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Based on facility policy review, medical record review, and interview, the facility failed to provide a medical screening exam, failed to provide stabilizing treatment, and failed to provide an appropriate transfer for 1 patient (#1) of 33 Emergency Department patients reviewed.

Refer to A-2406 for failure to provide a medical screening exam

Refer to A-2407 for failure to provide stabilizing treatment

Refer to A-2409 for failure to provide an appropriate transfer

Based on facility policy review, medical record review, and interview, the facility failed to provide available treatment and medication for 1 patient (Patient #1) after a snake bite of 33 Emergency Department (ED) patients reviewed.

The findings include:

Review of Facility A's policy titled "Registration and EMTALA (Emergency Medical Treatment and Labor Act) Compliance" revised 6/2016 showed "...It is the policy...for all patients to be medically screened for severity of illness by a qualified...physician...The medical screening exam will be performed by the ED physician..."

Review of Facility A's policy titled "Emergency Department Transfers" revised 6/2016 showed "...REACHING THE TRANSFER DECISION...It is the policy...to prevent any patient from being arbitrarily transferred to another facility...If the patient has an emergency medical condition or is in active labor, emergency treatment will be initiated and the patient maximally stabilized within the resources available before transfer..."

Patient #1 presented to the ED at Facility A on 6/21/2019 at 11:45 PM with complaint of being bitten by a copperhead snake 20 minutes prior to arrival to the ED. Patient #1 complained of pain in the left foot and rated her pain as an 8 on a scale from 1 to 10 (10 equals worse pain). Patient #1's left foot was swollen and tender and had one bite mark.

Medical record review of an ED Nurse's note at Facility A dated 6/21/2019 at 11:50 PM showed Patient #1 told the facility she contacted poison control and was directed to go to the nearest hospital for treatment and antivenom. The patient was advised by the facility that the antivenom was available at the facility, but the physician was uncomfortable with the administration of the antivenom due to possible adverse reactions.

Medical record review of an ED Nurse's note at Facility A dated 6/22/2019 at 12:10 AM showed Patient #1 told the facility she was going to leave and go to another acute care facility. Patient #1 left Facility A on 6/22/2019 at 12:15 AM.

Medical record review showed no documentation laboratory diagnostic tests were completed for Patient #1 at Facility A.

Medical record review of an ED Physician's note at Facility A dated 6/22/2019 at 3:01 AM (2 hours and 51 minutes after Patient #1 left Facility A) showed "...The patient appears alert, in obvious distress, moderately distressed...Extremities: noted in the left foot: erythema [redness], puncture, swelling, tenderness...severe pain noted...can bear weight with assistance only..."

Medical record review of a discharge note at Facility A dated 6/22/2019 at 3:09 AM (2 hours and 59 minutes after Patient #1 left Facility A) showed Patient #1's diagnosis was Toxic Effect of Unspecified Snake Venom, accidental.

Medical record review showed Patient #1 presented to the ED at Facility C via private vehicle on 6/22/2019 at 1:16 AM with chief complaint of snakebite to the left foot and complained of swelling and tingling to the left foot and calf. The patient was admitted to Facility C and was discharged home on 6/24/2019.

Medical record review of an ED Physician's History and Physical at Facility C dated 6/22/2019 at 1:30 AM showed "...Patient reports she was bit by a snake...believes it was a copperhead...Patient reports she went to [Facility A]...She reports an IV (intravenous line) was placed, but she was discharged and told to come to this facility...symptoms are worsening...Review of Systems...had redness and some bruising on the left inner ankle...has left leg edema and left leg pain...Musculoskeletal/Extremities...skin puncture with some bruising and oozing some blood on the left inner ankle...foot diffusely swollen...extending up into the calf ..."

During an interview on 7/2/2019 at 1:25 PM, the ED Director at Facility A stated the facility had antivenom available.

During a telephone interview on 7/2/2019 at 1:55 PM Physician #1 at Facility A stated he was concerned about the side effects of the antivenom and felt it would be best to transfer the patient to another facility. Physician #1 confirmed antivenom was not administered to Patient #1 at Facility A.

During an interview on 7/2/2019 at 2:35 PM the Pharmacy Director at Facility A stated the facility stored 8 vials of antivenom in the ED.

During a telephone interview on 7/2/2019 at 7:15 PM Patient #1 stated Physician #1 told her there was no antivenom in the hospital, but the nurse acted as though the antivenom was available. Patient #1 stated she went to Facility C where she was admitted to the Intensive Care Unit and received antivenom.

During a telephone interview on 7/2/2019 at 7:35 PM Registered Nurse #1 at Facility A stated Physician #1 asked if antivenom was available at the hospital and he was informed it was available, but he was uncomfortable with administering the antivenom and preferred the patient be transferred to another facility.

Based on facility policy review, medical record review, and interview, the facility failed to provide stabilizing treatment and an appropriate transfer after a snake bite and failed to document an informed refusal of treatment for 1 patient (Patient #1) after a snakebite of 33 Emergency Department (ED) patients reviewed.

The findings include:

Review of Facility A's policy titled "Emergency Department Transfers" revised 6/2016 showed "...REACHING THE TRANSFER DECISION...It is the policy...to prevent any patient from being arbitrarily transferred to another facility...If the patient has an emergency medical condition or is in active labor, emergency treatment will be initiated and the patient maximally stabilized within the resources available before transfer...TRANSFER PROCEDURE...The physician will discuss the risks and benefits of appropriate transfer to the patient, family or legal representative and have the consent signed. The patient must be accompanied by an individual whose level of training and skill is appropriate to the patient's needs...RESPONSIBILITIES OF TRANSFERRING FACILITY Render emergency care and obtain maximum stabilization within the resources available...Obtain consent from patient or family for transfer and release of medical records. Complete a Patient Transfer Form. A copy goes with the patient, and the original is attached to the patient's permanent chart..."

Patient #1 presented to the ED at Facility A on 6/21/2019 at 11:45 PM with complaint of being bitten by a copperhead snake 20 minutes prior to arrival to the ED. Patient #1 complained of pain in the left foot and rated her pain as an 8 on a scale from 1 to 10 (10 equals worse pain). Patient #1's left foot was "...swollen and tender, 1 bite mark noted..."

Medical record review of an ED Nurse's note at Facility A dated 6/21/2019 at 11:50 PM showed Patient #1 told the facility she contacted poison control and was directed to go to the nearest hospital for treatment and antivenom. The patient was advised by the facility that the antivenom was available at the facility, but the physician was uncomfortable with the administration of the antivenom due to possible adverse reactions.

Medical record review of an ED Nurse's note at Facility A dated 6/22/2019 at 12:10 AM showed Patient #1 told the facility she was going to leave and go to another acute care facility. Patient #1 left Facility A on 6/22/2019 at 12:15 AM.

Medical record review showed no documentation of a written informed refusal of treatment for Patient #1 (form indicating the patient is leaving against medical advice) at Facility A.

Medical record review of an ED Physician's note at Facility A dated 6/22/2019 at 3:01 AM (2 hours and 51 minutes after Patient #1 left Facility A) showed "...The patient appears alert, in obvious distress, moderately distressed...Extremities: noted in the left foot: erythema [redness], puncture, swelling, tenderness...severe pain noted...can bear weight with assistance only..."

Medical record review of a discharge note at Facility A dated 6/22/2019 at 3:09 AM (2 hours and 59 minutes after Patient #1 left Facility A) showed Patient #1's diagnosis was Toxic Effect of Unspecified Snake Venom, accidental.

Medical record review showed Patient #1 presented to the ED at Facility C via private vehicle on 6/22/2019 at 1:16 AM with chief complaint of snake bite to the left foot and complained of swelling and tingling to the left foot and calf. The patient was admitted to Facility C and discharged home on 6/24/2019.

During an interview on 7/2/2019 at 1:25 PM, the ED Director at Facility A stated the facility had antivenom available.

During a telephone interview on 7/2/2019 at 1:55 PM Physician #1 at Facility A stated he was concerned about the side effects of the antivenom and felt it would be best to transfer the patient to another facility. Physician #1 confirmed antivenom was not administered to Patient #1 at Facility A.

During a telephone interview on 7/2/2019 at 7:15 PM Patient #1 stated Physician #1 told her there was no antivenom in the hospital, but the nurse acted as though the antivenom was available. Patient #1 stated she was not asked to sign any documents stating she was leaving against medical advice. Patient #1 stated she went to Facility C on her own where she was admitted to the Intensive Care Unit and received antivenom.

During a telephone interview on 7/2/2019 at 7:35 PM Registered Nurse (RN) #1 at Facility A stated Physician #1 asked if antivenom was available at the hospital and he was informed it was available, but he was uncomfortable with administering the antivenom and preferred to transfer the patient. RN #1 stated Patient #1 did not receive antivenom prior to leaving the facility.

Based on facility policy review, medical record review, and interview, the facility failed to provide written documentation of the risks and benefits of a transfer for 1 patient (Patient #1) with a snakebite of 33 Emergency Department (ED) patients reviewed.

The findings include:

Review of Facility A's policy "Emergency Department Transfers" revised 6/2016 showed "...THE TRANSFER DECISION... TRANSFER PROCEDURE...The physician will discuss the risks and benefits of appropriate transfer to the patient, family or legal representative and have the consent signed...RESPONSIBILITIES OF TRANSFERRING FACILITY Render emergency care and obtain maximum stabilization within the resources available...Obtain consent from patient or family for transfer and release of medical records. Complete a Patient Transfer Form. A copy goes with the patient, and the original is attached to the patient's permanent chart..."

Patient #1 presented to the ED at Facility A on 6/21/2019 at 11:45 PM with complaint of being bitten by a copperhead snake 20 minutes prior to arrival to the ED. Patient #1 complained of pain in the left foot and rated her pain as an 8 on a scale from 1 to 10 (10 equals worse pain). Patient #1's left foot was "...swollen and tender, 1 bite mark noted..."

Medical record review of an ED Nurse's note at Facility A dated 6/21/2019 at 11:50 PM showed Patient #1 told the facility she contacted poison control and was directed to go to the nearest hospital for treatment and antivenom. The patient was advised by the facility that the antivenom was available at the facility, but the physician was uncomfortable with the administration of the antivenom due to possible adverse reactions.

Medical record review of an ED Nurse's note at Facility A dated 6/22/2019 at 12:10 AM showed Patient #1 told the facility she was going to leave and go to another acute care facility. Patient #1 left Facility A on 6/22/2019 at 12:15 AM

Medical record review showed no documentation of a written informed refusal of treatment for Patient #1 (form indicating the patient is leaving against medical advice) at Facility A.

Medical record reviewed showed no written documentation the risks and benefits of a transfer to another acute care facility were explained to Patient #1.

Medical record review showed Patient #1 presented to the ED at Facility C via private vehicle on 6/22/2019 at 1:16 AM with chief complaint of snake bite to left foot. Patient #1 complained of swelling and tingling of left foot and calf. The patient was admitted to Facility C and discharged home on 6/24/2019.

During a telephone interview on 7/2/2019 at 1:55 PM Physician #1 at Facility A stated he was concerned about the side effects of the antivenom and felt it would be best to transfer the patient to another facility.

During a telephone interview on 7/2/2019 at 7:15 PM Patient #1 stated there was no discussion with the Physician or the Nurse regarding the risks and benefits of a transfer.