1. Based on medical record review, review of facility policy and procedures, transfer agreement review and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided and failed to document ongoing monitoring according to individual's needs until stabilized and prior to transfer for 1 of 20 sampled patients. Refer to findings in Tag A-2406. 2. Based on medical record review, staff interview, and review of facility policy and procedure it was determined the facility failed to offer an individual further medical examination and treatment, and failed to inform an individual of the risks and benefits of the examination or treatment or both for 1 (#14) of 20 sampled patients. Refer to findings in Tag A-2407. 3. Based on review of the medical record, transfer center calls review, review of facility's policy and procedure, and staff interview it was determined the facility failed to ensure medical treatment was provided, within its capacity, to minimize risk to an individual's health prior to transfer to another medical facility for one (#3) of twenty-one patients sampled. Refer to findings in Tag A- 2409.

Based on medical record review, review of facility policy and procedures, transfer agreement review and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination was provided and failed to document ongoing monitoring according to individual's needs until stabilized and prior to transfer for 1 of 20 sampled patients. Findings included: 1. Medical Record Reviews Review of the medical record for patient #3 revealed the patient presented to the facility ED (Emergency Department) on 02/15/2018 at 7:46 PM. Documentation stated the patient was a walk-in and the stated medical complaint was hit in head with baseball while playing as pitcher rating pain as 7 out of 10 on a scale of 0 to 10 with 10 being worst pain ever. Review of nursing triage documentation on 02/15/2018 at 7:58 PM documented vital signs of oral temperature 98.9 degrees Fahrenheit, heart rate of 98, blood pressure of 137/87 and respiratory rate of 18 with oxygen saturation of 98 percent of room air. Medical Screening Exam [MSE] initiated at 7:48 PM. Computerized Tomography [CT] scan completed at 8:03 PM "CT Neuro Alert" documents a depressed skull fracture with subdural hematoma with parenchymal contusion involving the left frontal lobe, and the results called to physician at 8:20 PM. CT scan Orbits completed 8:14 PM documents multiple comminuted fractures and hemorrhagic contusions. At 8:20 PM patient rates pain as 10 out of 10 and given Morphine 4 milligrams intravenously [IV] for pain and Zofran 4 milligrams IV for nausea. At 9:00 PM blood pressure recorded as 139/72 and heart rate 52. (Normal Pulse rate 60-100). At 9:11 PM the facility contacted the call center to initiate a transfer. Review of the facility's transfer form dated 2/15/2018 at 2246 revealed that patient #3 had an identified emergency medical condition, "Depressed (L) skull fracture with small subdural ." patient #3's condition was listed as unstable and that the transfer was medical necessary. The risks and benefits of the transfer, were: Medical Benefits: checked was to obtain level of care/service unavailable at this facility and the medical benefits outweighed the risks. Further review of the transfer form revealed the transfer was accepted by another local acute care facility at 9:16 PM. No documentation signifying emergency medical services [ground ambulance] was informed that this was an urgent transfer. At 10:03 p.m., blood pressure was 144/84 and heart rate was 40. At approximately 10:08 PM, the patient was intubated by the physician. A repeat CT scan at 2242 revealed in part, "Impression: Interval worsening of the left frontal Intraparenchymal hematoma now with approximately 10 mm of left-to- right midline shift and effacement to the left lateral ventricle. These findings are new since the prior study." Further review revealed that the Critical findings of the repeat CT scan was discussed with ED in the ED at 2245 on 2/15/2018. The subdural bleed had significantly increased. No documentation of Neuro checks, no documentation of Glasgow coma scale (a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person) and no documentation of ongoing assessments were available in the medical record. The facility failed to ensure that an appropriate medical screening examination was provided for patient #3 on 2/15/2018. The medical record from the receiving facility dated 2/15/2018 for patient #3 was reviewed. Documentation revealed that patient #3 was initially seen at Trinity Hospital where his neurologic function declined and he was subsequently intubated. He was later transferred to the (name of acute care facility where patient #3 was transferred to) and went for an emergent craniotomy by (name of Doctor) neurosurgeon. 2. Transfer Agreement Review A review of the facility's Transfer agreement revealed the hospital offers Neurosurgery services through transfer agreement only. 3. Policies and Procedures A review of the facility policy entitled, "Provision of Care, Treatment and Services, Plan", #ADMIN-11-PC-P.011, published 10/2017, showed the following: Assessment/ Reassessment depends on patient's diagnosis, and setting emergency department (ED), and as appropriate, each patient will have needs assessed by an RN. Reassessment after initiation of the medical screening examination (MSE) is performed by RN's according to policy. Level 3 / Urgent will be performed and documented every 2-4 hours as condition dictates. Reassessments should be done anytime there is the following: 1. Change in patient's status 2. Change in vital signs (VS's) 3. Change in patient's condition A review of the policy entitled, "EMTALA Definitions and General Guidelines", #ADMIN.LD.011, effective 10/2012, showed the following: Definition of an emergency medical condition (EMC) is a medical condition manifesting itself by acute signs and symptoms (S/S) of sufficient severity (including pain) such that the absence of immediate medical attention could reasonably expect to result in placing the patient at jeopardy. MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether or not an EMC exists. Screening is to be conducted to the extent necessary by a qualified medical provider (QMP). Stabilized, with respect to an EMC, means that no material deterioration of the condition is likely within reasonable medical probability to result from or occur during the transfer of the individual from the facility. A review of the policy entitled, "Assessment / Reassessment Patient Care Acuity Levels", ED-A.003, reviewed on 11/13 showed the following: The purpose is to provide assessment/ reassessment guidelines for [DIAGNOSES REDACTED]il evaluation, continued monitor and /or changes in patient status or condition. To ensure that each patient's physical and social status is assessed to determine the patient's care needs and to ensure the patient's changing needs are reassessed in response to treatment and care. 4. Interviews: Interview with the Medical Director of Emergency Department on 03/16/2018 at 10:00 am stated he would "assume the nurses are doing Neuro checks and performing assessments frequently." Interview with the Assistant Chief Nursing Officer on 3/16/2018 at 1:45 PM confirmed the above findings.

Based on medical record review, staff interview, and review of facility policy and procedure it was determined the facility failed to offer an individual further medical examination and treatment, and failed to inform an individual of the risks and benefits of the examination or treatment or both for 1 (#14) of 20 sampled patients. Findings included: 1. Medical Record Review Review of the medical record for patient #14 revealed the patient presented to the facility ED (Emergency Department) on 3/13/2018 at 10:06 PM. Documentation stated the patient was a walk-in and the stated medical complaint was a nosebleed for 2 hours. Review of nursing documentation on 3/13/2018 at 10:45 PM revealed the RN (Registered Nurse) documented the patient notified the staff of departure and the patient was alert at the time. Review of the medical record revealed no evidence the staff provided the patient with the risks and benefits associated with leaving prior to receiving an MSE. Review of the medical record revealed no evidence the patient was asked to sign the Refusal of MSE and/or Consent to Treatment form. There was no evidence staff documented the patient refused to sign the form. 2. Policy and Procedure Review Review of the facility policy, "EMTALA Definitions and General Guidelines", states on page 12 of 14, (B) when the individual leaves before the EMTALA obligation is met, (1) Leaving DED (Dedicated Emergency Department) Prior to Triage "LPT": if an individual presents to the DED and requests services for a medical condition, but the individual desires to leave prior to triage, the facility must request that the individual complete the Sign-In sheet; (b) Logistics (iii) if the individual indicates that he is leaving prior to triage or it is noticed that the individual is leaving prior to triage, the risks and benefits associated with leaving prior to receiving an MSE (Medical Screening Exam) must be discussed with the individual, (iv) if the individual still desires to leave, the individual should be asked to sign the Refusal of MSE and/or Consent to Treatment form. If the individual does not sign the form, the individual refusal should be documented, with the individual completing the form signing and documenting the form as to the date and time of refusal. 3. Interview Interview with the Assistant Chief Nursing Officer on 3/16/2018 at 1:45 PM confirmed the above findings. The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to obtain a written informed refusal of the risks and benefits of the examination or treatment or both for patient #14 on 3/13/2018 prior to leaving the hospital.

Based on review of the medical record, transfer center calls review, review of facility's policy and procedure, and staff interview it was determined the facility failed to ensure medical treatment was provided, within its capacity, to minimize risk to an individual's health prior to transfer to another medical facility for one (#3) of twenty-one patients sampled. Findings included: 1. Medical Record Review Review of the medical record for patient #3 revealed the patient presented to the facility ED (Emergency Department) on 2/15/2018. Review of the physician's medical screening exam and radiological tests completed revealed the patient had a left depressed skull fracture with subdural hematoma (collection of blood between the covering of the brain (dura) and surface of the brain), multiple comminuted fractures and hemorrhagic contusions which required neurosurgical services. Review of nursing assessments revealed no evidence neurological checks or increased frequency of monitoring of the patient was conducted. Review of nursing documentation and physician treatments revealed the patient's condition deteriorated and the patient required intubation (insertion of a flexible tube into the trachea to maintain an open airway and facilitate ventilation of the lungs) at 10:08 pm. Review of radiological tests revealed a repeated CT scan of the brain was performed which revealed the subdural hematoma had significantly increased. Review of the Memorandum of Transfer form revealed box (d) marked on transfer of patient, "Stable for Transfer" was crossed out and the box labeled "Unstable" was then marked. Review of the form revealed no evidence who made the change of the patient from stable to unstable or when the change was made. 2. Interview Interview with the Assistant Chief Nursing Officer and Risk Manager on 3/16/2018 at 1:45 PM confirmed the above findings. 3. Transfer Center Call review Review of the transfer center calls between the transferring facility and receiving facility revealed on 2/15/2018 at 9:16 pm the transferring facility ED physician provided report to the receiving facility accepting physician. The transferring ED physician stated the patient was stable for ground transport. Review of the transfer center calls revealed ground transport with ALS (Advanced Life Support) was arranged at 9:18 pm with a stated estimated time of arrival at the transferring facility at 9:54 pm Review of the transfer center calls revealed the transferring facility called to request urgent transport of the patient via helicopter. Due to weather conditions transport via helicopter was declined. Review of the transfer center calls revealed the transferring facility ED physician called the receiving facility physician to provide an update on the patient's deteriorated condition. Review of the physician to physician call revealed the accepting facility physician stated, "its been over two hours why is he (patient #3) still there (at transferring facility), he is bleeding, and the only thing that is going to save him is when he is in the hands of a neurosurgeon in the OR (Operating Room)". The transferring facility ED physician stated he did not know why the patient's transfer was delayed. 4. Policy and Procedure Review The facility's policy and procedure titled, "EMTALA Definitions and General Guidelines", policy #ADMIN. LD.011, Effective 12/12, Replaces Policy dated 11/2011 was reviewed. The policy revealed in part, page 3 of 14, "Procedure: Definitions: Appropriate Transfer occurs when: (i) The transferring hospital provides medical treatment within it capacity that minimizes the risks to the individuals' health."