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Based on findings at A2407, the facility failed to ensure compliance with CFR 489.24.

Based on interview, clinical record review and policy review, the facilty failed to ensure stabilizing medical treatment was provided prior to transfer to a higher level of care for 1 of 26 sampled patients (Patient 5) .

Findings include:

Clinical Record Review from Transferring Hospital:

Patient #5 (P5) presented to the Emergency Department (ED) on 05/22/16 at 2:44PM, with a chief complaint of being dizzy, black stools, diarrhea, yellowing of skin, and stiff muscles. The symptoms had been present since Friday, skin color pale and cool to touch. The patient's acuity was Emergent.

The Emergency Department Physician report dated 05/22/16 at 2:43PM, documented the patient arrived by private vehicle to the ED. The patients physicians included Physician #1 a gastroenterologist. The patient's chief complaint included being dizzy, black stools, diarrhea, yellowing of skin, and stiff muscles. Per the ED triage assessment, the symptoms had been present since Friday, color pale, cool to touch.

The History of Present Illness revealed the patient presented with dark stool that began 2 days ago. The patient stated the stools were dark and tarry.

The Review of Systems revealed the following:
Constitutional symptoms: no fever, no chills
Respiratory symptoms: no shortness of breath, no cough
Cardiovascular symptoms: no chest pain
Gastrointestinal symptoms: change in stool color, no abdominal pain, no nausea, no vomiting
Musculoskeletal symptoms: no back pain
Additional review of systems information: all other systems reviewed and otherwise negative, other than the above

Medication reconciliation revealed the patient was taking the following medications: fish oil (supplement), vitamin B 6 (supplement), Fenofibrate (used to treat high cholesterol and high triglycerides), Hydrochlorothiazide-Losartan (blood pressure medication), indomethacin (anti-inflammatory), isoniazid (antibiotic), and pravastatin (used to treat high cholesterol).

Past Medical History included aortic stenosis, blood in stool, cardiac murmur, diarrhea, dizziness, hyperlipidemia, and hypertension.

Nursing Assessment revealed the following:
General: alert
Skin: warm, dry
Eye: pupils were equal, round and reactive to light, conjunctiva both eyes pale
Ears, nose, mouth and throat: oral mucosa moist
Neck: supple
Cardiovascular: regular rate and rhythm
Respiratory: lungs were clear to auscultation, respirations were non-labored, breath sounds were equal
Gastrointestinal: soft, nontender, non distended, guarding negative, rebound negative, bowel sounds normal, rectal exam revealed stool color black, guaiac positive
Musculoskeletal: normal range of motion
Neurological: no focal neurological deficit observed, normal speech, orient to person, place and time
Psychiatric: appropriate mood and affect

ED orders included normal saline 1000 milliliters (ml) at 999 ml/hr, normal saline 250 ml at 20 ml/hr (hour), Pantoprazole (Protonix) 40 milligrams (mg) intravenous (IV) times one.

Patient received normal saline 1000 milliliters.

Electrocardiogram (EKG) dated 05/22/16 at 3:08PM, documented a rate of 85, normal sinus rhythm, no ectopy, T-wave inversion new from previous EKG.

Laboratory results dated 05/22/16 at 3:10PM, documented the following abnormal findings:
White Blood Count 21.8 (high) (normal range 4.0-12.0)
Red Blood Count 2.29 (low) (normal range 4.00-6.00)
Hemoglobin 6.5 (low) (normal range 12.5-17.5)
Hematocrit 19.6% (low) (normal range 35.0-50.0)
Glucose Level 106 (high) (normal range 65-99)
Blood Urea Nitrogen (BUN) 26 (high) (normal range 5-23)
Calcium 8.0 (low) (normal range 8.1-10.0)
Total Protein 5.4 (low) (normal range 6.3-8.6)
Albumin 3.0 (low) (normal range 3.2-5.0)

Medical Decision Making documented the differential diagnosis as gastrointestinal (GI) bleed, rectal bleeding, gastritis, peptic ulcer disease, variceal bleeding. The ED physician documented the patient had an active GI bleed, Physician #1 recommended transfer. Hospital #1 called, unable to get timely acceptance. Hospital #2 accepted patient immediately. Critical Care Transport at bedside, will transfer without waiting for transfusion. Patient agreed to plan.

Diagnosis included anemia, GI bleed, and hypotension.

The ED physician documentation revealed on 05/22/16 at 4:16PM, consulted with Physician #1, who recommended to send the patient to Hospital #1, declined to see patient, call returned by Physician #1 at 4:54PM.

P5 was transferred to Hospital #2 on 05/22/16 at 5:10PM in stable condition. The receiving hospital's ED physician accepted the patient, reason for transfer was GI bleed. ED physician counseled patient regarding diagnosis, diagnostic results, treatment plan and patient indicated understanding of instructions.

Emergency Department Nursing Notes revealed the following:
Vital signs taken at 2:44PM, revealed the following:
Temperature: 37.2 degrees Celsius (C) (98.6 degrees Fahrenheit) {reference range 36.0 C - 37.5 C}
Heart Rate: 93 {reference range 50-120}
Blood Pressure: 105/66 {reference range 90-160 / 40-140}
Respirations: 20 {reference range 12-20}
Oxygen Saturation: 100% in room air {reference range 87-100}

Vital signs taken at 3:58PM, revealed the following:
Heart Rate: 88
Blood Pressure: 95/60
Respirations: 16
Oxygen Saturation: 99% in room air

Nursing Note dated 05/22/16 at 3:58PM, documented the patient was received from triage, placed on a cardiac monitor, inserted a #20 gauge intravenous catheter in the left antecubital, fluids started.

Nursing Assessment completed at 3:59PM, documented lungs clear with regular respiratory effort, cardiac rhythm status monitored with normal sinus rhythm, skin color normal and warm to touch, pulses normal, patient awake, alert and oriented times 3, positive nausea and rectal bleeding, and abdomen not tender.

Vital signs taken at 4:00PM, revealed the following:
Heart Rate: 87
Blood Pressure: 92/56
Respirations: 17
Oxygen Saturation: 98% in room air

Vital signs taken at 5:00PM, revealed the following:
Heart Rate: 85
Blood Pressure: 89/56 (documentation revealed 89 was a low reading)
Respirations: 16
Oxygen Saturation: 99% in room air

Nursing Note dated 05/22/16 at 5:18PM, documented report given to Registered Nurse at Receiving Hospital Emergency Department. Patient went to Receiving Hospital with Critical Care Transport with 2 liters of fluid infusing. Called blood bank and blood was not ready, per Emergency Department physician, patient could go without blood.

The Authorization For Transfer form dated 05/22/16 at 5:00PM, documented the patient had been stabilized such that, within reasonable medical probability, no material deterioration of this individual's condition is likely to result from transfer. The individual consented to the transfer and had been informed of the risks involved in transfer and acknowledges that no guarantees or assurances had been made as the results that be obtained by this transfer. This was signed by patient on 05/22/16 at 5:08PM. The patient was being transferred for GI specialty care and the potential risks of the transfer included death and/or deterioration. The patient was to be transferred via Critical Care Transport. The form was completed and signed by ED physician.

The Patient Transfer Sheet dated 05/22/16 at 5:08PM documented the following:
- Patient was being transferred to be evaluated by a gastroenterologist
- Patient was being transferred by Critical Care Transport
- Report was given to receiving hospital Registered Nurse at 5:05PM
- Patient had a #20 gauge IV in left antecubital
- Vital signed were documented at 2:44PM as temperature 37.2, heart rate 87, blood pressure 105/66, respiratory rate 16, oxygen saturation 100%, no pain
- Vital signs were documented at 4:30PM, as heart rate 88, blood pressure 92/56, respiratory rate 17, oxygen saturation 99%
- Patient received 1 liter of normal saline at 3:58PM
- Patient received 40 mg of Protonix at 5:10PM
- Arrival assessment at 3:59PM, revealed normal sinus rhythm, equal breath sounds bilaterally, alert and oriented x4, pupils 2 milliters (mm) and reactive bilaterally, abdomen soft with positive nausea and rectal bleeding, skin was warm, dry and pale.
- Discharge assessment at 5:08PM, was unchanged from the arrival assessment

The Patient Transfer Sheet lacked documentation of the vital signs taken at 5:00PM which revealed a low blood pressure reading of 89/56.

The Emergency Department Transfer of Care Summary dated 05/22/16, documented the following:
- Length of stay in the ED was 2 hours 45 minutes
- Blood Pressure was 89/56 mm/Hg (millimeters/mercury)
- Patient was transferred to another acute care facility
- Lab tests performed during this visit included:
- Prothrombin Time (PT) 11.6 seconds (normal range 9.4-12.5)
- International Normalized Ratio (INR) 1.06 ratio (normal range 0.86-1.14)
- Partial Thromboplastin Time (PTT) 27.5 seconds (normal range 25.1-36.5)
- Antibody Screen negative
- Blood Type O Positive

The Critical Care Transport Physician Certification Statement for Ambulance Transport form dated 05/22/16, documented the patient was to be transported from the transferring hospital to the receiving hospital. The form documented the patient required Intravenous (IV) medications/fluids during transport and cardiac/hemodynamic monitoring during transport. The form was signed by a Registered Nurse.

Clinical Record Review from the Receiving Hospital:

Receiving Hospital's Emergency Department (ED) Notes revealed the patient presented from the transferring hospital with gastrointestinal (GI) bleed. Patient presented today with several days of melena, found to have hemoglobin of 6.5 and transferred here for further GI care. Emergency Medical Services (EMS) report stated the patient had seizure activity immediately upon entering emergency room, described as screaming with arms raised above his head. Recent fingerstick of 106. Upon arrival of ED physician, patient writhing in pain on stretcher, complaining of epigastric abdominal pain. Unable to ascertain further history secondary to pain. Patient following simple commands. EMS reported only normal saline ordered during transfer, persistent hypotension throughout transit.

Initial and Last documented vital signs taken at the Receiving Hospital on 05/22/16 at 5:42PM, documented temperature 37.1, heart rate 106, blood pressure 96/57, respirations 26, oxygen saturations 100%.

Physical Exam at the Receiving Hospital revealed the patient had tenderness in the epigastric area with involuntary guarding. Patient was diaphoretic, pallor, and noted melena.

Laboratory results from the Receiving Hospital revealed the following abnormal findings:
Chloride 110 (normal range 98-107)
Total CO2 (carbon dioxide) 12 (normal range 23-31)
Anion Gap 25 (normal range 5-16)
BUN 25 (normal range 7-18)
Creatinine 0.70 (normal range 0.80-1.30)
Glucose 205 (normal range 70-139)
Troponin I 0.09 (normal range 0.00-0.08)
B-Natriuretic Peptide 108 (normal range 0-99)
Alanine aminotransferase (ALT) 9 (normal range 10-49)
Total Alkaline Phosphatase 29 (normal range 55-120)
White Blood Cell Count 20.6 (normal range 4.8-10.8)
Red Blood Cell Count 1.20 (normal range 4.5-6.20)
Hemoglobin 3.5 (normal range 14.0-18.0)
Hematocrit 11.3% (normal range 42.0-52.0%)

Chest X-ray taken at the Receiving Hospital on 05/22/16 at 6:02PM, revealed new bilateral mild peribronchial infiltrates suggestive of aspiration or pneumonia.

Patient #5 was intubated at the receiving hospital on 05/22/16 at 6:18PM done as an emergent procedure.

Re-evaluation Note by the ED physician at the Receiving hospital revealed the patient was transferred for GI bleed. Patient with supposed seizure activity while transporting patient into ED at Receiving Hospital. Upon ED arrival, patient writhing complaining of abdominal/epigastric pain, reportedly new since transfer. Patient provided 50 micrograms (mcg) Fentanyl for pain with improvement in symptoms. Repeat vital signs with heart rate 97, blood pressure 107/79 status post Fentanyl. Concern for ulcer perforation vs. great vessel vascular catastrophe: dissection or aneurysm. Computerized Tomography (CT) tech called for expedited scan, and type and crossmatch ordered for patient. Shortly thereafter, EKG shown to provider, displaying AVR elevation and diffuse ST depressions, consult call made to cardiology for concern for acute coronary syndrome (ACS) and provider returned to room to evaluate patient with CT tech. Arrived to find patient with sonorous respirations and unresponsive, followed by bradycardic arrest in front of provider. Cardiopulmonary resuscitation (CPR) started immediately and code called. Patient underwent intubation with 8.0 endotracheal tube, confirmed by CO2 and bilateral breath sounds. Bedside ultrasound (US) during code revealed no fluid in Morison's pouch (space that separates the liver from the right kidney). Suspicion for massive myocardial infarction (MI) vs. Ulcer perforation/hemorrhage or ruptured aortic aneurysm/retroperitoneal bleed or dissection given sudden onset of abdominal pain upon ED arrival and rapid decline. Emergent blood was administered for patient (Hemoglobin 3.5 value revealed or return labs and identified during code) during resuscitation, though with no improvement in pulseless electrical activity (PEA) status. patient underwent multiple rounds of epinephrine, sodium bicarbonate and volume resuscitation with normal saline and blood on level 1 transfuser with coding for greater than 35 minutes. Despite heroic efforts, PEA repeatedly found on monitor and with bedside cardiac US without return of spontaneous circulation (ROSC). Given significant potential causes of cardiac arrest and irreversibility, prolonged resuscitation without ROSC, further efforts were deemed futile and code was called.

Interview:

On 12/08/16 at 1:30PM, the attending Emergency Department (ED) physician from the transferring hospital revealed blood was ordered for the patient. It would take another 1-2 hours before the blood would be available to hang. Critical Care Transport was at the facility ready to transport the patient to the receiving hospital. The ED physician indicated O negative blood could have been administered to the patient, but believed the patient was stable for transport. The ED physician was not aware of the blood pressure reading at 5:00PM, which indicated the patient's blood pressure was 89/56. The ED physician indicated if he would have known about the low blood pressure he would have considered administering the O negative blood. The attending ED physician felt the patient was stable for transport and it was important to get the patient to a higher level of care for further treatment. The ED physician indicated the patient's vital signs were stable and GI consult was not available at the facility.

Document Review from Transferring Hospital:

On 12/08/16, the ED physician provided the following letter from Physician #1 (Gastroenterologist) regarding the physician's participation in consulting for patients being treated or admitted through the Emergency Department. The letter was provided to clarify Physician #1's availability to consult on patients with gastrointestinal problems or complaints. The letter indicated Physician #1 would remain unavailable to see patients being treated in or admitted through the Emergency Department. The exceptions to this would be limited to:
1. Patients currently covered through Health Care Partners (HCP)/Humana Gold HMO (health maintenance organization) health insurance
2. Recently hospitalized patients not covered under HCP/Humana Gold HMO that I have consulted to or performed an endoscopic procedure on within the past 30 days
3. Patient that I have been actively following in my private practice
The letter indicated private practice patient that Physician #1 had seen in the office on only one or two occasions previously, or whom Physician #1 had not seen for an extended period of time, as well as patient that had been seen in the hospital within the past 90 days, might be accepted in consultation on a case by case basis. These patients would required the ED physician to contact Physician #1, or the physician covering calls, to present the particular patient for consideration for acceptance in consultation.

A review of the Emergency Department clinical record for Patient #5 revealed Physician #1 was listed as one of the patient's physicians. The ED physician contacted Physician #1 for consultation. Physician #1 declined to see the patient and recommended transfer to Hospital #1. The ED did not have gastroenterology services as an on-call ED provider.

The facility's EMTALA (Emergency Medical Treatment and Labor Act): Definitions and General Requirements policy originating in 07/99 and effective in 10/12 documented a medically indicated transfer would be the transfer of an individual to a facility with higher level of care or to a facility with a service that the transferring facility did not provide in order to provide further care and treatment to an individual with an emergency medical condition (EMC) or a woman in labor.

The on-call list was defined as a list the hospital was required to maintain that defines those physicians who were on the hospital's medical staff or who had privileges at the hospital and were available to provide treatment necessary after the initial examination to stabilize individuals with and EMC. The purpose of the on-call list is to ensure the dedicated emergency department was prospectively aware of which physicians, including specialist and sub-specialists were available to provide treatment necessary to stabilize individuals with EMCs.

Stabilize was defined as no material deterioration of the condition was 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, the woman delivered the child and the placenta.

Transfer Obligations include the hospital may transfer an individual with an EMC that had not been stabilized if the transfer was appropriate and if the licensed independent practitioner (LIP) certified in writing that based on the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or unborn child, from being transferred.

The facility Medical Staff Rules and Regulations with a review and approval date of April 2015 documented each medical staff committee would make recommendations to the Medical Executive Committee (MEC) for Emergency Department on-call coverage. Medical specialities that comprise primary services (including but not limited to general surgery, internal medicine, orthopedic surgery, obstetrics and gynecology, pediatrics, and cardiology) were expected to provide continuous Emergency Department on-call coverage.

The facility Emergency Severity Index (ESI) Triage System originated in 05/04 and effective 07/16 documented ESI was a five level triage scale to prioritize patient care based on the urgency of the patient's condition.

Triage was the process which identified patients and groups them according to their need for care, nature of their complaint or illness, severity of the problem, and the facility and resources available to govern the process.

Every patient presenting to the ED would be triaged by a Registered Nurse (RN) using the five level ESI triage acuity system. The ESI level were as follows:

ESI level one (1) - patients required immediate life-saving intervention. These patients were to be seen and/or treated immediately.

ESI level two (2) - patients present with a high risk situation. Patient had new onset confusion, lethargy or disorientation. Patient was in severe pain or distress. These patients generally remain a high priority and placement and treatment should be initiated rapidly.

ESI level three (3) - patient was predicted to require two or more resources and vital signs are within the accepted parameters for age. These patients often required a more in-depth evaluation, but were deemed stable in the short term.

ESI level four(4) - patient was predicted to require one resource. the patient's physical condition was stable, with non-acute presentation and may safely wait to be seen.

ESI level five (5) - patient was predicted to require no resources. The patient's physical condition was stable, with non-acute presentation and may safely wait to be seen.

Based on interview, clinical record review and policy review, the facilty failed to ensure stabilizing medical treatment was provided prior to transfer to a higher level of care for 1 of 26 sampled patients (Patient 5) .

Findings include:

Clinical Record Review from Transferring Hospital:

Patient #5 (P5) presented to the Emergency Department (ED) on 05/22/16 at 2:44PM, with a chief complaint of being dizzy, black stools, diarrhea, yellowing of skin, and stiff muscles. The symptoms had been present since Friday, skin color pale and cool to touch. The patient's acuity was Emergent.

The Emergency Department Physician report dated 05/22/16 at 2:43PM, documented the patient arrived by private vehicle to the ED. The patients physicians included Physician #1 a gastroenterologist. The patient's chief complaint included being dizzy, black stools, diarrhea, yellowing of skin, and stiff muscles. Per the ED triage assessment, the symptoms had been present since Friday, color pale, cool to touch.

The History of Present Illness revealed the patient presented with dark stool that began 2 days ago. The patient stated the stools were dark and tarry.

The Review of Systems revealed the following:
Constitutional symptoms: no fever, no chills
Respiratory symptoms: no shortness of breath, no cough
Cardiovascular symptoms: no chest pain
Gastrointestinal symptoms: change in stool color, no abdominal pain, no nausea, no vomiting
Musculoskeletal symptoms: no back pain
Additional review of systems information: all other systems reviewed and otherwise negative, other than the above

Medication reconciliation revealed the patient was taking the following medications: fish oil (supplement), vitamin B 6 (supplement), Fenofibrate (used to treat high cholesterol and high triglycerides), Hydrochlorothiazide-Losartan (blood pressure medication), indomethacin (anti-inflammatory), isoniazid (antibiotic), and pravastatin (used to treat high cholesterol).

Past Medical History included aortic stenosis, blood in stool, cardiac murmur, diarrhea, dizziness, hyperlipidemia, and hypertension.

Nursing Assessment revealed the following:
General: alert
Skin: warm, dry
Eye: pupils were equal, round and reactive to light, conjunctiva both eyes pale
Ears, nose, mouth and throat: oral mucosa moist
Neck: supple
Cardiovascular: regular rate and rhythm
Respiratory: lungs were clear to auscultation, respirations were non-labored, breath sounds were equal
Gastrointestinal: soft, nontender, non distended, guarding negative, rebound negative, bowel sounds normal, rectal exam revealed stool color black, guaiac positive
Musculoskeletal: normal range of motion
Neurological: no focal neurological deficit observed, normal speech, orient to person, place and time
Psychiatric: appropriate mood and affect

ED orders included normal saline 1000 milliliters (ml) at 999 ml/hr, normal saline 250 ml at 20 ml/hr (hour), Pantoprazole (Protonix) 40 milligrams (mg) intravenous (IV) times one.

Patient received normal saline 1000 milliliters.

Electrocardiogram (EKG) dated 05/22/16 at 3:08PM, documented a rate of 85, normal sinus rhythm, no ectopy, T-wave inversion new from previous EKG.

Laboratory results dated 05/22/16 at 3:10PM, documented the following abnormal findings:
White Blood Count 21.8 (high) (normal range 4.0-12.0)
Red Blood Count 2.29 (low) (normal range 4.00-6.00)
Hemoglobin 6.5 (low) (normal range 12.5-17.5)
Hematocrit 19.6% (low) (normal range 35.0-50.0)
Glucose Level 106 (high) (normal range 65-99)
Blood Urea Nitrogen (BUN) 26 (high) (normal range 5-23)
Calcium 8.0 (low) (normal range 8.1-10.0)
Total Protein 5.4 (low) (normal range 6.3-8.6)
Albumin 3.0 (low) (normal range 3.2-5.0)

Medical Decision Making documented the differential diagnosis as gastrointestinal (GI) bleed, rectal bleeding, gastritis, peptic ulcer disease, variceal bleeding. The ED physician documented the patient had an active GI bleed, Physician #1 recommended transfer. Hospital #1 called, unable to get timely acceptance. Hospital #2 accepted patient immediately. Critical Care Transport at bedside, will transfer without waiting for transfusion. Patient agreed to plan.

Diagnosis included anemia, GI bleed, and hypotension.

The ED physician documentation revealed on 05/22/16 at 4:16PM, consulted with Physician #1, who recommended to send the patient to Hospital #1, declined to see patient, call returned by Physician #1 at 4:54PM.

P5 was transferred to Hospital #2 on 05/22/16 at 5:10PM in stable condition. The receiving hospital's ED physician accepted the patient, reason for transfer was GI bleed. ED physician counseled patient regarding diagnosis, diagnostic results, treatment plan and patient indicated understanding of instructions.

Emergency Department Nursing Notes revealed the following:
Vital signs taken at 2:44PM, revealed the following:
Temperature: 37.2 degrees Celsius (C) (98.6 degrees Fahrenheit) {reference range 36.0 C - 37.5 C}
Heart Rate: 93 {reference range 50-120}
Blood Pressure: 105/66 {reference range 90-160 / 40-140}
Respirations: 20 {reference range 12-20}
Oxygen Saturation: 100% in room air {reference range 87-100}

Vital signs taken at 3:58PM, revealed the following:
Heart Rate: 88
Blood Pressure: 95/60
Respirations: 16
Oxygen Saturation: 99% in room air

Nursing Note dated 05/22/16 at 3:58PM, documented the patient was received from triage, placed on a cardiac monitor, inserted a #20 gauge intravenous catheter in the left antecubital, fluids started.

Nursing Assessment completed at 3:59PM, documented lungs clear with regular respiratory effort, cardiac rhythm status monitored with normal sinus rhythm, skin color normal and warm to touch, pulses normal, patient awake, alert and oriented times 3, positive nausea and rectal bleeding, and abdomen not tender.

Vital signs taken at 4:00PM, revealed the following:
Heart Rate: 87
Blood Pressure: 92/56
Respirations: 17
Oxygen Saturation: 98% in room air

Vital signs taken at 5:00PM, revealed the following:
Heart Rate: 85
Blood Pressure: 89/56 (documentation revealed 89 was a low reading)
Respirations: 16
Oxygen Saturation: 99% in room air

Nursing Note dated 05/22/16 at 5:18PM, documented report given to Registered Nurse at Receiving Hospital Emergency Department. Patient went to Receiving Hospital with Critical Care Transport with 2 liters of fluid infusing. Called blood bank and blood was not ready, per Emergency Department physician, patient could go without blood.

The Authorization For Transfer form dated 05/22/16 at 5:00PM, documented the patient had been stabilized such that, within reasonable medical probability, no material deterioration of this individual's condition is likely to result from transfer. The individual consented to the transfer and had been informed of the risks involved in transfer and acknowledges that no guarantees or assurances had been made as the results that be obtained by this transfer. This was signed by patient on 05/22/16 at 5:08PM. The patient was being transferred for GI specialty care and the potential risks of the transfer included death and/or deterioration. The patient was to be transferred via Critical Care Transport. The form was completed and signed by ED physician.

The Patient Transfer Sheet dated 05/22/16 at 5:08PM documented the following:
- Patient was being transferred to be evaluated by a gastroenterologist
- Patient was being transferred by Critical Care Transport
- Report was given to receiving hospital Registered Nurse at 5:05PM
- Patient had a #20 gauge IV in left antecubital
- Vital signed were documented at 2:44PM as temperature 37.2, heart rate 87, blood pressure 105/66, respiratory rate 16, oxygen saturation 100%, no pain
- Vital signs were documented at 4:30PM, as heart rate 88, blood pressure 92/56, respiratory rate 17, oxygen saturation 99%
- Patient received 1 liter of normal saline at 3:58PM
- Patient received 40 mg of Protonix at 5:10PM
- Arrival assessment at 3:59PM, revealed normal sinus rhythm, equal breath sounds bilaterally, alert and oriented x4, pupils 2 milliters (mm) and reactive bilaterally, abdomen soft with positive nausea and rectal bleeding, skin was warm