symptoms resulting from an inflammatory response in body] criteria [criteria for evaluating for sepsis] was not followed. RN 1 stated Patient 22 met the SIRS criteria due to increased heart rate, increased WBCs, and having a cholecystectomy two weeks ago. He further stated the sepsis protocol [set of guidelines designed to help healthcare providers to quickly identify and treat sepsis] should have been called.

On May 29, 2025, at 12:02 p.m., a concurrent interview and review of Patient 22's record were conducted with RN 2. RN 2 stated a code sepsis should have been called because Patient 22's heart rate was 108, the blood pressure was low at 109/51, and the patient's JP drain had light green drainage which would have been the source of sepsis. RN 2 further stated a code sepsis was not called even though the patient met criteria.

On May 29, 2025, at 1:27 p.m., a concurrent interview and record review were conducted with CM 1. CM 1 stated she was told to transfer Patient 22 to an appointment that had been previously made before her hospitalization. CM 1 stated, "I did not give anyone report at the facility because the patient was going to an appointment." She stated, "I set up transportation the day before." CM 1 further stated there was no transfer order in the chart and there was an order to the patient to her home. CM 1 stated, as far as I knew, the patient was transferred to an outpatient appointment and was not transported to their home.

On May 29, 2025, at 2:20 p.m., a concurrent interview and review of Patient 22's record were conducted with ED Physician 1. ED Physician 1 stated, due to the patient's blood pressure, Patient 22 could have met the sepsis criteria. ED physician 1 stated he did not order a lactic acid test (blood test to determine that cells are not getting enough oxygen due to serious infection because he felt Patient 22 was probably not septic. After reading his ED notes which indicated, "Patient is appearing septic...Condition: Critical...," ED Physician 1 stated, "If it's there then I wrote it." ED Physician 1 stated he spoke with Internal Medicine Physician 1 and the general surgeon on call who both agreed Patient 22 needed to be transferred to [name of Facility A] to have the infected stent removed. ED Physician 1 stated a direct transfer to [name of Facility 2] was attempted but there were no beds available, and he was told [name of Facility 2] was closed to transfers. ED physician 1 stated Patient 22 was too sick to go back to a skilled nursing facility.

The facility policy and procedure (P&P) titled, "VITAL SIGNS-STANDARD OF CARE," dated September 2024, was reviewed. The policy indicated, "...Vital signs should be obtained on all patients ESI level 3 [three], 4 [four], and 5 [five], upon triage. Vital Signs should be repeated per patient condition and per interventions to assess response or at least every 2 hours..."

A facility P&P titled, "ADULT SEPSIS SCREENING AND PHYSICIAN APPROVED NURSING SEPSIS," dated May 2024, was reviewed. The policy indicated, "...This health system protocol applies to Registered Nurses (RNs) only and include the Emergency Department (ED) and inpatient populations >18 years of age...Systemic Inflammatory Response Syndrome (SIRS) = two (2) or more of the following....Temperature above 100.9F or less than 96.8 °F...Heart rate greater than 90 beats/min...Respiration rate is greater than 20 breaths/min or PaCO2 less than 32mmHg...WBC greater than 12,000 cells/mm3 or less than 4,000 cells/mm3, or greater than 10% bands...Sepsis = Two (2) or more SIRS criteria plus a suspected or confirmed infection...SEPSIS TEAM MEMBERS & RESPONSIBILITIES...Registered Nurse caring for the patient....Initiate code sepsis when sepsis, severe sepsis, or septic shock is recognized...Initiate and maintain the sepsis protocol as outlined under procedure ...Completing the Sepsis Worksheet and forwarding to appropriate department Leader when complete...Emergency Department Physician...Team Lead for ED code sepsis...Must work collaboratively with Charge Nurse & Registered Nurse...Must oversee completion of Sepsis Worksheet and confirm with print name..."

A facility P&P titled, "EMTALA - DEFINITION AND GENERAL REQUIRMENTS," dated April 2023, was reviewed. The policy indicated, "...To require, in conjunction with state-specific policies, that an acute care or specific hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to ant individual, including every infant who id born alive, at any stage of development, who comes to the emergency Department and request such examination, as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder...Appropriate transfer occurs when...the transferring hospital provides medical treatment within its capacity that minimizes the risks of the individual's health and, in the case of a woman in labor, the health and safety of the unborn child...the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...the transferring hospitals sends to the receiving hospital all medical records...related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual's EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer...the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual...Emergency Medical Treatment and Labor Act ("EMTALA") refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. §§ 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with EMCs or women in labor. It is also referred to as the "anti-dumping" statute and COBRA...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...Exception applicable to inpatient...If a hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC, the hospital has satisfied its responsibilities with respect to the individual under EMTALA...The hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer..."

Based on interview and record review, the facility failed to ensure stabilizing treatment was provided to the patient prior to transferring the patient to another a clinic, for one of 22 sample patients (Patient 22).

This failure had the potential for the delay in treatment and for the patient's condition to deteriorate.c

Findings:

On May 29, 2025, at 11:13 a.m., a concurrent interview and review of Patient 22's record were conducted with Registered Nurse (RN) 1.

A facility document titled, "Triage [a system for prioritizing patients for treatment]," dated March 31, 2025, at 7:22 a.m., was reviewed. The document indicated Patient 22 was seen at the facility for a chief complaint of abnormal laboratory (lab) results. The document indicated, "...Acuity [severity of patient's illness]: 3 - Urgent...Vitals and Measurements...31-Mar-2025 [March 31, 2025] 07:25 [7:25 a.m.]...Temp [temperature]: 97 F [Fahrenheit, unit of measurement, normal is 97.7 - 99.0] (Forehead)...Resp [respiration, normal is 12-20 breaths per minute]:16...HR[heart rate, normal is 60-100 beats per minute (bpm)]: 86...BP [blood pressure, normal is 120/80] 1: 90/45..."

A facility document titled, "Assessment Type: Daily," dated March 31, 2025, 7:24 a.m., authored by Case Manager (CM) 1 was reviewed. The document indicated, "...Spoke with [name of Facility A Clinic Staff 1] at [Name of outpatient Facility A's telephone number] to confirm pt's [Patient 22] outpatient appointment. Per [Name of Internal Medicine Physician 1] to transfer pt from ER to her appointment in [Name of Facility A] Per [Facility Clinic Staff 1], pt has appointment on 4-1-25 [April 1, 2025] W [with] [Name of physician scheduled to see patient at the outpatient clinic], for pt to be there at 0945 [9:45 a.m.] for a 1045am [10:45 a.m.] procedure. Procedure will be done at [Name of Facility A] med [medical] ctr. [center] Comp. [Comprehensive] Digestive Disease Center, [address of outpatient clinic]. Pre procedure instructions received [name of Facility A Clinic Staff 1]. ALS [Advanced Life Support (lifesaving protocols, interventions airway management and cardiac monitoring] transport arranged w/ [Name of person who works at transportation company] for a 5am [5 a.m.] ETA [estimated time of arrival]...will call return transport back to [Name of facility] arranged w/ [Name of employee who works at transportation company]..."

A facility document titled, "Emergency Department Record," dated March 31, 2025, at 7:27 a.m., was reviewed. The document indicated, "...female presents to the ER [Emergency Room, ED] via [by way of] EMS [Emergency Medical Services, ambulance service] for evaluation of abnormal lab values [results]. Patient [Patient 22] reported to have a gallbladder surgery and was found to have a doubled white count [WBC, white blood cells, a component of the blood with high levels signifying possible infection, normal range is between 3.6-11.2] at [name of skilled nursing facility]...Past surgical history: Cholecystectomy [a surgery to remove the gallbladder], Biliary Stent Placement [a thin hollow tube inserted into the bile duct to keep it open]...Physical Examination...Abdomen...Purulent [with pus drainage from JP [Jackson-Pratt drain, a medical device used to drain fluid] drain...WBC 15.8...1232 [12: 32 p.m.] Patient will be admitted to Telemetry [unit where the patient will receive continuous remote monitoring of the heart rate and rhythm]...1257 [12:57 p.m.] [Name of Surgeon 1]...General Surgery, called back and states to try to send patients [sic] to [name of Facility A] instead...1330 [1:30 p.m.] [name of Facility A] unable to accept patient for transfer but patient can follow upas [sic] she has an appointment...1340 [1:40 p.m.]...Patient is appearing septic [a serious medical condition that occurs when body responds to an infection]. Heart rate is 115bpm with blood pressure at 89/49. Will give vanco [vancomycin, a medication to treat infections] and more fluids [fluids administered through the vein]...Disposition Time...12:32 [12:32 p.m.]...Condition: Critical...Diagnosis: Acute Intraabdominal Abscesses [collection of pus in the abdomen]..."

A facility document titled, "Vitals," dated March 31, 2025, at 7:50 a.m., through April 1, 2025, at 6:06 a.m., was reviewed. The document indicated Patient 22's vital signs (HR, Resp, Temp, and BP) on the following dates and times:

- on March 31, 2025, at 7:50 a.m., Temp 98.2 F...HR 86...Resp 14...BP 105/52;
- on March 31, 2025, at 10 a.m., Temp 98.4 F...HR 94...Resp 14...BP 110/58;
- on March 31, 2025, at 12 p.m., Temp 98.2 F...HR 102...Resp 16...BP 125/52;
- on March 31, 2025, at 2 p.m., Temp 98.4 F...HR 108...Resp 16...BP 109/51;
- on March 31, 2025, at 8 p.m., Temp 96 F...HR 114...Resp 20...BP 100/51;
- on March 31, 2025, at 10 p.m., Temp 97.8 F...HR 116...Resp 22 ...BP 103/42;
- on April 1, 2025, at 2 a.m., Temp 98 F...HR 102...Resp 19...BP 97/50;
- on April 1, 2025, at 4 a.m., Temp 98.1...HR 104...Resp 21...BP 100/48; and
- on April 1, 2024, at 6:06 a.m., Temp 98 F...HR 92 ...Resp 18...BP 123/42.

A facility document titled, "Order Entry," dated March 31, 2025, at 12:35 p.m., was reviewed. The document indicated, "...Admit to Inpatient Telemetry...Instructions...Intrabdominal Abscesses s/p [status post, after] recent Cholecystectomy under [Name of Internal Medicine Physician 1]...Reason/Indication: Epigastric pain..."

A facility document titled, "Order Entry," dated March 31, 2025, at 12:39 p.m., was reviewed. The document indicated, "...Admit To Inpatient - Telemetry...Discontinued..." (Four minutes after the initial admission order was given)

A facility document titled, "TRANSFER SUMMARY AND CERTIFICATION," dated March 31, 2025, at 4:54 p.m., authored by [Internal Medicine Physician] 1, was reviewed. The document indicated, "...Patient has been stabilized such that within medical probability, no material deterioration of the patient's condition or the condition of the unborn child(ren) is likely to result from transfer...Time of Transfer...0606 [6:06 a.m.]...Vital Signs...BP 124/62; HR 92; RR 18; O2 sat 99; Temp 98.0...TRANSFER REQUIREMENTS...The receiving facility [Name of Facility A Digestive Disease Center] has available space and qualified personnel for treatment as acknowledged by [Facility A Clinic Staff 1]...The receiving physician has agreed to accept transfer and to provide appropriate medical treatment as acknowledged by...[Name of physician scheduled to see patient at the outpatient clinic]...Appropriate medical records of the examination and treatment of the patient are provided at the time of transfer as follows...Physician's record; Lab Results; Diagnostics; EKG...The physician has determined that appropriate means of transportation for transfer which includes qualified personnel and transportation equipment as required...CCT [Critical Care Transport]...Provider Certification...Signature of Physician: [signed by Internal Medicine Physician 1]..."

A facility document titled, "Assessment Type, Daily," dated March 31, 2025, at 5:15 p.m., authored by RN 2 was reviewed. The document indicated, "...[Name of ED Physician] at bedside, assessing pt [Patient 22], Dr. [doctor] stated tht [sic, that] the pt appears septic. MD does nto [sic, not] want to call a cde [sic, code] sepsis [serious medical condition that occurs when body responds to an infection], he requested luids [sic, fluids] and antibiotics [medications to treat infections], pt is having a procedure tomorrow at [Name of Facility A], pt neds [sic, needs] to be at the appointment to have her stent [tiny tube placed in a hollow structure of the body] removed as it is cauing [sic, causing] an infection in her abdomen. MD made aware of pts low pbp [sic, blood pressure], he requested fluids until her bp improves. 2 [two] L [liters, unit of measurement] in so far..."

A facility document titled, "Order Entry," dated March 31, 2025, at 6:09 p.m., was reviewed. The document indicated, "...Discharge to Home...Instructions...Intraabdominal pain/ abscess...to [Name of Facility A] gi [gastrointestinal, pertaining to the stomach and intestines] lab..."

A facility document titled, "Assessment Type Daily," dated March 31, 2025, at 8 pm., was reviewed. The document indicated, "...patient had cholecystectomy 2 weeks ago then another surgery for stents placement, patient was discharged to [name of skilled nursing facility], patient had a JP to low right quadrant [an area o f the abdomen] with green discharge...bloodpressure [sic, blood pressure ] low withSBP [sic] [systolic blood pressure, top number in blood pressure reading that represents pressure in the artery when heart beats, normal is 120] in 90's...at this time patient is pending transport to [Name of Facility A] for surgery to remove stents. NPO [nothing by mouth] after midnight..."

A facility document titled, "Assessment Type Daily," dated April 1, 2025, at 6:06 a.m., was reviewed. The document indicated, "...patient departed ED with medical transport, on monitor, with vanoc [sic, vancomycin] running at 125ml/hr [milliliter per hour, unit of measurement]...patient transferred to [Name of Facility A]..."

There was no documented evidence the Internal Medicine Physician evaluated or assessed Patient 22.

There was no documented evidence Patient 22 was assessed in accordance with the facility's sepsis protocol. There was not documented evidence a Code Sepsis was called for Patient 22.

On May 29, 2025, at 11:47 a.m., a concurrent interview and review of Patient 22's record were conducted with RN 1. RN 1 stated the SIRS [systemic inflammatory response syndrome, a group of symptoms resulting from an inflammatory response in body] criteria [criteria for evaluating for sepsis] was not followed. RN 1 stated Patient 22 met the SIRS criteria due to increased heart rate, increased WBCs, and having a cholecystectomy two weeks ago. He further stated the sepsis protocol [set of guidelines designed to help healthcare providers to quickly identify and treat sepsis] should have been called.

On May 29, 2025, at 12:02 p.m., a concurrent interview and review of Patient 22's record were conducted with RN 2. RN 2 stated a code sepsis should have been called because Patient 22's heart rate was 108, the blood pressure was low at 109/51, and the patient's JP drain had light green drainage which would have been the source of sepsis. RN 2 further stated a code sepsis was not called even though the patient met criteria.

On May 29, 2025, at 1:27 p.m., a concurrent interview and record review were conducted with CM 1. CM 1 stated she was told to transfer Patient 22 to an appointment that had been previously made before her hospitalization. CM 1 stated, "I did not give anyone report at the facility because the patient was going to an appointment." She stated, "I set up transportation the day before." CM 1 further stated there was no transfer order in the chart and there was an order to the patient to her home. CM 1 stated, as far as I knew, the patient was transferred to an outpatient appointment and was not transported to their home.

On May 29, 2025, at 2:20 p.m., a concurrent interview and review of Patient 22's record were conducted with ED Physician 1. ED Physician 1 stated, due to the patient's blood pressure, Patient 22 could have met the sepsis criteria. ED physician 1 stated he did not order a lactic acid test (blood test to determine that cells are not getting enough oxygen due to serious infection because he felt Patient 22 was probably not septic. After reading his ED notes which indicated, "Patient is appearing septic...Condition: Critical...," ED Physician 1 stated, "If it's there then I wrote it." ED Physician 1 stated he spoke with Internal Medicine Physician 1 and the general surgeon on call who both agreed Patient 22 needed to be transferred to [name of Facility A] to have the infected stent removed. ED Physician 1 stated a direct transfer to [name of Facility 2] was attempted but there were no beds available, and he was told [name of Facility 2] was closed to transfers. ED physician 1 stated Patient 22 was too sick to go back to a skilled nursing facility.

The facility policy and procedure (P&P) titled, "VITAL SIGNS-STANDARD OF CARE," dated September 2024, was reviewed. The policy indicated, "...Vital signs should be obtained on all patients ESI level 3 [three], 4 [four], and 5 [five], upon triage. Vital Signs should be repeated per patient condition and per interventions to assess response or at least every 2 hours..."

A facility P&P titled, "ADULT SEPSIS SCREENING AND PHYSICIAN APPROVED NURSING SEPSIS," dated May 2024, was reviewed. The policy indicated, "...This health system protocol applies to Registered Nurses (RNs) only and include the Emergency Department (ED) and inpatient populations >18 years of age...Systemic Inflammatory Response Syndrome (SIRS) = two (2) or more of the following....Temperature above 100.9F or less than 96.8 °F...Heart rate greater than 90 beats/min...Respiration rate is greater than 20 breaths/min or PaCO2 less than 32mmHg...WBC greater than 12,000 cells/mm3 or less than 4,000 cells/mm3, or greater than 10% bands...Sepsis = Two (2) or more SIRS criteria plus a suspected or confirmed infection...SEPSIS TEAM MEMBERS & RESPONSIBILITIES...Registered Nurse caring for the patient....Initiate code sepsis when sepsis, severe sepsis, or septic shock is recognized...Initiate and maintain the sepsis protocol as outlined under procedure ...Completing the Sepsis Worksheet and forwarding to appropriate department Leader when complete...Emergency Department Physician...Team Lead for ED code sepsis...Must work collaboratively with Charge Nurse & Registered Nurse...Must oversee completion of Sepsis Worksheet and confirm with print name..."

A facility P&P titled, "EMTALA - DEFINITION AND GENERAL REQUIRMENTS," dated April 2023, was reviewed. The policy indicated, "...To require, in conjunction with state-specific policies, that an acute care or specific hospital with an emergency department provide an appropriate medical screening examination and any necessary stabilizing treatment to ant individual, including every infant who id born alive, at any stage of development, who comes to the emergency Department and request such examination, as required by EMTALA and all Federal regulations and interpretive guidelines promulgated thereunder...Appropriate transfer occurs when...the transferring hospital provides medical treatment within its capacity that minimizes the risks of the individual's health and, in the case of a woman in labor, the health and safety of the unborn child...the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment...the transferring hospitals sends to the receiving hospital all medical records...related to the EMC for which the individual has presented, available at the time of transfer, including records related to the individual's EMC, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of diagnostic studies or telephone reports of the studies, and the informed written consent for transfer or certification if applicable, name and address of any on-call physician who has refused or failed to appear within a reasonable and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer...the transfer is effected through qualified personnel, transportation and equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual...Emergency Medical Treatment and Labor Act ("EMTALA") refers to Sections 1866 and 1867 of the Social Security Act, 42 U.S.C. §§ 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with EMCs or women in labor. It is also referred to as the "anti-dumping" statute and COBRA...Stabilized with respect to an EMC means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta...Exception applicable to inpatient...If a hospital has screened an individual and found that the individual has an EMC and admits that individual as an inpatient in good faith in order to stabilize the EMC, the hospital has satisfied its responsibilities with respect to the individual under EMTALA...The hospital determines that an individual does have an EMC, provide necessary stabilizing treatment to the individual or provide for an appropriate transfer..."