HospitalInspections.org

Based on interview and record review, Facility A failed to comply with the Emergency Medical Treatment and Labor Act (EMTALA) as evidenced by:

1. Facility A transferred Patient 1 on 4/28/25 to Facility B, without exhausting all of its capabilities to resolve Patient 1's EMC of having a Foreign Body (FB-an object inside the body that is not normally seen in the body) before transferring.

This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1's emergent medical condition, and had the potential to negatively affect Patient 1's health in delaying treatment.

Findings:

1. During a review of Patient 1's "ED Provider Note" dated 4/27/25, by Medical Doctor (MD) A, at 11:20 pm, note indicated, "Chief Complaint Patient presents with Abdominal Pain General abd [abdominal] pain and rectal pain after eating breakfast this AM. + nausea [with nausea]. . .Describes abdominal pain as intermittent [comes and goes], cramping sensation, 10/10 intensity, with associated nausea. Reports diaphoresis [excessive sweating], chills, and rectal pain causing difficulty sitting. . .CT [computed tomography a type a scan using x-rays to create cross section of internal body structures] abdomen and pelvis with IV contrast performed, reported by Radiology, showing 1.9cm linear radio-opaque [object that is seen on x-ray imaging] density [measure of how dark an object appears on scan] Regional [in location to] the anus [The opening of the rectum to the outside of the body] correlation for foreign body. . .I attempted to perform anoscopy [procedure used to examine the anus. It involves the insertion of a short, hollow, lighted tube called an anoscope to visualize the area] . . .but patient was not tolerable to this exam. . .I consulted the on-call general surgeon, [MD B]".

During a review of Patient 1's "CT Abdomen and Pelvis" dated 4/28/25, exam indicated, "Findings: Bowel: 1.9cm linear radiodensity regional to the anus".

During an interview on 7/7/25, at 2:32 p.m., with MD A, MD A stated, he was the emergency department provider for Patient 1 on 4/27/25. MD A stated, he attempted to perform the anoscopy to see the foreign body in Patient 1, but Patient 1 was unable to tolerate the procedure. MD A stated, he then consulted the general surgeon who had just left the hospital and came back to see Patient 1. MD A stated, MD B told him to transfer the patient to Facility B. MD A stated, he can do an anoscopy exam under procedural sedation [technique used to help patients relax during medical procedures. It involves administering medication that can range from minimal to deep sedation, reducing pain, and anxiety] but deferred to MD B's decision.

During a review of Patient 1's "General Surgery Consult Note", dated 4/29/25, by MD B, at 2:40 am, note indicated, "I d/w [discussed with] her in presence of her nurse [Nurse C]. . .[MD A] tried to do an endoscope [anoscopy] and it was unsuccessful too. . .I would suggest to perform vaginal exam and also consult to check her vagina. If there is no FB at her vagina. We can transfer to [Facility B] to have a colorectal surgeon with EUS [Endoscopic Ultrasound- a medical device that combines endoscopy and ultrasound to visualize the digestive tract and surrounding organs, aiding in diagnosis and treatment] to be able to find the FB".

During an interview on 7/7/25, at 12:51 p.m., with MD B, MD B stated, "CT showed foreign body there was a concern in would in the perianal [the area of skin surrounding the anus] to the rectum and [Patient 1] has a lot of pain, we couldn't do any rectal exam. I told her we need some type of colorectal [refers to the colon (large intestine) and rectum] surgery and we need EUS to look the FB". MD B stated, he has performed numerous exams under anesthesia for removal of foreign bodies in the rectum/anus. MD B stated, "We have to put the scope in. . .the EUS and take a look in the rectum, if something penetrated in the area I need an US [ultrasound] to see the area, and then figure out how to take it out. I don't have the ability to do that".

During a review of MD B's "Clinical Privileges" (Clinical privileges are the permissions granted to healthcare professionals to provide specific medical services within a particular healthcare facility) Dated 2024-2026 indicated, MD B was granted privileges for "General Surgery. . . Core privileges for General Surgery include the ability to admit, evaluate, diagnose, consult, and provide pre[before]-, intra-[during], and postoperative [after surgery] care and perform surgical procedures for patients of all ages to correct or treat various conditions"

During a review of facility 's on call list dated 4/27/25-4/28/25 indicated, the on-call colorectal surgeon was MD D.

During an interview on 7/8/25, at 12:00 p.m., with MD C, MD C stated, he was the on call Gastroenterology surgeon [specializes in surgical procedures of the digestive system] on 4/27/25-4/28/25. MD C stated, he was not consulted regarding any foreign body cases. MD C, his specialty is available to assist the general surgeon on cases of foreign body they may need help with. MD C stated, if a foreign body penetrated into soft tissues it would be hard to perform an endoscopy, sometimes the general surgeon will call us. MD C stated, they can sedate the patient to assist with the procedure.

During an interview on 7/8/25, at 9:12 a.m., with MD D, MD D stated, he was a gastroenterology surgeon. MD D stated, the facility here does have an endoscopic ultrasound.

During an interview on 7/8/25, at 9:50 a.m., with Chief of General Surgery (CGS), CGS stated, both MD A, and MD B were unable to visualize the foreign body during their anoscopy exam due to patient discomfort. CGS stated, the next steps could have been to offer procedural sedation, or do an exam under anesthesia. CGS stated, he read the CT scan and the assumption would have been that the foreign body is in the anus. CGS stated, it is in the scope of practice as a general surgeon to perform an exam under anesthesia to look for the foreign body.

During an interview on 7/1/25, at 11:28 a.m., with MD E, MD E stated, he is an emergency department physician at Facility A. MD E stated, if a patient is not able to tolerate an anoscopy procedure, "you don't want to delay care". It could be completed in the OR [operating room]. You can do procedural sedation also. MD F stated, the next step if the patient cannot tolerate the anoscopy would be to do the procedure under sedation or in the OR.

During a review of Patient 1's "Emergency Transfer Notification" dated 4/28/25, at 0506 a.m., document indicated, "Physician Authorization 2. Reason for Transfer Need for higher level of care than provided at [Facility A]".

During a review of a recorded phone call between MD B and MD F dated 4/28/25, phone call indicated, a physician to physician phone call occurred to explain the reason for the transfer of Patient 1 from Facility A to Facility B. MD F stated, he was a general surgeon at Facility B and needed clarification of why the transfer was necessary. MD F stated, if we accepted the patient (Patient 1) "we would just put the patient under general anesthesia and take a look". MD F stated, "the problem is I don't have the experience for the EUS and I don't want to something I cannot do that [sic] I never did this". MD F stated, "an exam under anesthesia [is a medical procedure where a patient undergoes an examination while under anesthesia to allow for a more thorough and comfortable assessment] is a standard general surgery operation, I'm just trying to understand, we would not take them [Patient 1] for an ultrasound, we would just take them to the OR [operating room] and just put them under general anesthesia". MD B stated, "The point is the foreign body is not just the anus". MD F stated, "So we would just take the patient to the OR and look under anesthesia, this is a very standard general surgery operation, so I'm just wondering why on a recorded line why you as a general surgeon feel like you're unable to do this operation". MD B stated, "Yeah I told them because we did an anoscope to take a look at that and it goes through the vagina and I'm not sure from the just anoscope I don't have anything to do that [sic] I need somebody with access if they cannot find it they can get the EUS to see where it is there. If its in the anus I can go and find that a lot of foreign body I have removed from the anus but this is not inside the of the anus this is something inside the perineal [he area of the body between the anus and the external genitalia] area and we don't know where is that [sic] ". MD F stated, "So as a general surgeon you feel you're not able to handle this perianal". MD B stated, "No I can't", if this is inside the anus I can. . .we don't know which part of the tissue it is". MD F stated, "Ok, we'll take this patient". The recorded phone call indicated, MD B left the line, while MD F spoke with Staff Member (SM) G. MD F stated, we can find out if this is an EMTALA violation or not once the patient gets here. SM G stated, "I've heard some other surgeons say, I'm sorry you're a general surgeon if you're board certified you should be able to take care of this".

During an interview on 7/8/25 at 1p.m., with MD F, MD F stated, he was a general surgeon at Facility B. MD F stated, his facility got a request for transfer of Patient 1 so for a foreign body in the anal area. MD F stated, he requested to speak with the transferring surgeon to ask why they were not able to treat the patient. MD F stated, in his clinical opinion, as a surgeon for Patient 1's case you would not need an endoscopic ultrasound. MD F stated, if a patient is not able to tolerate an anoscopy procedure the next step would be to perform an exam under anesthesia and any board certified general surgeon is able to perform this procedure.

During a review of Patient 1's "Operative Report" dated 4/28/25 at 4:48 p.m., Report indicated, ""Procedure: Rectal exam under anesthesia, removal of foreign body. . .findings: 2cm chicken bone approximately 3 cm from the anal verge [end of the anal canal and the point where stool exits the body]".

During an interview with Patient 1 on 7/16/25, at 106 p.m., Patient 1 stated, she went to Facility A's Emergency Department with severe 10/10 pain in her rectum and abdomen. "To be honest it was the worst experience of my life". Patient 1 stated, MD A attempted to look inside my behind to see, but it was too painful, so he called the surgeon (MD B). Patient 1 stated, the surgeon (MD B) could not do the procedure either because it was too painful, I've been through childbirth and this was worse. Patient 1 stated, MD B left the room and didn't say anything to me after the attempt. Patient 1 stated, the ED Doctor (MD A) came back in and told her "I'm going to be honest with you he [MD B] said to send you home, but we need to take care of your emergency, if you leave you will just come back in a few hours, so I'm going to call the ambulance and have you sent to [Facility B]". Patient 1 stated, the facility never offered to give her sedation or to perform surgery to find out what was causing her pain. Patient 1 stated, "[MD A] told me the reason I'm sending you to [Facility B] is because the surgeon doesn't want to deal with you".

During a review of the facility's Policy and Procedure (P&P) titled, "Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)", dated 2025 the P&P indicated, "It is the policy of [Facility A] to comply with state and federal laws regarding EMTALA in accordance with the policy below. . .D. Patient who have an EMC 1. When a Physician or Qualified Medical Professional determines that the patient has an EMC the hospital shall: a within the capability of the staff and facilities, provide further medical examination and treatment as required to stabilize the patients EMC".

Based on interview and record review the facility (Facility A) failed to provide necessary stabilizing treatment to one of 20 sampled patients (Patient 1) with an emergency medical condition (EMC-a health condition or situation that needs immediate medical attention) within the capabilities of the staff and facilities available when:

1. Facility A transferred Patient 1 on 4/28/25 to Facility B, without exhausting all of its capabilities to resolve Patient 1's EMC of having a Foreign Body (FB-an object inside the body that is not normally seen in the body) before transferring.

This deficient practice resulted in the facility failing to promptly treat and stabilize Patient 1's emergent medical condition, and had the potential to negatively affect Patient 1's health in delaying treatment.

Findings:
1. During a review of Patient 1's "ED Provider Note" dated 4/27/25, by Medical Doctor (MD) A, at 11:20 pm, note indicated, "Chief Complaint Patient presents with Abdominal Pain General abd [abdominal] pain and rectal pain after eating breakfast this AM. + nausea [with nausea]. . .Describes abdominal pain as intermittent [comes and goes], cramping sensation, 10/10 intensity, with associated nausea. Reports diaphoresis [excessive sweating], chills, and rectal pain causing difficulty sitting. . .CT [computed tomography a type a scan using x-rays to create cross section of internal body structures] abdomen and pelvis with IV contrast performed, reported by Radiology, showing 1.9cm linear radio-opaque [object that is seen on x-ray imaging] density [measure of how dark an object appears on scan] Regional [in location to] the anus [The opening of the rectum to the outside of the body] correlation for foreign body. . .I attempted to perform anoscopy [procedure used to examine the anus. It involves the insertion of a short, hollow, lighted tube called an anoscope to visualize the area] . . .but patient was not tolerable to this exam. . .I consulted the on-call general surgeon, [MD B]".

During a review of Patient 1's "CT Abdomen and Pelvis" dated 4/28/25, exam indicated, "Findings: Bowel: 1.9cm linear radiodensity regional to the anus".

During an interview on 7/7/25, at 2:32 p.m., with MD A, MD A stated, he was the emergency department provider for Patient 1 on 4/27/25. MD A stated, he attempted to perform the anoscopy to see the foreign body in Patient 1, but Patient 1 was unable to tolerate the procedure. MD A stated, he then consulted the general surgeon who had just left the hospital and came back to see Patient 1. MD A stated, MD B told him to transfer the patient to Facility B. MD A stated, he can do an anoscopy exam under procedural sedation [technique used to help patients relax during medical procedures. It involves administering medication that can range from minimal to deep sedation, reducing pain, and anxiety] but deferred to MD B's decision.

During a review of Patient 1's "General Surgery Consult Note", dated 4/29/25, by MD B, at 2:40 am, note indicated, "I d/w [discussed with] her in presence of her nurse [Nurse C]. . .[MD A] tried to do an endoscope [anoscopy] and it was unsuccessful too. . .I would suggest to perform vaginal exam and also consult to check her vagina. If there is no FB at her vagina. We can transfer to [Facility B] to have a colorectal surgeon with EUS [Endoscopic Ultrasound- a medical device that combines endoscopy and ultrasound to visualize the digestive tract and surrounding organs, aiding in diagnosis and treatment] to be able to find the FB".

During an interview on 7/7/25, at 12:51 p.m., with MD B, MD B stated, "CT showed foreign body there was a concern in would in the perianal [the area of skin surrounding the anus] to the rectum and [Patient 1] has a lot of pain, we couldn't do any rectal exam. I told her we need some type of colorectal [refers to the colon (large intestine) and rectum] surgery and we need EUS to look the FB". MD B stated, he has performed numerous exams under anesthesia for removal of foreign bodies in the rectum/anus. MD B stated, "We have to put the scope in. . .the EUS and take a look in the rectum, if something penetrated in the area I need an US [ultrasound] to see the area, and then figure out how to take it out. I don't have the ability to do that".

During a review of MD B's "Clinical Privileges" (Clinical privileges are the permissions granted to healthcare professionals to provide specific medical services within a particular healthcare facility) Dated 2024-2026 indicated, MD B was granted privileges for "General Surgery. . . Core privileges for General Surgery include the ability to admit, evaluate, diagnose, consult, and provide pre[before]-, intra-[during], and postoperative [after surgery] care and perform surgical procedures for patients of all ages to correct or treat various conditions"

During a review of facility 's on call list dated 4/27/25-4/28/25 indicated, the on-call colorectal surgeon was MD D.

During an interview on 7/8/25, at 12:00 p.m., with MD C, MD C stated, he was the on call Gastroenterology surgeon [specializes in surgical procedures of the digestive system] on 4/27/25-4/28/25. MD C stated, he was not consulted regarding any foreign body cases. MD C, his specialty is available to assist the general surgeon on cases of foreign body they may need help with. MD C stated, if a foreign body penetrated into soft tissues it would be hard to perform an endoscopy, sometimes the general surgeon will call us. MD C stated, they can sedate the patient to assist with the procedure.

During an interview on 7/8/25, at 9:12 a.m., with MD D, MD D stated, he was a gastroenterology surgeon. MD D stated, the facility here does have an endoscopic ultrasound.

During an interview on 7/8/25, at 9:50 a.m., with Chief of General Surgery (CGS), CGS stated, both MD A, and MD B were unable to visualize the foreign body during their anoscopy exam due to patient discomfort. CGS stated, the next steps could have been to offer procedural sedation, or do an exam under anesthesia. CGS stated, he read the CT scan and the assumption would have been that the foreign body is in the anus. CGS stated, it is in the scope of practice as a general surgeon to perform an exam under anesthesia to look for the foreign body.

During an interview on 7/1/25, at 11:28 a.m., with MD E, MD E stated, he is an emergency department physician at Facility A. MD E stated, if a patient is not able to tolerate an anoscopy procedure, "you don't want to delay care". It could be completed in the OR [operating room]. You can do procedural sedation also. MD F stated, the next step if the patient cannot tolerate the anoscopy would be to do the procedure under sedation or in the OR.

During a review of Patient 1's "Emergency Transfer Notification" dated 4/28/25, at 0506 a.m., document indicated, "Physician Authorization 2. Reason for Transfer Need for higher level of care than provided at [Facility A]".

During a review of a recorded phone call between MD B and MD F dated 4/28/25, phone call indicated, a physician to physician phone call occurred to explain the reason for the transfer of Patient 1 from Facility A to Facility B. MD F stated, he was a general surgeon at Facility B and needed clarification of why the transfer was necessary. MD F stated, if we accepted the patient (Patient 1) "we would just put the patient under general anesthesia and take a look". MD F stated, "the problem is I don't have the experience for the EUS and I don't want to something I cannot do that [sic] I never did this". MD F stated, "an exam under anesthesia [is a medical procedure where a patient undergoes an examination while under anesthesia to allow for a more thorough and comfortable assessment] is a standard general surgery operation, I'm just trying to understand, we would not take them [Patient 1] for an ultrasound, we would just take them to the OR [operating room] and just put them under general anesthesia". MD B stated, "The point is the foreign body is not just the anus". MD F stated, "So we would just take the patient to the OR and look under anesthesia, this is a very standard general surgery operation, so I'm just wondering why on a recorded line why you as a general surgeon feel like you're unable to do this operation". MD B stated, "Yeah I told them because we did an anoscope to take a look at that and it goes through the vagina and I'm not sure from the just anoscope I don't have anything to do that [sic] I need somebody with access if they cannot find it they can get the EUS to see where it is there. If its in the anus I can go and find that a lot of foreign body I have removed from the anus but this is not inside the of the anus this is something inside the perineal [he area of the body between the anus and the external genitalia] area and we don't know where is that [sic] ". MD F stated, "So as a general surgeon you feel you're not able to handle this perianal". MD B stated, "No I can't", if this is inside the anus I can. . .we don't know which part of the tissue it is". MD F stated, "Ok, we'll take this patient". The recorded phone call indicated, MD B left the line, while MD F spoke with Staff Member (SM) G. MD F stated, we can find out if this is an EMTALA violation or not once the patient gets here. SM G stated, "I've heard some other surgeons say, I'm sorry you're a general surgeon if you're board certified you should be able to take care of this".

During an interview on 7/8/25 at 1p.m., with MD F, MD F stated, he was a general surgeon at Facility B. MD F stated, his facility got a request for transfer of Patient 1 so for a foreign body in the anal area. MD F stated, he requested to speak with the transferring surgeon to ask why they were not able to treat the patient. MD F stated, in his clinical opinion, as a surgeon for Patient 1's case you would not need an endoscopic ultrasound. MD F stated, if a patient is not able to tolerate an anoscopy procedure the next step would be to perform an exam under anesthesia and any board certified general surgeon is able to perform this procedure.

During a review of Patient 1's "Operative Report" dated 4/28/25 at 4:48 p.m., Report indicated, ""Procedure: Rectal exam under anesthesia, removal of foreign body. . .findings: 2cm chicken bone approximately 3 cm from the anal verge [end of the anal canal and the point where stool exits the body]".

During an interview with Patient 1 on 7/16/25, at 106 p.m., Patient 1 stated, she went to Facility A's Emergency Department with severe 10/10 pain in her rectum and abdomen. "To be honest it was the worst experience of my life". Patient 1 stated, MD A attempted to look inside my behind to see, but it was too painful, so he called the surgeon (MD B). Patient 1 stated, the surgeon (MD B) could not do the procedure either because it was too painful, I've been through childbirth and this was worse. Patient 1 stated, MD B left the room and didn't say anything to me after the attempt. Patient 1 stated, the ED Doctor (MD A) came back in and told her "I'm going to be honest with you he [MD B] said to send you home, but we need to take care of your emergency, if you leave you will just come back in a few hours, so I'm going to call the ambulance and have you sent to [Facility B]". Patient 1 stated, the facility never offered to give her sedation or to perform surgery to find out what was causing her pain. Patient 1 stated, "[MD A] told me the reason I'm sending you to [Facility B] is because the surgeon doesn't want to deal with you".

During a review of the facility's Policy and Procedure (P&P) titled, "Compliance with Emergency Medical Treatment and Active Labor Act (EMTALA)", dated 2025 the P&P indicated, "It is the policy of [Facility A] to comply with state and federal laws regarding EMTALA in accordance with the policy below. . .D. Patient who have an EMC 1. When a Physician or Qualified Medical Professional determines that the patient has an EMC the hospital shall: a within the capability of the staff and facilities, provide further medical examination and treatment as required to stabilize the patients EMC".