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Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#31 and #44) of 44 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC. The hospital failed to follow its policies and procedures when they failed to provide an appropriate transfer for four patients (#13, #32, #42 and #43) out of 44 ED records reviewed from 01/01/25 through 06/30/25. The hospital's average monthly census over the past six months was 1,445, and the average monthly transfer of patients over the past six months was 115.
Findings included:

Review of the hospital's policy titled, "Transfer of Patients/Residents," approved 08/2024, showed no patient/resident shall be arbitrarily transferred. Transferring a patient to another medical facility will be appropriate in those cases in which the patient requires medical treatment, that is not within Citizens Memorial Hospital ability or scope of service.

Review of the hospital's policy titled, "Admission, ED," reviewed 04/2026, showed an EMC is a medical condition manifesting itself by acute (sudden onset) systems of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. If the provider determines the patient has an EMC, the patient shall receive within the capabilities of the staff and facilities, further medical examination and treatment as required to stabilize the medical condition and admission to Citizens Memorial Hospital; or transfer of the patient to another medical facility.

Review of the hospital's document titled "Medical Staff By-Laws," dated 07/2023, showed:
- An active staff member must consult with other staff members consistent with his or her scope of practice and clinical privileges and accept the care and treatment of patients who present at the ED that do not have an assigned physician.
- The active medical staff shall consist of physicians, both medical and osteopathic, who assume all the functions and responsibilities of membership including, appropriate care of patients, emergency service care and consultation assignments.
- Active medical staff shall accept the follow-up care and treatment of patients who present at the emergency room that do not have an assigned physician through the episode of treatment.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Citizens Memorial Hospital," reviewed 11/03/20, showed:
- If a staff physician is on call to provide emergency services or to consult with an emergency room physician in the area of his/her expertise, that physician will be considered to be available by phone for consultation or to come in to physically assess the patient in the ED.
- The determination as to whether the on-call physician must physically assess the patient in the ED is the decision of the treating emergency physician.
- Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendations.
- Any qualified practitioner with clinical privileges in the hospital can be called for consultation within his area of expertise.
- If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor who in turn may refer the matter to the director of the nursing service. If warranted, the director of nursing may bring the matter to the attention of the physician advisor of the service wherein the practitioner has clinical privileges.

Based on interview, record review and policy review the hospital failed to ensure that an emergency medical condition (EMC) was stabilized for two patients (#31 and #44) of 44 Emergency Department (ED) records reviewed. This failed practice had the potential to cause harm to all patients who presented to the ED seeking care for an EMC.

Findings included:

Review of the hospital's policy titled, "Admission, ED," reviewed 04/2026, showed an EMC is a medical condition manifesting itself by acute (sudden onset) systems of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in the following: placing the health of the individual in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of a bodily organ or part. If the provider determines the patient has an EMC, the patient shall receive: within the capabilities of the staff and facilities, further medical examination and treatment as required to stabilize the medical condition and admission to Citizens Memorial Hospital; or transfer of the patient to another medical facility.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Citizens Memorial Hospital," reviewed 11/03/20, showed:
- The determination as to whether the on-call physician must physically assess the patient in the ED is the decision of the treating emergency physician.
- If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor who in turn may refer the matter to the director of the nursing service.
- If warranted, the director of nursing may bring the matter to the attention of the physician advisor of the service wherein the practitioner has clinical privileges.

Review of the hospital's document titled, "Privileges - Standard," dated 11/21/23 through 11/21/25, showed:
- Staff K, Hospitalist (physician whose primary professional focus is the general medical care of hospitalized patients), had internal medicine core privileges: Evaluate, diagnose, treat, and provide consultation (including medical history and physical examination) to patients 18 years of age and older with common and complex illnesses, diseases, and functional disorders of the circulatory (the system that contains the heart and the blood vessels and moves blood throughout the body), respiratory (your body's breathing system), endocrine (a system of glands that make hormones to control moods, growth and development), metabolic (the process when your body converts food and drinks into energy to keep you alive and functioning), musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement), hematopoietic (anything related to the process of making blood cells), gastrointestinal (GI, stomach and intestines), and genitourinary (the body parts involved in making and removing urine and the body parts involved in reproduction) systems.
- May provide care to patients in the intensive care setting in conformance with unit policies.
- Assess, stabilize, and determine disposition of inpatients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

Review of Patient #31's medical record, dated 02/11/25, showed:
- At 12:01 PM, a 44-year-old female presented to the ED with a chief complaint of abdominal pain.
- Her past medical history included gastritis (inflammation of the stomach) and alcohol abuse.
- Her past surgical history included cholecystectomy (surgical removal of the gallbladder; a small organ that stores liquid called bile and helps your body break down food).
- The course narrative indicated she drank multiple drinks of alcohol every day, with her last drink of alcohol the previous day at 12:00 PM.
- Her pain scale assessment (pain rating on a scale of zero to ten, zero means no pain and a ten means worst pain possible) was 10.
- Her physical examination showed abdominal tenderness with some guarding (tightening of muscles to prevent further harm or discomfort), rebound tenderness (pain that increases when pressure is relieved) and hypoactive bowel sounds.
- From 10/02/24 through 10/06/24, she was admitted to the Intensive Care Unit (ICU, a unit where critically ill patients are cared for) for the same symptoms.
- The ED was not able to get her pain-free and planned to discuss admission with Staff K, Hospitalist.
- At 12:19 PM, her blood work showed her potassium (mineral in the blood or body fluid, normal is 3.5-5.0) was 2.8, carbon dioxide (CO2, a gas produced by exhaling, normal is 22-30) was 35, lactic acid (an acid produced in muscle tissues during strenuous exercise, normal is 0.5-1.9) was 6.3, total bilirubin (yellowish pigment that is made during the breakdown of red blood cells, normal is 0.5-1.3) was 2.6, aspartate aminotransferase (AST, an enzyme that is found mostly in the liver, normal is 8-39) was 259, alanine transaminase (ALT, an enzyme found mostly in the liver, normal is 0-35) was 76, alkaline phosphatase (an enzyme responsible for bone growth and repair, normal is 38-126) was 203 and lipase (an enzyme produced by the pancreas which the body uses to break down fats, normal is 23-300) was 1,074.
- Her liver function tests were chronically (long term, ongoing) elevated due to her alcoholism.
- At 12:28 PM, her urinalysis (UA, a laboratory examination of a person's urine) showed color interference, red blood cells (RBC, oxygen carrying cells, normal is none) were five to nine, white blood cells (WBC, infection-fighting cells, normal is none) were three to four, squamous epithelial cells (skin cells that show contamination of the urine sample, normal is none) were 51-100, many mucus and was unacceptable for a culture and sensitivity (a test to identify bacteria that may cause an infection and see what kind of medication will work best to treat the infection).
- At 1:09 PM and 4:12 PM, she was given intravenous (in the vein) medication for nausea (feeling of sickness, with an urge to vomit).
- At 1:10 PM, she was given IV medication to treat alcohol withdrawal (symptoms that occur when the intake of a substance such as alcohol or drugs is reduced or stopped).
- At 1:11 PM, 2:46 PM and 4:39 PM, she was given IV pain medication.
- At 1:18 PM and 2:46 PM, she was given one liter (L) of IV fluids for her elevated lactic acid.
- At 1:45 PM, an abdominal and pelvic computed tomography (CT, a combination of x-rays [test that creates pictures of the structures inside the body-particularly bones] and a computer to produce detailed images of blood vessels, bones, organs and tissues in the body) showed mild acute uncomplicated pancreatitis (inflammation of the pancreas), thrombosis (blood clot formation in a deep vein) of right gonadal vein (a blood vessel that carries blood away from the organs that produce sex cells) and fatty infiltration of the liver (fat build up on the liver cells).
- At 2:07 PM, she was given IV potassium.
- At 3:21 PM, an abdominal ultrasound (a test that uses sound waves to create images of structures within the body) showed a common bile duct (tiny canals that connect some of the organs in your digestive system) measuring 0.8 centimeters (cm) and an enlarged liver.
- The Radiologist (a medical doctor who uses imaging technology to look inside the body to figure what is wrong) recommended clinical correlation of symptoms for the common bile duct dilation.
- Staff R, ED Medical Director, did not clinically believe the patient had a bile duct stone, she was comfortable with right upper quadrant abdominal pain, the pain was more generalized throughout the entire abdomen.
- Staff K's, Hospitalist, evaluation showed she was admission appropriate. A Magnetic Resonance Cholangiopancreatography (MRCP, a test to examine your pancreas and bile duct systems) was recommended because the common bile duct had doubled in size since 11/2024, her alkaline phosphatase elevation was new, and the elevated total bilirubin raised concerns for a common bile duct stone.
- The hospital was unable to perform the MRCP due to scheduling conflicts.
- Staff R requested Staff K admit the patient, pending the MRCP in the morning, but was declined. Staff K indicated the patient needed to remain in the ED or be transferred until a confirmatory MRCP showed no evidence of a common bile duct stone.
- Staff K advised Staff R to hold the patient until the follow morning for the MRCP, if the MRCP was negative the Hospitalist team would admit the patient.
- Staff R believed the patient could have been admitted having her pain appropriately managed and then transferred from the medical floor "just as easily" as she could from the ED, which would have benefited the patient's care.
- The patient refused transfer and declined to stay in the ED all night for the MRCP in the morning.
- Staff R expressed his concerns to Staff K and asked him to admit the patient for medical management. He informed Staff K the patient planned to sign out against medical advice (AMA) due to the ED constraints and the admission request was again declined. Staff K was aware the patient planned to sign out AMA which was less than ideal for the patient's medical condition.
- At 4:45 PM, Patient #31 signed a refusal to permit treatment or test form because she would have had to stay in a hall bed all night due to the ED's capacity constraints.
- She planned to return at 7:00 AM for the MRCP.

Review of Patient #31's medical record dated 02/12/25, showed:
- At 8:52 AM, she presented to the ED for cardiac arrest (when the heart suddenly and unexpectedly stops pumping).
- Her electrocardiogram (EKG, test that records the electrical signal from the heart to check for different heart conditions) showed sinus tachycardia (an increased heart rate [HR] that exceeds 100 beats per minute [bpm]) with a HR of 122, marked ST depression (a level below baseline on one part of the EKG) indicating myocardial ischemia (the heart muscle is not getting enough blood and oxygen) and heart attack.
- At 8:40 AM, her blood work showed her WBCs were 13.3 (normal is 4.8-10.8).
- At 9:48 AM, her blood work showed her sodium (a mineral in the blood or body fluid, normal is 137-145) was 138, CO2 was 13, anion gap (a measure for electrolyte imbalances and acid-base imbalances in your blood, normal is 6-18) was 24.8, lactic acid was 18.3, calcium (a mineral in the blood or body fluid, normal is 8-10.2) was 7.7, phosphate (a mineral in the blood or body fluid, normal is 2.5-4.5) was 6.7, total bilirubin was 3.3, AST was 743, ALT was 145, troponin (a type of blood test that measures whether or not a person is experiencing a heart attack, normal is less than 0.01) was high and brain natriuretic peptide (BNP, blood tests that measures levels of protein made by the heart and blood vessels that indicate heart failure, normal is 0-95.3) was 1,560.
- At 8:55 AM, she had a cardiac catheterization (a procedure where a long, thin tube is inserted in a large blood vessel that leads to the heart to diagnose or treat certain heart conditions) that showed normal anatomy.
- At 10:30 AM, she was admitted to the ICU, started on antibiotics for possible septic thrombophlebitis (infection of a thrombosis) in the setting of acute pancreatitis, and developed tonic-clonic seizure (a type of seizure that causes the loss of consciousness and violent muscle contractions) activity of greater than 10 episodes in six hours.
- At 8:05 PM, she was transferred to Hospital B per the family's request to continue aggressive cares.

Review of Patient #31's Hospital B medical record dated 02/12/25, showed:
- At 9:04 PM, she was directly admitted to the ICU.
- On 03/12/25, she was terminally extubated (withdrawal of a ventilator [a machine that supports breathing] from critically ill patients who are not expected to survive without respiratory support).
- On 03/14/25, she was transferred to the medical floor for comfort care (a patient care plan that is focused on symptom control, pain relief, and quality of life at the end of life).

During a telephone interview on 07/10/25, at 3:00 PM, Staff R, ED Medical Director, stated that the hospital had the capability and capacity to care for Patient #31 on her 02/11/25 visit. She was not stable for transfer because she was in "profound withdrawal." The patient stated that she was transferred the last time she presented to the hospital for a MRCP, and she did not have a common bile duct stone. She was discharged the day after she arrived at the receiving hospital, and it took her three days to find a ride home. If a patient refused to transfer, the Hospitalists convinced them to leave AMA. Staff K, Hospitalist, created an uncomfortable environment for Patient #31, by remaining in the ED hallway, which encouraged her to leave AMA. A repeat potassium level would have been completed on the inpatient side if she had been admitted. An EKG order was not triggered with a potassium of 2.8, but would be ordered at the Physician's discretion. A potassium of 2.8 met the hospital's Utilization Review (UR, staff who review documentation as a safeguard against unnecessary and inappropriate medical care) guideline for an observation service (assessment, treatment, and reassessment, to determine whether a patient will require further inpatient treatment or could be safely discharged) admission. He suspected Patient #31 died from a withdrawal seizure.

During a telephone interview on 07/09/25, at 1:45 PM, Staff K, Hospitalist, stated that he physically evaluated Patient #31 in ED room four. She had severe abdominal pain with a history of pancreatitis and alcohol abuse. He was concerned with the increased dilation of her common bile duct and laboratory findings compared to her previous results. He was aware Staff R, ED Medical Director, did not believe the patient had a common bile duct stone, he spoke with the Surgeon on-call and the decision was made to keep the patient in the ED until the MRCP was completed. If the MRCP showed a common bile duct stone the hospital was not capable of performing an endoscopic retrograde cholangiopancreatography (ERCP, a procedure to diagnosis and treat problems in the digestive system) procedure because there was no GI provider available. He planned to provide co-management of the patient and wrote orders for her care while she remained in the ED, "that way he did not have to worry about transferring her anywhere as an in-patient." It was "very challenging to transfer inpatients to a higher level of care, all hospitals were busy." He was not aware the patient was in a hallway bed, that knowledge would not have changed his recommendation to hold her in the ED pending the MRCP. If Staff R believed Patient #31 needed to be admitted right then, she should have been transferred. He was not aware the patient refused to be transferred. There were no treatment guidelines for a gonadal vein thrombosis, and it was not an emergent condition. "In an ideal world an EKG would have been done due to her low potassium. She did not have chest pain, and her low potassium level was related to her vomiting." Her diagnosis was "pretty slam dunk." He expected a repeat potassium level if the patient had not left AMA. He did not know what transpired between Staff R and the patient, it was her choice to leave AMA.

During a telephone interview on 07/09/25, at 3:50 PM, Staff L, Surgeon, stated that he vaguely remembered speaking with Staff K, Hospitalist, regarding Patient #31. He did not recall speaking with Staff M, ED Medical Director. He was familiar with the patient, he performed surgery on her the year before. The patient had to quit drinking alcohol before he was able to perform the surgery. Unfortunately, she began drinking again and there was concern for pancreatitis versus common bile duct stone. The work-up was incomplete without a MRCP, therefore the patient should have remained in the ED.

During a telephone interview on 07/10/25, at 10:30 AM, Staff T, Chief Operating Officer (COO), stated that he was not aware of Patient #31's hospital experience and that was concerning to him. In his personal opinion admitting the patient rather than boarding in the ED hallway made the most sense over allowing her to leave AMA. She could have been transferred as an inpatient if that became necessary. This patient was managed as a "what if scenario. In spite of the challenges the hospital faced the patient needed care." He was not aware of delays the hospital faced when transferring patients from an inpatient status.

Review of the hospital's document titled, "Tiger Text," dated 07/10/25, showed at 10:39 PM, Staff V, ED Physician, wrote, that hall bed (Patient #44) that we were going to send back to the nursing home was standing but with 50%-75% assist, I think he will get sent right back if we discharge him. At 10:45 PM, Staff S, Hospitalist, replied, he does not have a diagnosis that would meet criteria for admission. If he is weak, they can do PT and OT at the nursing home.

Review of Patient #44's medical record dated 07/10/25, showed:
- At 6:02 PM, he was a 62-year-old who presented to the ED for a chief complaint of altered mental status (AMS, mental functioning ranging from slight confusion to coma).
- His past medical history included a stroke (a medical emergency that occurs when the blood supply to part of the brain is interrupted or reduced, preventing brain tissue from getting oxygen and nutrients), memory problems, Traumatic Brain Injury (TBI, an injury in how the brain works). and chronic kidney disease (CKD, ongoing, gradual loss of kidney function).
- The course narrative showed he had AMS and lethargy (weak, sluggish). He had a new oxygen requirement that appeared to be related to obstruction due to sleeping. His blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) improved with IV fluids and the plan was to discharge home.
- The history of present illness showed he was poorly responsive and unable to provide a coherent history. The nurse obtained additional history from the patient's nursing home (NH). He had slipped while he attempted to sit on a chair and landed on his bottom. He did not strike his head, but did not seem able to get up on his own. He was awake and alert today.
- At 6:12 PM, his BP was 95/72.
- At 6:30 PM, his WBC's were 4.4, hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal is 9-20) was 11.2, platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal is 150-400) were 147, sodium (a mineral in the blood or body fluid, normal is 137-145) was 135, blood urea nitrogen (BUN, blood test that specifies kidney function normal is 9-20) was 25, creatinine (blood test that shows how the kidney is functioning, normal is 0.8-1.5) was 1.53 and lactic acid was 1.3.
- At 7:38 PM, 2,400 milliliters (mls) of IV fluids were administered
- At 8:10 PM, a brain Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body) showed no abnormality.
- At 8:17 PM, a head CT showed no abnormality.
- At 8:30 PM, Staff S, Hospitalist, was consulted and stated there was no indication for admission if the patient's BP improved, he could be discharged.
- At 8:31 PM, a pelvis x-ray showed osteoarthritis (when the flexible tissue at the end of bones wears down and cause pain).
- At 8:34 PM, a chest x-ray showed atelectasis (collapse of part or all of a lung) of both lungs.
- At 8:45 PM, Staff S, was contacted again and stated there was no admission criteria and recommended going back to the NH with physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) and occupational therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) consults.
- The nurse reported she did not think the patient was able to go back to his NH at that time, he was not able to stand. He was normally able to walk without assistance.
- At 8:46 PM, his UA showed urobilinogen (a substance formed in the intestines when bacteria break down bilirubin [yellowish pigment that is made during the breakdown of red blood cells], normal is 0.2-1) was 6.
- At 8:49 PM, IV antibiotics were administered.
- At 10:04 PM, IV antibiotics were administered.
- At 11:15 PM, his BP was 107/85.
- The patient was discharged home.


Review of Patient #44's medical record dated 07/11/25, showed:
- At 12:19 AM, he presented to the ED after a fall and AMS.
- The course narrative showed he was seen previously and discharged from the ED, although at the time of the discharge there was still concern about the patient's AMS and instability with walking. Shortly after he arrived at the NH he was found down on the ground. He had no signs of trauma but was confused and lethargic.
- At 2:40 AM, his WBCs were 7.8, hgb was 13.3, platelets were 132 and BUN was 24.
- At 3:06 AM, a venous blood gas (VBGs, blood that is low in oxygen content and is carried through blood vessels from the body back to the heart) showed a pH (measurement of acidity and alkalinity of blood, normal is 7.33-7.43) was 7.35, partial pressure of carbon dioxide (PCO2, measurement of how much carbon dioxide is in your blood and how well your lungs are removing it, normal is 35-48) was 54.7, partial pressure of oxygen (pO2, amount of oxygen dissolved in blood, normal is 38-50) was 28.2 and base excess (a measurement of acid base balance, normal is -3.2-1.8) was 4.3.
- At 3:34 AM, his UA showed ketones (when a type of sugar is present in the urine, may indicate high blood sugar levels in the body, normal is zero) was trace, leukocyte esterase (substance that suggests there are white blood cells in the urine, normal is zero) was 75, WBCs were 15-19 urobilinogen was 2, bacteria was trace (normal is zero) and a urine drug screen (UDS, a test that analyzes urine for the presence of certain illegal drugs and prescription medications) was positive for marijuana.
- At 7:05 AM, IV antibiotics were administered.
- At 2:10 PM, one L of IV fluids were administered.
- Staff G, Hospitalist suspected some sort of marijuana edible spread among the patients at the NH.
- The nursing home called to the hospital and informed them the patient exceeded their ability to provide safe care, he was not allowed to return and required placement.
- Staff S, Hospitalist, was consulted and the patient was admitted for polypharmacy (taking too many medications at the same time), marijuana abuse and potential urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra).

During a telephone interview on 07/16/25, at 10:30 AM, Staff V, ED Physician, stated that he was employed at the hospital since 2022 on an as needed basis. He was credentialled as an ED Physician at 11 other hospitals. Patient #44 was "definitely not" at his baseline when he was discharged from the ED, his mentation (mental activity) improved but his gait (a person's manner of walking) had not. He walked independently at his baseline, and he was a two person assist to stand at the end of his first ED visit. He consulted Staff S, Hospitalist, and his admission request was denied. Patient #44 was to discharge back to the NH with PT and OT consults. Staff V felt he could try the discharge to the NH but believed the patient would "bounce back" to the ED. In his experience with other hospitals, Patient #44 would have been admitted. He felt Patient #44's discharge to the NH did not meet the standard of care and he was not surprised he returned to the ED. He was "disappointed" with the "push back" from the Hospitalists to the ED Physicians. There was more push back at this hospital than any other hospital he worked at. In his experience, other hospitals had a more collaborative approach with a focus on what was in the best interest of the patient. He sometimes experienced a lot of resistance from the Hospitalist and felt the patient's quality of care and safety were impacted. He felt that he had to pick his battles. The hospital was not patient centered, and he had to worry about maintaining relationships with the Hospitalists. The Hospitalists focused on UR and payment; "this was 100% the issue. It was a huge issue" that the hospitalists were so concerned about the recommendations of UR and patient payments.

During a telephone interview on 07/15/25, at 12:00 PM, Staff S, Hospitalist, stated that the ED Physician consulted him because "he did not know what to do with the guy." The patient was alert and oriented times four (A&O x 4, a person is oriented to person, place, time, and situation), he was "just different." It was "hard to get Patient #44 to talk," he thought maybe there was a physiological condition (the condition or state of the body or bodily function). There was no focal deficit. He was aware the nurse was concerned the patient was too weak to walk. The patient "did not necessarily meet criteria for admission without a specific cause for his weakness." He could have had a PT and OT consult in the ED but would have had to stay longer. When Patient #44 returned to the ED it was clear he had marijuana intoxication (the condition of having physical or mental control markedly diminished by the effects of alcohol or drugs). He was placed in observation because he fell "again", and he wanted to observe Patient #44 until the morning so he could "sleep it off." He felt the first discharge was safe and it was unfortunate he fell the second time.

During a telephone interview on 07/11/25, at 2:00 PM, Staff R, ED Medical Director, stated that Staff S, Hospitalist, refused to admit Patient #44 after a UR review. Staff S was "notorious for wallet biopsies and chart surfing." The patient had AMS and generalized weakness. He was normally independent and was not at his normal function at discharge due to weakness. Staff V, ED Physician, wanted to admit but was denied by Staff S because the patient "did not meet UR's admission criteria." Two hours later Patient #44 was found on the floor, returned to the ED and was admitted.

During a telephone interview on 07/15/25 at 1:30 PM, Staff T, Registered Nurse (RN), stated that she assumed care of Patient #44 prior to his discharge from the ED. She tried to dress him and felt he was "not appropriate" for an assisted living home. She communicated her concerns to Staff V, ED Physician, a couple of times and knew he communicated her concerns to Staff S, Hospitalist. She thought "the home will return him and hoped the Hospitalist would have a shift change and he would be admitted." She felt the discharge was not safe. When Patient #44 returned to the ED, Staff G, Hospitalist, tried again to have the patient admitted. It turned out the patient had marijuana intoxication, but it could have been something else. Staff T stated that there seemed to be "patterns of animosity between the ED Physicians and the Hospitalists." The conflict affected patient care. Recent changes had taken place in response to the "fighting" between the ED Physicians and the Hospitalists. When the patient was accepted for admission, the patient was "held in the ED" until the Hospitalists informed the floor staff, they were able to call the ED for report. Quick admissions from the ED benefited the patients, there were beds available, but the ED was not allowed to transfer the patient until the Hospitalists "decided it was okay." That process resulted in "delays in care" and back up in the ED. The ED was "so small with a high census."

During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that the Hospitalists referred to UR before patients were admitted. This was screening patients for their ability to pay for care. If the patient was not a "slam dunk" admission the Hospitalists requested the ED Physician review the patient with UR. That meant Physicians were being told how to manage patients by non-clinically educated staff. The UR department stated the final decision to admit was up to the Physician but called the Hospitalist to inform them the patient did not meet admission criteria, and the Hospitalist refused to admit the patient based on the UR recommendation. When he requested the Hospitalist to evaluate patients face-to-face, he was told there was "nothing they had to offer" the patient and did not perform the face-face evaluation.

Based on interview, record review and policy review, the hospital failed to follow its policies and procedures when they failed to provide an appropriate transfer for four patients (#13, #32, #42 and #43) out of 44 Emergency Department (ED) records reviewed from 01/01/25 through 06/30/25. The hospital's average monthly census over the past six months was 1,445, and the average monthly transfer of patients over the past six months was 115.

Findings included:

Review of the hospital's policy titled, "Transfer of Patients/Residents," approved 08/2024, showed no patient/resident shall be arbitrarily transferred. Transferring a patient to another medical facility will be appropriate in those cases in which the patient requires medical treatment, that is not within Citizens Memorial Hospital ability or scope of service.

Review of the hospital's document titled, "Medical Staff By-Laws," dated 07/2023, showed:
- An active staff member must consult with other staff members consistent with his or her scope of practice and clinical privileges and accept the care and treatment of patients who present at the ED that do not have an assigned physician.
- The active medical staff shall consist of physicians, both medical and osteopathic, who assume all the functions and responsibilities of membership including, appropriate care of patients, emergency service care and consultation assignments.
- Active medical staff shall accept the follow-up care and treatment of patients who present at the emergency room that do not have an assigned physician through the episode of treatment.

Review of the hospital's document titled, "Rules and Regulations of the Medical Staff of Citizens Memorial Hospital," reviewed 11/03/20, showed:
- If a staff physician is on call to provide emergency services or to consult with an emergency room physician in the area of his/her expertise, that physician will be considered to be available by phone for consultation or to come in to physically assess the patient in the ED.
- The determination as to whether the on-call physician must physically assess the patient in the ED is the decision of the treating emergency physician.
- Consultations shall show evidence of a review of the patient's record by the consultant, pertinent findings on examination of the patient, the consultant's opinion and recommendations.
- Any qualified practitioner with clinical privileges in the hospital can be called for consultation within his area of expertise.
- If a nurse has any reason to doubt or question the care provided to any patient or believes that appropriate consultation is needed and has not been obtained, he/she shall call this to the attention of his/her supervisor who in turn may refer the matter to the director of the nursing service. If warranted, the director of nursing may bring the matter to the attention of the physician advisor of the service wherein the practitioner has clinical privileges.

Review of the hospital's document titled, "Physician Resource Optimization Meeting," dated 06/18/25, showed:
- From 04/04/25 through 05/31/25, 77 Hospitalist consults from ED Physicians resulted in 44 transfers.
- In 2021, 5.8% of ED patients were transferred;
- In 2022, 6.2% of ED patients were transferred;
- In 2023, 6.7% of ED patients were transferred;
- In 2024, 7.6% of ED patients were transferred; and
- In 2025, 8.2% of ED patients were transferred.

Review of the hospital's document titled, "Privileges - Standard," dated 05/21/24 through 05/21/26, showed Staff E, Orthopedic (medical specialty dealing with bones) Surgeon, had orthopedic surgery core privileges to:
- Evaluate, diagnose, consult, and provide non-surgical and surgical care to patients of all ages;
- Correct or treat various conditions, illnesses, and injuries of the musculoskeletal system, including the provision of consultation; and
- Including specific processes such as intermedullary rods (femur, tibia), total knee replacements, and revisions of total knee.

Review of the hospital's document titled, "Privileges - Standard," dated 04/23/24 through 04/23/26, showed Staff J, Hospitalist, had internal medicine core privileges to:
- Evaluate, diagnose, treat, and provide consultation (including medical history and physical examination) to patients 18 years of age and older with common and complex illnesses, diseases, and functional disorders of the circulatory (the system that contains the heart and the blood vessels and moves blood throughout the body), respiratory (your body's breathing system), endocrine system (a system of glands that make hormones to control moods, growth and development), metabolism (the process when your body converts food and drinks into energy to keep you alive and functioning), musculoskeletal (bones, muscles, joints, tendons and ligaments which all work together to provide the body with support, protection, and movement), hematopoietic (anything related to the process of making blood cells), gastrointestinal (GI, stomach and intestines), and genitourinary (the body parts involved in making and removing urine and the body parts involved in reproduction) systems.
- Provide care to patients in the intensive care setting in conformance with unit policies.
- Assess, stabilize, and determine disposition of inpatients with emergent conditions consistent with medical staff policy regarding emergency and consultative call services.

Review of the hospital's untitled electronic mail (email) dated 07/08/25, showed:
- On 06/25/25, there were no telemetry (remote observation of a person's heart rhythm, using signals that are transmitted from the patient to a computer screen) boxes available;
- Medical-telemetry patients needed transfer; and
- Boarding Progressive Care Unit (PCU, a telemetry monitored unit that provides care for adult patients requiring continuous cardiac monitoring) in the ED was appropriate as cardiac monitoring was possible with their mobile or in room monitors.

Review of the hospital's document titled, "Department: Cardiology (a physician that specializes in the care of your heart and blood vessels)," dated 03/2025, showed a Cardiologist was on call every day in 06/2025.

Review of Patient #32's medical record dated 06/24/25, showed:
- At 10:07 PM, he was a 60-year-old who presented to the ED for a chief complaint of left sided pain and altered mental status (AMS, mental functioning ranging from slight confusion to coma).
- His past medical history included alcohol abuse.
- His past surgical history included a thoracotomy (a surgical incision through the chest wall, used to visualize and treat illnesses within the chest) and heart bypass surgery of five vessels.
- The course narrative showed he had a slow heart rate (HR, the number of times the heart beats within a certain time period, normal pulse/heartbeats for adults range from 60 to 100 per minute) enroute to the ED per Emergency Medical Services (EMS, emergency response personnel, such as paramedics, first responders, etc.) and atropine (an emergency medication used to treat a slow HR) was administered. He was lethargic (weak, sluggish) but would awaken to verbal and physical stimulation. He complained of abdominal pain and was tender in the left lower abdomen. He had phimosis (the foreskin of the penis is too tight to be fully pulled back over the head of the penis) with associated urinary retention (when the bladder doesn't empty completely or at all) with greater than 600 milliliters (ml).
- Staff G, ED Physician, suspected his AMS was caused by a urinary tract infection (UTI, an infection in any part of the urinary system, the kidneys, ureters, bladder and urethra) and the kidney injury was in part due to the phimosis which was addressed.
- A rectal exam was negative for blood.
- At 10:11 PM, his blood work showed his blood urea nitrogen (BUN, blood test that specifies kidney function, normal is 9-20) was 46, creatinine (blood test that shows how the kidney is functioning, normal is 0.8-1.5) was 2.08 and magnesium (mineral in the blood or body fluid, normal is 1.6-2.3) was 3.1.
- From 10:12 PM through 06/25/25 at 12:03 PM, his HR ranged from 25 to 130 beats per minute (BPM), his blood pressure (BP, normal adult blood pressure is between 90/60 and 120/80) ranged from 96/59 to 139/62 and his oxygen saturation (SpO2, measure of how much oxygen is in blood. A normal is between 95% and 100%) ranged from 93% to 99% on room air (not receiving supplemental oxygen).
- At 11:00 PM, one-liter (L) of intravenous (IV, in the vein) fluids was administered.
- At 11:03 PM, he had a three-beat run of ventricular tachycardia (V-tach, a condition in which the lower chambers of the heart [ventricles] beat very quickly).
- At 11:18 PM, his EKG showed a first-degree AV block (a heart condition where the electrical signals that travels from the heart's upper chambers [atria] to the lower chambers are delayed) and frequent premature ventricular contractions (PVCs, a type of abnormal heartbeat).
- On 06/25/25 at 12:05 AM, his urinalysis (UA, a laboratory examination of a person's urine)
showed leukocyte esterase (substance that suggests there are white blood cells [WBC, infection-fighting cells] in the urine, normal is negative) were 500, red blood cells (RBC, cells that carry oxygen throughout the body, normal is negative) were five to nine and WBCs were too numerous to count (normal is zero).
- At 1:41 AM, IV antibiotics were administered.
- At 2:52 AM, Staff J, Hospitalist, was consulted for admission for hepatic encephalopathy (inflammation of the brain brought on by severe liver disease) due to UTI. Staff J felt the patient required an Intensive Care Unit (ICU, a unit where critically ill patients are cared for) level of care related to the episode of V-tach and episodic slow HR.
- Staff J, did not perform a bedside assessment.
- The patient was transferred to Hospital B.

Review of Patient #32's Hospital B medical record dated 06/25/25, showed:
- At 10:12 AM, he was directly admitted to the Cardiac-Medical Unit.
- His treatment plan included a brain Magnetic Resonance Imaging (MRI, test that uses a magnetic field and radio waves to create images of the organs and tissues within the body), blood and urine laboratories, Cardiologist consult, echocardiogram (ECHO, a test that makes images of the heart and surrounding structures), telemetry monitoring, medication administrations and adjustments and rib and hip x-rays (test that creates pictures of the structures inside the body-particularly bones).
- His code status (refers to whether or not a patient wants medical intervention if their heart or breathing stops) was Do Not Resuscitate (DNR, written instructions from a physician telling health care providers not to perform CPR).
- On 06/28/25 at 2:14 PM, Patient #32 was discharged home.

During a telephone interview on 07/09/24 at 12:00 PM, Staff G, ED Physician, stated that the transfer of Patient #32 "was ridiculous." He had metabolic encephalopathy (a disease in which the functioning of the brain is affected by an illness or organs that are not working as well as they should, such as with a viral infection or toxins in the blood) from the UTI, not hepatic encephalopathy. "The voice to dictation made an error." The patient was not symptomatic with the slow HR. Staff G believed "low voltage of his QRS complex (electrical impulse as it travels through the ventricles of the heart) with frequent PVCs was why the telemetry monitor showed a slow HR. The three-beat run of V-tach was actually three PVCs in a row and the telemetry monitor "called it V-tach." Staff J, Hospitalist, "threw up roadblocks to admissions." He requested a surgical consult for this patient for possible bleeding varices (expanded blood vessels that develop most commonly in the esophagus [a muscular tube that food travels through from the throat to reach the stomach] and stomach). To overcome the gastrointestinal (GI) bleed (excessive bleeding that starts in the intestinal tract) obstacle, Staff G performed a rectal examination, and the patient was guaiac (a test that checks for hidden blood in stool, normal is negative) negative. Staff G believed the surgery consult was requested because Staff J knew the on-call surgeon would request the patient was transferred because the hospital was not capable of performing esophageal varices banding (a procedure where tight elastic band are placed around a bulging vein to stop it from bursting and bleeding). Patient #32 needed antibiotics to treat the UTI. Staff J, called the House Supervisor and her perspective was the patient needed an ICU level of care, but there were no ICU beds available. "We sent this guy out for a three-beat run of V-tach!" The ED was unable to determine the patient's code status, he was confused. Staff G believed the patient required telemetry monitoring. It was not uncommon for patient's to be held in the ED for telemetry monitoring if bed and telemetry availability was limited. Boarding patients happened on a regular basis. Patients appropriately transferred for telemetry needs were on medication drips and intubated (process where a healthcare provider inserts a tube through a person's mouth or nose down into their windpipe when a person is not breathing on their own) or those with critical care needs. Staff J, "found reasons patients could not be admitted."

During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that a diagnosis of V-tach required six beats. Patient #32 had a wide complex ventricular beat (irregular HR rhythm). "At the most," the patient needed a Cardiology consult. The hospital had a Cardiologist provider available that was capable of caring for Patient #32. The working process in the ED was to board up to two ICU patients before transferring. Patient #32 could have boarded in the ED until an ICU bed was available.

During a telephone interview on 07/09/25 at 5:00 PM, Staff J, Hospitalist, stated that Patient #32's UA results "were not impressive" for a UTI. His goal was to always keep patients local, if possible. No ICU beds were available, and Staff J needed to be sure he could care for the patient. He collaborated with the House Supervisor, and due to the patient's "persistent" low HR and episode of V-tach it was recommended the patient needed an ICU level of care. He was looking to work with the House Supervisor to determine if the patient was able to be cared for locally, the decision to transfer was not unilateral. He had a "very close relationship with the House Supervisors and was instrumental in developing their program to support consistency with available resources." He recalled reviewing the patient's EKG's but not his telemetry monitoring. He was not informed of Staff G's suspicions for a low voltage QRS and PVC run interpreted as V-tach which would have potentially changed his decision to transfer. It would have prompted further review. He depended on the ED Physician to provide details of the patient's situation. He was surprised the patient was not directly admitted to an ICU at the receiving hospital and stated different hospitals have different capabilities in their units.

During a telephone interview on 07/10/25 at 7:45 AM, Staff M, House Supervisor, stated that no ICU beds were available for Patient #32. The ED had the only hemodynamic monitoring (a procedure that checks your blood circulation and evaluates how well your heart is working) available in the hospital. As the House Supervisor she tried not to hold ICU level of care patients in the ED.

Review of Patient #42's medical record dated 07/05/25, showed:
- At 9:54 PM, he was a 64-year-old who presented to the ED with a chief complaint of shortness of breath with concerns for sepsis (life threatening condition when the body's response to infection injures its own tissues and organs) and pneumonia (infection in the lungs).
- His past medical history included sarcoidosis (a disease that causes small patches of swollen tissue to develop in the organs of the body), chronic hypoxic respiratory failure (a condition where there is not enough oxygen reaching the tissues of the body caused by a failure of the respiratory system) requiring three (Ls) of oxygen, chronic urinary catheter (a small flexible tube inserted into the bladder to provide continuous urinary drainage) for urinary retention and long-term anticoagulant (medications used to prevent blood clots) therapy.
- His past surgical history included a permanent pacemaker (small device that's placed in the chest or abdomen to help control abnormal heart rhythms).
- The course narrative showed he had a peripherally inserted central catheter (PICC line, a flexible tube inserted into an arm, leg or neck vein to infuse fluids, blood products, and medications, or to withdraw blood for testing) and received IV antibiotics at home for a recurrent UTI bacteremia (bacteria in the bloodstream). He was confused, had a labored cough, had a high HR and respiration rate (RR, normal breaths per minute for an adult at rest ranges from 12 to 20) and was placed on bi-level positive airway pressure (Bi-PAP, type of ventilator that is used to treat conditions in which a person is able to breathe on their own but needs assistance).
- At 10:10 PM, arterial blood gases (ABGs, a blood test that measures the amount of oxygen and carbon dioxide in the blood) showed the arterial pH (measurement of acidity and alkalinity of blood, normal is 7.35-7.45) was 7.35 and partial pressure of carbon dioxide (PCO2, measurement of how much carbon dioxide is in your blood and how well your lungs are removing it, normal is 35-48) was 69.1. Staff G, ED physician, suspected a venous blood gas (VBGs, blood that is low in oxygen content and is carried through blood vessels from the body back to the heart) was obtained.
- At 10:15 PM, his blood work showed WBCs were 29.3, RBCs were 1.25 and hemoglobin (Hgb, a protein in red blood cells that carries oxygen throughout the body, normal is 14-18) was 4. Staff G suspected a laboratory error. His platelets (cell fragments in the blood that initiate clot formation and stop or prevent bleeding, normal is 150-400) were 141.
- At 10:15 PM, he was administered an albuterol nebulizer (bronchodilator medication used to relax muscles in the airways and increase airflow to the lungs).
- At 10:46 PM, he was given IV antibiotics.
- At 11:21 PM, his blood work showed WBCs were 15.7, RBCs were 2.63 and Hgb was 8.2.
- At 11:39 PM, he was given IV antibiotics.
- On 07/06/25 at 1:48 AM, he was given an IV medication to treat a yeast infection.
- At 3:51 AM, he was administered an albuterol nebulizer.
- At 3:53 AM, his UA, after the urinary catheter was exchanged, showed brown colored urine, urine blood was greater than 1 (normal is negative), leukocyte esterase (substance that suggests there are white blood cells in the urine, normal is zero) were 500, WBCs were too numerous to count, and yeast was observed. Blood work showed his lactic acid was 2.1. VBGs showed an arterial pH of 7.43 and his PCO2 was 52.4.
- At 6:21 AM, his lactic acid was 1.9.
- At 8:56 AM, a chest x-ray showed increased infiltrates (accumulation of a foreign substance, typically within the lungs)/atelectasis (collapse of part or all of a lung) of his left lower lobe without other changes.
- At 9:01 AM, he was given IV antibiotics.
- Staff J, Hospitalist, was consulted for admission and responded that he was "uncomfortable caring for him locally due to lack of supportive services, chiefly Pulmonology-critical care (a physician who specialized in lung issues), Infectious Disease (a doctor who specializes in diagnosing, treating, and preventing illnesses caused by infections), Hematology (a doctor who specializes in diagnosing and treating disease of the blood, bone marrow and lymphatic system [the tissues and organs that produce, store, and carry WBCs that fight infections and other diseases]) and Rheumatology (medical specialty concerned with disorders of the joints, muscles and ligaments)." During his recent admissions, he failed three antibiotic treatments. "There was a recent concern for hemolytic anemia (a condition where the body's RBCs are destroyed faster than your bone marrow can create new ones). Given his multiple comorbidities, to include chronic immunosuppression (the body's immune system is unable to fight infections and other diseases), he required transfer to a higher level of care."
- Staff J, did not perform a bedside assessment.
- After several hours of Bi-PAP his VBG showed his pCO2 improved. He was uncomfortable with the BiPAP and was transitioned to a nasal cannula (NC, a lightweight tube with two prongs for insertion into the nostrils and delivery of oxygen) and was able to maintain his SpO2 on four L of oxygen per NC while he boarded in the ED waiting for EMS shift change for transport.
- He was transferred to Hospital F.

Review of Patient #42's Hospital F medical record dated 07/06/25, showed at 12:35 AM, he was directly admitted to the ICU and transferred to the medical floor for continued diuresis (increase urine production) with improved breathing and his infection workup was unremarkable. His treatment plan included physical therapy (PT, focuses on range of motion and decreasing pain after an injury or illness) and occupational therapy (OT, focuses on the use of fine motor and cognitive skills to perform tasks required in daily life) consults, chest x-ray, NC during daytime hours and BiPAP at night, medication adjustments and administrations and blood laboratories.

During a telephone interview on 07/09/25 at 12:00 PM, Staff G, ED Physician, stated that Patient #42 was previously treated at the hospital for bacteremia and came into the ED with sepsis. He expected the patient would be admitted and treated with broad spectrum antibiotics (an antibiotic that is effective against many different types of bacteria). He believed the patient did not require the care of a critical care Pulmonologist; he was stable in the ED "all night long and his VBGs improved." He agreed the patient may need to see an Infectious Disease physician, but that need was not emergent. When Staff G was asked about the need for the patient to see a Rheumatologist he responded, "come on!" When Staff G was asked about Staff J's, Hospitalist, concern for Hemolytic Anemia he responded, he had no idea what Staff J referred to, he makes "shit" up when he decided he did not want to do "stuff." Staff G stated that Staff J "sat in his office and dug through the chart, he never saw the patient." Staff G asked, why transfer a patient emergently with improved VBGs? Historically, Staff J argued against consults, requested unneeded testing and still wanted to transfer patients.

During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that a Rheumatology consult was "never" emergent. The hospital had an Infectious Disease Physician available by phone consult. That provider was available 24 hours a day seven days a week in an unofficial capacity.

During a telephone interview on 07/09/25 at 5:00 PM, Staff J, Hospitalist, stated that he knew Patient #42 well. He had cared for him on "a couple of occasions." He was an "incredibly complicated and debilitated patient." He had two hospitalizations within a few weeks and was treated with three different antibiotics, which he failed. He was difficult to treat in regard to an infectious disease standpoint. He returned to the ED five days after his previous discharge having failed the third antibiotic. The concern for hemolytic anemia was related to the patient's use of Dapsone (medication used to treat a bacterial infection and reduce inflammation). The patient presented to the ED on a holiday weekend and the hospital lacked supportive services to care for a patient that required multidisciplinary care with a worsening condition. Staff J did not have higher level of care support without a Pulmonologist or Infectious Disease Provider. "What was he to do, the patient failed third level antibiotics and there was not access to an Infectious Disease provider." What he knew of the patient before was his respiratory status at baseline was "marginal" with pulmonary sarcoidosis, steroid (drugs used to relieve swelling and inflammation) dependence and chronic immunosuppression. The patient was on and off of BiPAP and he had no access to a Pulmonologist to manage acute respiratory failure.

Review of Patient #43's medical record dated 07/07/25, showed:
- At 8:50 PM, he was 73-year-old who presented to the ED with a chief complaint of fall.
- His past surgical history included a right knee replacement in 03/2024.
- The course narrative showed he had chest pain with palpation (using one's hands to assess the body) and a laceration (a deep cut or tear in skin) to his right knee. He maintained his SpO2 levels. He worked with Hospital E's orthopedics (medical specialty dealing with bones) and planned a revision of his right knee replacement. The patient refused to follow up with his previous Orthopedic Surgeon. The wound was irrigated, and a sterile (completely clean and free from germs) dressing was applied.
- At 9:00 PM, his WBCs were 13.1.
- On 07/08/25 at 7:14 AM, a right knee x-ray showed a total right knee replacement and no evidence of hardware failure.
- Staff E, Orthopedic Surgeon, was consulted and recommended wound care, he "advised that given the nature of the wound the knee was likely infected." He recommended a wound culture (a test to identify bacteria that may cause an infection), one dose of IV antibiotics and a referral back to the patient's previous Orthopedic Surgeon.
- An outside Orthopedic Surgeon was consulted and recommended the patient was transferred to Hospital E's ED.
- At 7:19 AM, a rib x-ray showed no disease or break.
- The patient was transferred to Hospital E.

Review of Patient #43's Hospital E medical record dated 07/08/25, showed:
- At 12:15 AM, he arrived at the ED.
- His knee laceration was repaired in the ED.
- His treatment plan included a head, cervical spine (neck region of the back), chest, abdomen and pelvis CT scan.
- He was admitted to the surgical floor with a diagnosis of rib fracture (a break in a bone), two middle back and one lower back compression fractures (a type of break in a bone caused by pressure and in which the bone collapses) and emphysema (a condition in which the air sacs of the lungs are damaged and enlarged, causing breathlessness).

During a telephone interview on 07/09/25 at 12:00 PM, Staff G, ED Physician, stated that Patient #43 presented after a fall with a laceration to his knee over previous hardware. He consulted Staff E, Orthopedic Surgeon, but did not push for him to come in to see the patient. Historically, Staff E was a difficult consult, if he was made to come in, he got "pissy." Staff G texted pictures of the wound to Staff E and the recommendation was for wound care. Staff E responded to the text with "probably infected, do not care to inherit." Which was a "really unhelpful consult, stating he did not want to be involved." Staff G did not think the wound was infected, it was too fresh. The antibiotic recommended required multiple doses to be effective, the plan was "useless." The patient had previously met with an outside orthopedic group at Hospital E and Staff G contacted their on-call provider to discuss the patient's care and needs. The outside Orthopedic Surgeon stated that "the current plan to clean the wound and follow up outpatient made no sense," and he requested the patient was transferred to his care. Staff G, suspected the receiving provider took the patient to the operating room for a formal wash out, which was "pretty standard." Staff G "absolutely" needed to ensure the patient had a short term follow up plan, that was why he consulted the outside Orthopedic Surgeon, looking for a safe plan. He could not confirm a solid and quick follow up plan with a doctor who said he did not want to inherit the patient. Staff G "could have pushed harder with Staff E who did not want to take care of the patient." Staff G stated that "he could not in good conscience send the patient to a doctor who did not want to take care of him. Telling me he did not want to get involved." Why subject a patient to a doctor with "crappy recommendations and refused follow-up?" The hospital was capable of performing a washout out with a physical evaluation from the Orthopedic Surgeon. The patient was transferred for an orthopedic evaluation. Staff G did not challenge Staff E because "he was not the most pleasant person and he had to continue working with him, and he was not receptive to consults."

During a telephone interview on 07/10/25 at 3:00 PM, Staff R, ED Medical Director, stated that there was no formal process for Physicians to escalate patient care concerns to department Medical Directors. He felt Staff E, Orthopedic Surgeon, should have come in to evaluate the patient and followed up with the patient as an outpatient. It was a standard of care if a patient was greater than six weeks post operative, they were to be cared for by the available Physician, not the operating Physician. Staff E had the capability to care for Patient #43.

During a telephone interview on 07/10/25 at 9:55 AM, Staff E, Orthopedic Surgeon, stated that Patient #43's wound looked like a knee infection. He did not perform knee replacements and did not want to "inherit" an infected knee. He stated that the ED Physician wanted to "sew the knee", he felt it was better to leave it open and have the patient return to his personal Orthopedic Surgeon. He was not informed the patient refused to return to the provider who performed the knee replacement or why the ED Physician consulted the Orthopedic Surgeon at Hospital E. He stated that it did not seem to him there was any reason for an emergent wash out. There was no purulent (pus) drainage. It looked like a wound dehiscence (separation of previously approximated wound edge, due to a failure of proper wound healing) of an older surgical site.

During a telephone interview on 07/10/25 at 7:45 AM, Staff M, House Supervisor, stated that she reviewed Patient #43's transfer paperwork. She did not know how much detail was provided to Staff E, Orthopedic Surgeon from Staff G, ED Physician. She did not understand why the patient was transferred when the specialist recommended a plan of care. If the ED Physician was not satisfied with the plan, he could have requested Staff E evaluate the patient face-to-face. Staff E did not come into the ED as often as other providers. The hospital had the capability of performing a formal wash out of the wound.

Review of Patient #13's ambulance report, dated 06/16/25, showed:
- At 1:58 PM, EMS was dispatched to a motor vehicle accident (MVA).
- The patient breathed normal and answered questions.
- The patient had no loss of consciousness and did not have life threatening blood loss.
- The patient was taken to the ED and report was given.

Review of Patient #13's medical record, dated 06/16/25, showed:
- At 2:50 PM, he was a 21-year-old who arrived at the ED by EMS after an MVA where he suffered a deformed, left leg fracture.
- The course narrative showed Patient #13 was a restrained driver of a vehicle that sideswiped a trailer going approximately 60 miles per hour, lost control of the vehicle and ended up in the ditch.
- His left lower leg had an intact pulse, motor function and sensation, he had swelling to his right ankle without deformity, lip pain and cuts to both arms.
- He had no acute (sudden onset) distress, was alert, awake, and oriented times three (A&O x 3, refers to being alert and oriented to person, place and time), was slow to answer some questions and his vital signs (VS, measurements of the body's most basic functions) were normal.
- At 3:18 PM, an x-ray of both ankles showed left mild to moderate tibia and fibula (lower leg bones) fractures.
- At 3:39 PM, chest, abdomen, pelvis, cervical spine (, thoracic spine (middle portion of the spine), lumbar spine (lower back) and brain CT scans were negative.
- At 4:00 PM, Staff E, Orthopedic Surgeon, was consulted and recommended to transfer the patient to a higher level of care.
- At 4:08 PM, Staff E, ordered an inpatient admission, scheduled surgery, surgery consent form for intermediary nail placement (a surgical procedure used to stabilize and promote healing of long bone fractures) of the left tibia, no food or drink, social service consult for discharge planning, medications and blood laboratories
- At 6:20 PM, the orders were cancelled due to discharge.
- The pat