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Based on interviews and record review, the facility failed to provide an appropriate stabilization for one of 21 sampled patients (Patient 1) when Patient 1 presented to the Emergency Department (ED - the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment.

This deficient practice resulted in the facility failing to provide further medical examination with a consulting general surgeon, in order to stabilize patient with emergency surgery to potentially stop the internal bleeding. (Refer to A-2407)



Findings:

A review of Patient 1 ' s face sheet (a document that provides a quick overview of key information about a person), dated 5/25/2025, indicated patient was admitted to the emergency department (ED – emergency room providing 24/7 unscheduled medical care to patients with urgent or life-threatening conditions) at 4:38 p.m., for ectopic pregnancy (a pregnancy that develops outside of the uterus, which is not viable and requires medical treatment).

A review of Patient 1 ' s Emergency Department (ED) Triage Nursing Notes and Nursing Flowsheet, dated 5/25/2025, indicated:

Patient arrived at 12:26 p.m.

At 12:33 p.m., triage vital signs were blood pressure (BP) of 103 /58 millimeters of mercury (mmHg), heart rate (HR) was 99 beats per minute (bpm), respiratory rate (RR) was 22 breaths per minute (bpm), temperature was not obtained, oxygen (O2) saturation was 100% on room air, and pain was the worse pain ever with a score of 10 out of 10.

Patient was classified with an Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care to prioritize patients for treatment, ensuring that those with the most urgent needs are seen first) of 2 – which is emergent(medical condition present an immediate threat to life, limb(arm or leg)or eyesight, that requiring prompt and potentially life-saving intervention).



A review of Patient 1 ' s pregnancy test, dated 5/25/2025, indicated a human chorionic gonadotropin (hCG – a hormone produced by the placenta during pregnancy with levels measured in the blood or urine to confirm pregnancy) level of 4367 mIU/ml.

A review of Patient 1 ' s Transvaginal ultrasound, dated 5/25/2025, indicated a live ectopic pregnancy at an estimated gestational age of five weeks and 4 days, with complex fluid seen in the pelvis – consistent with ruptured ectopic gestation, which was reported to Emergency Department Physician 1 (ED 1).



A review of Patient 1 ' s physician orders dated 5/25/2025, indicated:

norepinephrine 4 mcg per minute IV without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ' s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg.

Red blood cells (RBC ' s) two units to be given right away (STAT) and massive transfusion protocol.

Two (2) units of RBC ' s STAT and one (1) unit of fresh frozen plasma (FFP – a blood product containing various clotting factor and other plasma proteins to treat bleeding disorders) STAT.

One (1) unit of platelets (blood product that plays a crucial role in blood clotting and stopping bleeding) at 2:53pm.

Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm.

Labs to check for anemia at 3:55pm.



A review of Patient 1 ' s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated:

From 2:04 p.m. to 2:26 p.m., patient received 500 milliliters (ml) of RBC ' s.

From 3:02 p.m. to 3:21 p.m., patient received 2 units of RBC ' s.

Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm.

From 3:45 p.m. to 3:51 p.m., patient received 1 unit of platelets.

At 3:48 p.m., patient received 1 unit of FFP.



On 6/26/2025, at 8:35 a.m., interview with Nursing Services Director of Emergency Department (NSED) and Emergency Department Educator (EDE), EDE stated At 4:19 p.m., patient ' s hemoglobin (Hgb – a protein component in the RBC that carries oxygen from the lungs to the tissues) was 6.4 (normally 12-17.5 grams per deciliter) and hematocrit (the percentage of volume of red cells in the blood) was 19.9 (normally 36-44%). And the Patient received IV transfusion (the process of transferring blood or blood components into the blood stream to replace blood or blood products lost due to severe bleeding) summary, dated 5/25/2025, EDE stated the following blood products were administered to the patient: RBC 278 milliliters (ml – one-thousandth of a liter), Platelets 334 ml, RBC 500 ml x 4. And ED 1 did not order any consultations for general surgery.



A review of Patient 1 ' s vital signs (measurable physiological indicators that reflect a person ' s basic bodily functions including temperature, pulse rate, respiratory rate, blood pressure (BP), oxygen saturation) dated 5/25/2025, indicated:

12:32 p.m., BP was 100/58, HR was 99, RR was 18, O2 saturation was 100% on room air.

At 12:50 p.m., BP was lower at 88/54, HR was 100, RR was 20, O2 saturation was 100% on room air.

At 1:00 p.m., BP was lower at 86/50, HR was 80, RR was 22, O2 saturation was 100% on room air, and temperature was 97.2 degrees Fahrenheit.

At 1:35 p.m., BP was 98/74, HR was 86, RR was 22, O2 saturation was 100% on oxygen by nasal cannula (a medical device that provides supplemental oxygen therapy) at 2 liters per minute (lpm).

1:45 p.m., BP was lower at 66/42, HR was 78, RR was 17, O2 saturation was 99% on oxygen by nasal cannula at 2 lpm.

2:44 p.m., BP was 94/53.

3:17 p.m., BP was 107/74.

8. 3:36 p.m., BP was 127/74.

9. 3:51 p.m., BP was 113/56.

10. 4:19 p.m. BP 108/56, HR 93, O2 saturation 99% on nasal cannula at 2 lpm, temperature 97.7 degrees Fahrenheit



On 6/26/2025, at 3:34 PM, during an interview with the Chief of the Emergency Department (CED), the CED stated a patient is not considered to be stable if they are on a norepinephrine drip (medication used to increase blood pressure) during transfer. The CED stated, regarding Patient 1, he had called several different doctors at the surrounding facilities, but they would not accept the patient due to the physical distance of transport. The CED stated he understood that without first receiving acceptance from the receiving facility, the transferring facility would be at fault for sending a patient to a facility with no capacity to accept the patient.

Concurrently, during review of Patient 1 ' s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated norepinephrine 4 mcg per minute IV was ordered and administered without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ' s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg.



On 6/26/2025, at 4:01 PM, during an interview with the Emergency Department Physician 1 (ED 1), the ED 1 stated, to treat a ruptured (breaking of vessel or membrane) ectopic pregnancy (can be life threatening; a pregnancy that occurs outside the uterus and cannot be carried to term) he would need to stabilize the patient by keeping the blood pressure in normal range and by stopping the bleeding. The ED 1 stated, this medical condition would require surgical intervention, which the patient would have to be transferred out from the facility to another facility that had the capability of treating such condition.

On 6/27/2025, at 10:54 AM, during an interview with the Chief of General Surgery (CGS), the CGS stated, generally, a general surgeon should be able to handle a patient that comes into the emergency room and is bleeding. The DGS stated that the facility ' s general surgeon should be competent enough to stop a patient from bleeding. The CGS also stated with a patient who is unstable and has a ruptured ectopic pregnancy, a general surgeon is compelled (force to do something) to intervene (to step in) the best they can for that patient at the facility in an attempt to salvage (to rescue) the patient.



A review of Patient 1 ' s Emergency Department (ED) Physician record, dated 5/25/2025, indicated:

Arrived by private vehicle to the ED with complaint of abdominal pain with nausea and vomiting, vaginal bleeding heavier than usual, and worsening pain.

Active problems included abnormal pelvic ultrasound.

Physical examination with diffused abdominal tenderness.

Transvaginal ultrasound (a common and safe imaging technique used in early stages of pregnancy to visualize the pelvic organs, including the uterus, ovaries and cervix, to confirm early pregnancy and to monitor for potential complications) indicated a mass noted in the right area beside the uterus which was consistent with a live ectopic pregnancy (a pregnancy that occurs outside the uterus and that cannot be carried to term with an embryo identified, which can be life threatening).

Consulting services for obstetrics and gynecology (OB/GYN - medical doctor specializing in both obstetrics for pregnancy and gynecology for female reproductive health) were contacted from other facilities, with intent for transfer to a facility capable of stabilizing and treating patient with patient unstable for discharge.

General surgeon was not consulted for this patient.

Massive transfusion protocol initiated for hemorrhagic shock (a critical condition where severe blood loss leads to inadequate oxygen and nutrient delivery to the body – potentially causing organ damage or death), due to ruptured ectopic pregnancy (a serious life-threatening condition where a fertilized egg implanted outside the uterus and ruptured, leading to internal bleeding and shock, requiring immediate medical intervention, including surgery).

Intravenous (IV - into a vein) medications given, included norepinephrine (medication used to increase blood pressure) 4 micrograms (mcg – a unit of mass – one millionth of a gram) per minute, normal saline boluses.

IV blood products given included fresh frozen plasma (FFP – a blood product used to treat bleeding disorders), platelets (thrombocytes – blood cells to improve patient ' s ability to clot blood), and packed red blood cells (RBC - blood cells to increase a patient ' s oxygen carrying capacity and treat blood loss).

Patient will be transferred by 9-1-1 to another facility due to medical necessity with inherent risks and benefits of transfer discussed with patient and family.

Disposition – patient care transferred to another facility for higher acuity of care.



On 6/27/2025, at 2:15 PM, during an interview with the General Surgeon (GS), the GS stated, if there was no other way to transfer a patient with a ruptured ectopic pregnancy out of the facility to another receiving facility, he, as a general surgeon, would have decided to pack the abdomen as a means of stabilizing (secure) the patient for transportation. The GS stated he would have opened the abdomen (the belly area) and placed packs to tamponade (the surgical use of a plug of absorbent material) the bleeding and had the patient transferred to a trauma facility with the abdomen left open. The GS also stated he was not notified for consultation (meeting) regarding Patient 1 ' s case on 5/25/2025, when he was scheduled for general surgery.

A review of facility ' s Emergency Department Physician Call Schedule, dated May 2025, GS was scheduled for general surgery on 5/25/2025.



A review of Patient 1 ' s Assessment Forms (calls and communication for the patient), dated 5/25/2025, indicated the following:

At 12:54 p.m., Code Sepsis paged.

2:51 p.m., potential receiving facility indicated patient was too critical to transfer out.

3:04 p.m., massive blood transfusion was overhead paged.

3:28 p.m., potential receiving facility indicated patient is too critical to transfer.

3:51 p.m., patient was being 9-1-1 transferred out.

Transfer to another facility at 4:19 p.m. with a diagnosis of hemorrhagic shock and ruptured ectopic pregnancy.



A review of facility ' s Emergency Department (ED) Triage and Medical Screening Guidelines, dated 12/2024, indicated the following:

Triage is the process of collecting pertinent information about patients who are seeking emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity-designation system.

Facility uses a Five-Level scale called Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care; used to prioritize patients for treatment, ensuring that those with the most urgen needs are seen first) and references the most updated version of the Emergency Nurses Association (ENA – an accredited organization providing nursing professionals continuing development by the American Nurses Credentialing Center ' s Commision on accreditation).

Patients arriving to the ED will be triaged by an ESI triage-trained ED registered nurse (RN) to determine the patient ' s ESI level, after the ED triage RN performed the initial assessment after obtaining the five elements:

chief complaint

Allergies

vital signs – measurable physiological indicators that reflect a person ' s basic bodily functions to provide essential information about the person ' s health status and to help identify potential medical conditions, including temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation

Pain level

Height and weight

4. ED triage RN will consider the five elements and will assign the ESI level based on the decision points of the ENA criteria.

5. ESI level 1 and 2 are conditions which may result in loss of life or limb, if not treated immediately, including cardiac arrest (sudden unexpected loss of heart function, breathing, and consciousness), shock, gun-shot wounds, imminent delivery of a newborn.

6. ESI level 3 are conditions that require care, but will not generally cause loss of life, permanent or severe impairment, if untreated for one to three hours, including vomiting, diarrhea, childhood fever, vaginal bleeding in the first three months of pregnancy with stable vital signs and minimal bleeding.

7. All patients, who come to the ED and are ill or injured, are entitled to a medical screening examination (MSE – the initial assessment performed in an ED to determine if a patient has an emergency medical condition), regardless of insurance status, including a general and focused assessment based on the patient ' s symptoms by a qualified medical professional, continuous monitoring until stabilized, and treatment until stabilized.

8. Pregnant patients with suspected ectopic pregnancy (a pregnancy that develops outside of the woman ' s uterus and requires medical intervention to prevent serious complications, including internal bleeding which is potentially life-threatening).

A review of facility ' s Transfer of Patients – EMTALA policy, dated 3/18/2025, indicated the following:

Emergency department (ED) triages patients to the most appropriate area within the department for medical screening or based on medical/age-based criteria to another department for medical screening.

Medical Screening Examination (MSE) is the process requiring determining, with reasonable clinical confidence, whether an emergency medical condition (EMC) exists or a woman is in labor, which is documented in the patient ' s medical record, by a physician or qualified medical person, with additional screening and treatment performed to stabilize the emergency medical condition.

Stable for transfer – a patient is stable for transfer if the treating physician attending to the patient had determined that the patient is expected to leave the hospital and be received at the second facility, with no material deterioration in medical condition, and the treating physician reasonably believes the receiving facility has the capability to manage the patient ' s medical condition and any reasonably foreseeable complication of that condition.

Stabilize – providing medical treatment of the patient ' s condition necessary to assure that no material deterioration of the condition is likely to result from or occur during transfer of the patient from a facility, including a woman in labor.

Transfer – movement of a patient to another facility at the direction of any person employed by the facility to a higher level of care.

All transfers will be documented on a Transfer form with physician ' s evaluation of patient ' s condition at the time of transfer, signature of transferring physician, name of accepting physician for patient to be transferred to, informed consent by the patient/family (after being informed of the reasons for transfer and risks/benefits of transfer) with patient ' s signature.

A review of facility ' s Massive Blood Transfusion policy, dated 3/18/2025, indicated the following:

Purpose – to provide blood/blood components for massively transfused patients in the emergency department, operating room, and intensive care unit.

To manage patients at risk of bleeding for blood component replacement during the bleeding episode with replacement of patient ' s entire blood volume within a 24-hour period.

Activation with the attending physician ordering massive transfusion protocol by a telephone call to the blood bank, after initial laboratory testing, including type and screen.

Based on interviews and record review, the facility failed to provide an appropriate stabilization for one of 21 sampled patients (Patient 1) when Patient 1 presented to the Emergency Department (ED - the department of a hospital that provides immediate treatment for acute illnesses and trauma) seeking treatment.

This deficient practice resulted in the facility failing to provide further medical examination with a consulting general surgeon, in order to stabilize patient with emergency surgery to potentially stop the internal bleeding.



Findings:

A review of Patient 1 ' s face sheet (a document that provides a quick overview of key information about a person), dated 5/25/2025, indicated patient was admitted to the emergency department (ED – emergency room providing 24/7 unscheduled medical care to patients with urgent or life-threatening conditions) at 4:38 p.m., for ectopic pregnancy (a pregnancy that develops outside of the uterus, which is not viable and requires medical treatment).

A review of Patient 1 ' s Emergency Department (ED) Triage Nursing Notes and Nursing Flowsheet, dated 5/25/2025, indicated:

Patient arrived at 12:26 p.m.

At 12:33 p.m., triage vital signs were blood pressure (BP) of 103 /58 millimeters of mercury (mmHg), heart rate (HR) was 99 beats per minute (bpm), respiratory rate (RR) was 22 breaths per minute (bpm), temperature was not obtained, oxygen (O2) saturation was 100% on room air, and pain was the worse pain ever with a score of 10 out of 10.

Patient was classified with an Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care to prioritize patients for treatment, ensuring that those with the most urgent needs are seen first) of 2 – which is emergent(medical condition present an immediate threat to life, limb(arm or leg)or eyesight, that requiring prompt and potentially life-saving intervention).



A review of Patient 1 ' s pregnancy test, dated 5/25/2025, indicated a human chorionic gonadotropin (hCG – a hormone produced by the placenta during pregnancy with levels measured in the blood or urine to confirm pregnancy) level of 4367 mIU/ml.

A review of Patient 1 ' s Transvaginal ultrasound, dated 5/25/2025, indicated a live ectopic pregnancy at an estimated gestational age of five weeks and 4 days, with complex fluid seen in the pelvis – consistent with ruptured ectopic gestation, which was reported to Emergency Department Physician 1 (ED 1).



A review of Patient 1 ' s physician orders dated 5/25/2025, indicated:

norepinephrine 4 mcg per minute IV without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ' s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg.

Red blood cells (RBC ' s) two units to be given right away (STAT) and massive transfusion protocol.

Two (2) units of RBC ' s STAT and one (1) unit of fresh frozen plasma (FFP – a blood product containing various clotting factor and other plasma proteins to treat bleeding disorders) STAT.

One (1) unit of platelets (blood product that plays a crucial role in blood clotting and stopping bleeding) at 2:53pm.

Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm.

Labs to check for anemia at 3:55pm.



A review of Patient 1 ' s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated:

From 2:04 p.m. to 2:26 p.m., patient received 500 milliliters (ml) of RBC ' s.

From 3:02 p.m. to 3:21 p.m., patient received 2 units of RBC ' s.

Norepinephrine (a medication used to raise the blood pressure with severe low blood pressures) 8 mg by intravenous (IV – by way of vein) STAT for a low BP 56/37, at 3:06pm.

From 3:45 p.m. to 3:51 p.m., patient received 1 unit of platelets.

At 3:48 p.m., patient received 1 unit of FFP.



On 6/26/2025, at 8:35 a.m., interview with Nursing Services Director of Emergency Department (NSED) and Emergency Department Educator (EDE), EDE stated At 4:19 p.m., patient ' s hemoglobin (Hgb – a protein component in the RBC that carries oxygen from the lungs to the tissues) was 6.4 (normally 12-17.5 grams per deciliter) and hematocrit (the percentage of volume of red cells in the blood) was 19.9 (normally 36-44%). And the Patient received IV transfusion (the process of transferring blood or blood components into the blood stream to replace blood or blood products lost due to severe bleeding) summary, dated 5/25/2025, EDE stated the following blood products were administered to the patient: RBC 278 milliliters (ml – one-thousandth of a liter), Platelets 334 ml, RBC 500 ml x 4. And ED 1 did not order any consultations for general surgery.



A review of Patient 1 ' s vital signs (measurable physiological indicators that reflect a person ' s basic bodily functions including temperature, pulse rate, respiratory rate, blood pressure (BP), oxygen saturation) dated 5/25/2025, indicated:

12:32 p.m., BP was 100/58, HR was 99, RR was 18, O2 saturation was 100% on room air.

At 12:50 p.m., BP was lower at 88/54, HR was 100, RR was 20, O2 saturation was 100% on room air.

At 1:00 p.m., BP was lower at 86/50, HR was 80, RR was 22, O2 saturation was 100% on room air, and temperature was 97.2 degrees Fahrenheit.

At 1:35 p.m., BP was 98/74, HR was 86, RR was 22, O2 saturation was 100% on oxygen by nasal cannula (a medical device that provides supplemental oxygen therapy) at 2 liters per minute (lpm).

1:45 p.m., BP was lower at 66/42, HR was 78, RR was 17, O2 saturation was 99% on oxygen by nasal cannula at 2 lpm.

2:44 p.m., BP was 94/53.

3:17 p.m., BP was 107/74.

8. 3:36 p.m., BP was 127/74.

9. 3:51 p.m., BP was 113/56.

10. 4:19 p.m. BP 108/56, HR 93, O2 saturation 99% on nasal cannula at 2 lpm, temperature 97.7 degrees Fahrenheit



On 6/26/2025, at 3:34 PM, during an interview with the Chief of the Emergency Department (CED), the CED stated a patient is not considered to be stable if they are on a norepinephrine drip (medication used to increase blood pressure) during transfer. The CED stated, regarding Patient 1, he had called several different doctors at the surrounding facilities, but they would not accept the patient due to the physical distance of transport. The CED stated he understood that without first receiving acceptance from the receiving facility, the transferring facility would be at fault for sending a patient to a facility with no capacity to accept the patient.

Concurrently, during review of Patient 1 ' s medication administration record (MAR – a crucial document used to track the administration of medications to patients), dated 5/25/2025, indicated norepinephrine 4 mcg per minute IV was ordered and administered without delay (STAT – immediately or at once) with instructions to titrate (the process of gradually adjusting the dosage to achieve the optimal therapeutic effect while minimizing side effects) by 2 mcg per minute every five minutes to a mean arterial pressure (MAP – the average blood pressure in a person ' s arteries) greater than or equal to 65 millimeters of mercury (mmHg – a unit of pressure, used to measure blood pressure) of 65 mmHg.



On 6/26/2025, at 4:01 PM, during an interview with the Emergency Department Physician 1 (ED 1), the ED 1 stated, to treat a ruptured (breaking of vessel or membrane) ectopic pregnancy (can be life threatening; a pregnancy that occurs outside the uterus and cannot be carried to term) he would need to stabilize the patient by keeping the blood pressure in normal range and by stopping the bleeding. The ED 1 stated, this medical condition would require surgical intervention, which the patient would have to be transferred out from the facility to another facility that had the capability of treating such condition.

On 6/27/2025, at 10:54 AM, during an interview with the Chief of General Surgery (CGS), the CGS stated, generally, a general surgeon should be able to handle a patient that comes into the emergency room and is bleeding. The DGS stated that the facility ' s general surgeon should be competent enough to stop a patient from bleeding. The CGS also stated with a patient who is unstable and has a ruptured ectopic pregnancy, a general surgeon is compelled (force to do something) to intervene (to step in) the best they can for that patient at the facility in an attempt to salvage (to rescue) the patient.



A review of Patient 1 ' s Emergency Department (ED) Physician record, dated 5/25/2025, indicated:

Arrived by private vehicle to the ED with complaint of abdominal pain with nausea and vomiting, vaginal bleeding heavier than usual, and worsening pain.

Active problems included abnormal pelvic ultrasound.

Physical examination with diffused abdominal tenderness.

Transvaginal ultrasound (a common and safe imaging technique used in early stages of pregnancy to visualize the pelvic organs, including the uterus, ovaries and cervix, to confirm early pregnancy and to monitor for potential complications) indicated a mass noted in the right area beside the uterus which was consistent with a live ectopic pregnancy (a pregnancy that occurs outside the uterus and that cannot be carried to term with an embryo identified, which can be life threatening).

Consulting services for obstetrics and gynecology (OB/GYN - medical doctor specializing in both obstetrics for pregnancy and gynecology for female reproductive health) were contacted from other facilities, with intent for transfer to a facility capable of stabilizing and treating patient with patient unstable for discharge.

General surgeon was not consulted for this patient.

Massive transfusion protocol initiated for hemorrhagic shock (a critical condition where severe blood loss leads to inadequate oxygen and nutrient delivery to the body – potentially causing organ damage or death), due to ruptured ectopic pregnancy (a serious life-threatening condition where a fertilized egg implanted outside the uterus and ruptured, leading to internal bleeding and shock, requiring immediate medical intervention, including surgery).

Intravenous (IV - into a vein) medications given, included norepinephrine (medication used to increase blood pressure) 4 micrograms (mcg – a unit of mass – one millionth of a gram) per minute, normal saline boluses.

IV blood products given included fresh frozen plasma (FFP – a blood product used to treat bleeding disorders), platelets (thrombocytes – blood cells to improve patient ' s ability to clot blood), and packed red blood cells (RBC - blood cells to increase a patient ' s oxygen carrying capacity and treat blood loss).

Patient will be transferred by 9-1-1 to another facility due to medical necessity with inherent risks and benefits of transfer discussed with patient and family.

Disposition – patient care transferred to another facility for higher acuity of care.



On 6/27/2025, at 2:15 PM, during an interview with the General Surgeon (GS), the GS stated, if there was no other way to transfer a patient with a ruptured ectopic pregnancy out of the facility to another receiving facility, he, as a general surgeon, would have decided to pack the abdomen as a means of stabilizing (secure) the patient for transportation. The GS stated he would have opened the abdomen (the belly area) and placed packs to tamponade (the surgical use of a plug of absorbent material) the bleeding and had the patient transferred to a trauma facility with the abdomen left open. The GS also stated he was not notified for consultation (meeting) regarding Patient 1 ' s case on 5/25/2025, when he was scheduled for general surgery.

A review of facility ' s Emergency Department Physician Call Schedule, dated May 2025, GS was scheduled for general surgery on 5/25/2025.



A review of Patient 1 ' s Assessment Forms (calls and communication for the patient), dated 5/25/2025, indicated the following:

At 12:54 p.m., Code Sepsis paged.

2:51 p.m., potential receiving facility indicated patient was too critical to transfer out.

3:04 p.m., massive blood transfusion was overhead paged.

3:28 p.m., potential receiving facility indicated patient is too critical to transfer.

3:51 p.m., patient was being 9-1-1 transferred out.

Transfer to another facility at 4:19 p.m. with a diagnosis of hemorrhagic shock and ruptured ectopic pregnancy.



A review of facility ' s Emergency Department (ED) Triage and Medical Screening Guidelines, dated 12/2024, indicated the following:

Triage is the process of collecting pertinent information about patients who are seeking emergency care and initiating a decision-making procedure that uses a valid and reliable triage acuity-designation system.

Facility uses a Five-Level scale called Emergency Severity Index (ESI – a system used in the ED to quickly assess and categorize patients based on the severity of their condition and the resources needed for their care; used to prioritize patients for treatment, ensuring that those with the most urgen needs are seen first) and references the most updated version of the Emergency Nurses Association (ENA – an accredited organization providing nursing professionals continuing development by the American Nurses Credentialing Center ' s Commision on accreditation).

Patients arriving to the ED will be triaged by an ESI triage-trained ED registered nurse (RN) to determine the patient ' s ESI level, after the ED triage RN performed the initial assessment after obtaining the five elements:

chief complaint

Allergies

vital signs – measurable physiological indicators that reflect a person ' s basic bodily functions to provide essential information about the person ' s health status and to help identify potential medical conditions, including temperature, pulse rate, respiratory rate, blood pressure, oxygen saturation

Pain level

Height and weight

4. ED triage RN will consider the five elements and will assign the ESI level based on the decision points of the ENA criteria.

5. ESI level 1 and 2 are conditions which may result in loss of life or limb, if not treated immediately, including cardiac arrest (sudden unexpected loss of heart function, breathing, and consciousness), shock, gun-shot wounds, imminent delivery of a newborn.

6. ESI level 3 are conditions that require care, but will not generally cause loss of life, permanent or severe impairment, if untreated for one to three hours, including vomiting, diarrhea, childhood fever, vaginal bleeding in the first three months of pregnancy with stable vital signs and minimal bleeding.

7. All patients, who come to the ED and are ill or injured, are entitled to a medical screening examination (MSE – the initial assessment performed in an ED to determine if a patient has an emergency medical condition), regardless of insurance status, including a general and focused assessment based on the patient ' s symptoms by a qualified medical professional, continuous monitoring until stabilized, and treatment until stabilized.

8. Pregnant patients with suspected ectopic pregnancy (a pregnancy that develops outside of the woman ' s uterus and requires medical intervention to prevent serious complications, including internal bleeding which is potentially life-threatening).

A review of facility ' s Transfer of Patients – EMTALA policy, dated 3/18/2025, indicated the following:

Emergency department (ED) triages patients to the most appropriate area within the department for medical screening or based on medical/age-based criteria to another department for medical screening.

Medical Screening Examination (MSE) is the process requiring determining, with reasonable clinical confidence, whether an emergency medical condition (EMC) exists or a woman is in labor, which is documented in the patient ' s medical record, by a physician or qualified medical person, with additional screening and treatment performed to stabilize the emergency medical condition.

Stable for transfer – a patient is stable for transfer if the treating physician attending to the patient had determined that the patient is expected to leave the hospital and be received at the second facility, with no material deterioration in medical condition, and the treating physician reasonably believes the receiving facility has the capability to manage the patient ' s medical condition and any reasonably foreseeable complication of that condition.

Stabilize – providing medical treatment of the patient ' s condition necessary to assure that no material deterioration of the condition is likely to result from or occur during transfer of the patient from a facility, including a woman in labor.

Transfer – movement of a patient to another facility at the direction of any person employed by the facility to a higher level of care.

All transfers will be documented on a Transfer form with physician ' s evaluation of patient ' s condition at the time of transfer, signature of transferring physician, name of accepting physician for patient to be transferred to, informed consent by the patient/family (after being informed of the reasons for transfer and risks/benefits of transfer) with patient ' s signature.

A review of facility ' s Massive Blood Transfusion policy, dated 3/18/2025, indicated the following:

Purpose – to provide blood/blood components for massively transfused patients in the emergency department, operating room, and intensive care unit.

To manage patients at risk of bleeding for blood component replacement during the bleeding episode with replacement of patient ' s entire blood volume within a 24-hour period.

Activation with the attending physician ordering massive transfusion protocol by a telephone call to the blood bank, after initial laboratory testing, including type and screen.