Based on current hospital policy and procedure review, medical record review, the hospital's "emergency room on -Call Schedule," the hospital's "Medical Staff Roster," Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings included: Based on current hospital policy and procedure review, medical record review, the hospital's "emergency room on -Call Schedule," the hospital's "Medical Staff Roster," Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital failed to comply with 42 CFR §489.20 and §489.24. Findings included: 1. The hospital's Dedicated Emergency Department's (DED) medical staff failed to ensure that when emergency department physicians notified on-call physicians who were on the staff, had privileges at the hospital and were available to provide further treatment necessary after the initial examination to stabilize an individual who presented to the hospital a second time with a limb threatening hand injury for 1 ( #8) of 24 sampled patients. ~ Cross refer to §489.24(j) Availability of On-Call Physicians, Tag A2404. 2. The hospital's DED's medical staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 24 sampled patients who presented to the hospital's DED with an EMC (Emergency Medical Condition) and were transferred to another facility. (Patient #8). ~ Cross refer to §489.24(a) and §489.24(c) Stabilizing Treatment Condition, Tag A2407. 3. The hospital inappropriately transferred an individual by failing to provide medical treatment that was within its capability and capacity to render care that minimized the risks to an individual's health who presented to the hospital's emergency department with a limb threatening injury for 1 (#8) of 24 sampled patients. ~ Cross refer to§ 489.24 (2) ( i) Appropriate Transfer , Tag A2409.

Based on current hospital policy and procedure review, medical record reviews, the hospital's "emergency room on -Call Schedule," review, and physician core privileges review, the hospital's "Medical Staff Roster", Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital's Dedicated Emergency Department's (DED) medical staff failed to ensure that when emergency department physicians notified on-call physicians who were on the staff, had privileges at the hospital and were available to provide further treatment necessary after the initial examination to stabilize an individual who presented to the hospital a second time with a limb threatening hand injury for 1 ( #8) of 24 sampled patients. Findings included: Review on 05/17/2017 of the hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act): Medical Screening, Stabilization, and Transfer" (Revision Date: 12/2015), Policy Number 509, revealed "Purpose and Applicable Law: 1. To provide a medical screening examination to any individual who comes to the Emergency Department and requires examination or treatment to determine if an emergency medical condition exists (42 USC 1395dd(a))...2. If an emergency medical condition exists, to stabilize the condition or provide for an appropriate transfer of the patient to another facility (42 USC 1395 dd (b))...III. Definitions: C. Emergency Medical Condition- means either (a) a condition that manifest itself by such acute and severe symptoms that in the absence of immediate medical attention could reasonably result in serious jeopardy of the health of the individual ...serious impairment to bodily functions, or serious dysfunction of any bodily organ or part." ... D. Appropriate Medical Screening Examination - means a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists ...IV. PROCEDURE: Patient Evaluations and Treatment: ...4. If it is determined that an Emergency Medical Condition exists ...a. Stabilize the patient by providing further medical examination and treatment within the capabilities of the Hospital ...List of On-Call Physicians ...The on-call specialist must provide reasonable on call services when called upon for a medical emergency condition and respond within a reasonable period of time when called to the emergency department." Hospital A (Onslow Memorial Hospital), closed DED record review on 05/17/2017 for Patient #8, revealed a [AGE]-year-old male presented ambulatory via POV (privately owned vehicle) to the hospital's DED on 04/30/2017 at 2000 (visit #1). Review of a triage registration form revealed the reason for visit was "Unknown bite on hand." Review of PIVOT Triage Assessment documentation by an RN at 2107, revealed a chief complaint of "Insect Bite" and a History of Present Illness of "Pt (patient) states about 3hrs (3 hours) PTA (prior to arrival) he felt a bite or sting, states he called EMS (emergency medical services) and they stated no snake or any bite. Pt state at first it felt like a bee sting but, then felt 'a fire going up my arm' that he has never felt with a bee sting. States EMS circled the swelling with a pen and now swelling is past that point. Left hand is swollen to wrist." Review of initial triage vital signs at 2108 revealed Blood Pressure (BP) 154/91, Pulse Rate (P) 93, Respiratory Rate (R) 15, Pulse Oximetry (SpO2) 96% on room air, and Temperature (T) 98.9° F (Fahrenheit). Pain was assessed using a numerical pain scale of 0 to 5 (0 no hurt, 5 hurts worst) with a reported pain level of 5. The patient was assessed as Awake, Alert, Appropriate. Respiratory Pattern Normal. The patient was assigned a priority of 3H (ESI level 1-5, 1 severe, 5 least severe). Review of Triage/ED Nursing Assessment documentation by an RN at 2150 revealed, "Triage - Skin Rash/Insect Bite/Abscess" and "HPI - Skin Problem" with Problem - tender/swollen area; Skin character - [DIAGNOSES REDACTED], swelling, tenderness, warm. Occurred - this afternoon. Timing - worse. Quality of rash - painful. Skin temperature - warm. Notes - "Pt presents to ED with a swollen Rt. (right) hand. Pt states he was working in the yard today and may have gotten bitten by something. Pt states had has gotten more swollen and tender and the redness has moved out of the area that was originally marked. PMS (pulse, motor, sensation) intact." Overall pain level - 5. Initial Assessment - awake, alert, appropriate. Glasgow coma assessment - eye opening spontaneous, verbal response oriented, motor response obeys commands. Score 15 (normal). Skin - dry, pink, intact warm. Musculoskeletal - moves all extremities, pulse strong. Review revealed the following medications and nursing procedures were administered by an RN as ordered by Physician's Assistant (PA) #1: ~ Saline lock established at 2121; ~ Pepcid 20 mg (milligrams) IV (intravenous) now given at 2156; ~ Benadryl 25 mg IV now given at 2157; ~ Solu-Medrol 125 mg IV now given at 2157; and ~ Boostrix ([DIAGNOSES REDACTED]/Tetanus/Pertussis) Vaccine 0.5 mL (milliliter) IM (intramuscular) now, not given patient refused at 2200; and ~ Benadryl 25 mg IV now given at 2257. Review of nursing documentation revealed: ~ At 2311 - Hourly rounding. No needs at this time. No questions at this time. At 0005 (05/01/17) - Vital signs reassessed - BP 124/75, T 97.4° F, P 79, R 14, and SpO2 95% on room air. ~ At 0010 - Discharge documentation: Condition at discharge unchanged, IV removed yes, Pain level 3 (decreased). DC transport method: personal vehicle. Patient discharged via: ambulated. Discharge instructions given to patient. Notes: "Pt verbalized understanding of D/C, F/U (follow-up) and prescription instructions. Pt ambulated to D/C office with steady gait in NAD (no acute distress) at this time." Record review revealed a MSE was performed on 04/30/2017 at 2117 by PA #1. MSE documentation revealed, "ED Skin Rash / Insect Bite / Abscs (abscess) - General Chief Complaint: Insect Bite Stated Complaint: Possible Spider Bite Notes: Patient is a [AGE]-year-old male that comes [sic] emergency department for chief complaint of suspected insect bite or sting between his fourth and fifth digits of the right hand. Patient states that he was working with to swell [sic] (with soil) and he felt a sharp stinging sensation with burning pain shooting up his arm. He did not visualize any insect. He states EMS evaluated him shortly after and circled the area, he states that he began to have swelling of the hand and redness that was spreading almost immediately afterwards and has [sic] (as) a result came to the emergency department. Patient reports redness and swelling to the area was almost immediately after the contact. He is not up-to-date on his tetanus within 5 years. He denies and daily medications, medical history, or allergies. ...Review of Systems ...Musculoskeletal: See HPI Skin: See HPI ..." Review of Physical Exam revealed: General appearance: appears well, alert. In distress: None. Head: normocephalic, atraumatic. Eyes: normal. Pupils: PERRL (pupils equal round reactive to light). Pharynx: normal. Neck: normal, No: anterior cervical chain, posterior cervical chain. Respiratory status: no respiratory distress, no: labored. Chest status: Nontender. Breath sounds: normal, no: decreased air movement, stridor, wheezing. Chest palpation: Normal. Cardiovascular rhythm: Regular. Heart sounds: normal auscultation. Murmur: no. Abdominal inspection: normal. Distention: no distention. Bowel sounds: normal. Tenderness: nontender. Organomegaly: no organomegaly. Back: normal, nontender. Extremities: General upper extremity: other - right hand with [sic] (Note: refer to PA #1 interview regarding missing documentation of right hand assessment). General lower extremity: normal inspection, nontender, normal color, normal ROM (range of motion), normal temperature, normal weight bearing. No: Homan's sign. Neurology: grossly intact. Cognition: normal. Orientation: AAOX4 (alert and oriented to person, place, time, situation). Glasgow Coma Scale Total: 15 (normal). Speech: normal. Cranial nerves: normal. Cerebellar coordination: normal. Mother strength normal: LUE, RUE, LLE, RLE (all extremities). Additional motor exam normal: equal grip. Sensory: normal. Psychological: normal affect and mood. Skin temperature: warm. Skin moisture: dry. Skin color: normal. Review revealed "Re-evaluation: Patient refusing tetanus update, states that 'if he gets an infection with tetanus he will get treated afterwards.' Patient again refused when offered. No evidence of anaphylaxis on reevaluation patient's [sic]. Remains localized swelling. Examination consistent with local histamine inflammatory response from insect sting/bites, after multiple does of antihistamines swelling significantly reduced, and also given Solu-Medrol, will cover with antibiotic prophylaxis, continue medication s at home, patient satisfied with improvement, discussed return precautions, patient states understanding and agreement." Review of discharge revealed a clinical impression of "Swelling right hand." Discharge condition "Stable." Disposition: home, self-care. Review of additional instructions revealed, "Examination is consistent with local inflammatory/histamine reaction, most likely from an insect bite. Take the prednisone as prescribed, take the Benadryl and Pepcid for at least 3 days, take Bactrim antibiotic to completion. Return immediately if you develop any concerning worsening symptoms such as spreading redness, fever, worsening swelling, or any other concerning symptoms." Review revealed no documentation of lab and/or radiology studies ordered by PA #1. Review revealed the patient was discharged with the following prescriptions: ~ Diphenhydramine HCL (Benadryl) 25 mg PO (by mouth) Q6 (every 6 hours) #20 capsule; ~ Famotidine (Pepcid) 20 mg PO daily #14 tablet; ~ Prednisone (Deltasone) 10 mg PO ASDIR (as directed) PRN (as needed) #21 tablet; and ~ Sulfamethoxazole/Trimethoprim (Bactrim) 1 each PO BID (twice per day) # 10 tablet. Review revealed "I was personally available for consultation in the Emergency Department and serving as supervising physician for the MLP (mid-level provider)." Electronically signed by Physician A on 05/03/17 at 2103. Hospital A, closed DED record review on 05/17/2017 for Patient #8, revealed the patient returned to the hospital's DED on 05/01/2017 at 1057 (visit #2). Review of a triage registration form revealed the reason for visit was "Bite." Review of PIVOT Triage Assessment documentation by an RN at 1109, revealed a chief complaint of "Hand Swelling" and a History of Present Illness of "Pt ambulatory to ER (emergency room ) with c/o (complaints of) swelling to the right hand. States seen yesterday and was thought to be and insect bite. States only one puncture site was seen last night. States today he can see 2 puncture sites. States he now thinks it was a snake bite." The patient was assessed as Awake, Alert, Appropriate. Respiratory Pattern Normal. Skin color normal. Review of initial triage vital signs at 1111 revealed BP 157/98, P 103, R 20, SpO2 95% on room air, and T 98.4° F. Pain was assessed using a numerical pain scale of 0 to 5 (0 no hurt, 5 hurts worst) with a reported pain level of 5. The patient was assigned a priority of 3H. Review of Triage documentation by an RN at 1122 revealed, "Triage - Hand/Wrist Injury" and "HPI - Hand or Wrist Injury" with Occurred - yesterday. Timing - constant. Distal pulses present no. Sensations intact no. Capillary refill less than 3 seconds. Notes - "Pt seen here last night for unknown bite to right hand. States swelling and discomfort has gotten worse today." Overall pain level - 5. Review of ED Nursing assessment documentation by an RN at 1211, revealed initial Assessment - awake, alert, appropriate. Patient oriented to person, place, time, and events. Glasgow coma assessment - eye opening spontaneous, verbal response oriented, motor response obeys commands. Score 15 (normal). Musculoskeletal - moves all extremities. Review of nursing documentation revealed: ~ At 1125 - Elevate right arm above your heart. ~ At 1129 - Immobilize right arm in arm sling. ~ At 1334 - Hourly rounding. Provider at bedside at this time. ~ At 1342 - Saline lock established. ~ At 1623 - Received patient at this time to room 10 with IV infusing. ~ At 1645 - Telemetry Monitor. Vital signs reassessed - BP 145/90, P 75, R 18, SpO2 98%. ~ At 1651 - "Pt resting in bed. Pt c/o 3/5 pain to right hand and forearm at this time. Pt on cardiac monitor. Wife at bedside. Call bell within reach. Will continue to monitor." ~ At 1700 - Vital signs reassessed - BP 130/82, P 81, R 19, SpO2 94%, T 97.7° F. ~ At 1747 - X-ray at bedside. ~ At 1801 - Vital signs reassessed - BP 121/80, R 18, SpO2 94%. ~ At 1817 - Vital signs reassessed - BP 138/77, R 17, SpO2 97%, T 97.7° F. ~ At 1821 - "Pt Crofab (Snake antivenom) completed at this time. Pt c/o 4/5 pain to right hand at this time. Pt c/o rash to forearm at this time. Provider notified and new orders to follow." ~ At 1835 - Report called to (name) Vitalink (critical care transport service) at this time. ~ At 1840 - Report called to (name) RN, at (Hospital B) at this time. ~ At 1847 - "Pt states pain is a 2/5 at this time ..." ~ At 1901 - Vital signs reassessed - BP 149/80, P 85, R 18, SpO2 98%. ~ At 2000 - Hourly rounding. No needs at this time. Transport here ambulated to bathroom. Pain level 3. Vital signs reassessed - BP 141/85, P 65, R 18, SpO2 97% on RA, T 97.9° F. ~ At 2021 - Discharge documentation: Condition at discharge improved, IV removed no, Pain level 3. DC transport method: Vitalink. Patient discharged via: stretcher. Discharge instructions given to: report to transferring facility prior RN. Review revealed the following medications and nursing procedures completed by an RN as ordered by the DED Physician and/or QMP (Qualified Medical Personnel): ~ At 1125 - Elevate right arm above heart. ~ At 1129 - Immobilize right arm in arm sling. ~ At 1220 - Boostrix ([DIAGNOSES REDACTED], Tetanus, Pertussis) Vaccine 0.5 mL given. ~ At 1342 - Saline lock established. ~ At 1606 - IVF Normal Saline 0.9% 1000 mL bolus given. ~ At 1604 - Morphine 4 mg IV now given. ~ At 1605 - CroFab Antivenin 4 vials IV Bag given. ~ At 1825 - Morphine 4 mg IV now given. ~ At 1826 - Benadryl 25 mg PO now given. Review revealed an "ED Medical Screen (RME)" [rapid medical evaluation - performed at triage by QMP] was performed on 05/01/2017 at 1125 by FNP #1. RME documentation revealed, "General Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury ...Notes: [AGE]-year-old male seen last night with a bite while he was reaching under pine-needles to get a daffodil bulb at 6:30 PM has increased swelling past the wrist that is not pain out of proportion but it is tense and a second puncture mark showed up between the fourth and fifth base of the fingers. Dr. (Physician C) looked at it ..." Laboratory diagnostic studies were ordered by FNP #1. Review revealed an MSE was performed on 05/01/2017 at 1124 by PA #2. MSE documentation revealed, "Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury. Notes: Patient is a [AGE]-year-old male who presents with right hand swelling, warmth, and pain that started yesterday. He sates he was workin [sic] on replanting his daffodils when he felt a sting between his fourth and fifth finger and then a burning sensation 'like gasoline' travel up his right arm. This occurred yesterday at 6:30 PM. He was seen here last night around 2100, only one puncture wound was visible, diagnosed with [DIAGNOSES REDACTED]. He states when he cleaned his hand this morning, he noticed a second puncture wound which made him suspicious of a snake bite. He did not see a snake ad has not seen any around his house. He is right handed. Denies any fever, chills, [DIAGNOSES REDACTED], numbness, tingling, chest pain or SOB (shortness of breath). ...Review of Systems ...Musculoskeletal: See HPI Skin: See HPI ..." Review of Physical Exam revealed: Constitutional: Alert and oriented, well-appearing and in no acute distress. HENT: normocephalic, atraumatic. Oropharynx clear without edema, [DIAGNOSES REDACTED], tonsillar exudate or malocclusion. Trachea midline. Uvula midline. Moist mucous membranes. EYES: Pupils equal round and reactive to light, EOM intact. Sclera anicteric, conjunctiva are normal. No entrapment. NECK: supple without lymphadenopathy. ROM intact. HEART: Regular rate and rhythm without murmurs. LUNGS: CTAB and equal. No wheezes, rales or rhonchi. GI: Normoactive bowel sounds. Nontender, non-distended. No organomegaly. No CVAT. BACK: nontender, no paraspinous spasm, 5+//5 strengths, DTRs 2+, SLR -. EXTREMITIES: Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis to forearm that is tender to palpation. Cap refill <3 seconds. NEURO: Cranial nerves grossly intact. Normal sensory/motor exams. PSYCH: Normal mood, normal affect. SKIN: Warm and dry. Normal turgor. No rashes or lesions noted. Review revealed, "Re-evaluation: 05/01/2017 12:38 Patient seen and examined. Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis extends from PIP joints of fingers to wrist with mild edema and ecchymosis to forearm that is tender to palpation. Cap Refill <3 seconds and distal pulses intact. Mild warmth to the touch but no streaking or [DIAGNOSES REDACTED] noted at this time. Patient has no respiratory distress. Tetanus was updated, initial labs drawn - mild leukocytosis (11.9). ...13:38 I have consulted with Dr. (Physician B) per (company name) APC guidelines who examined patient [sic] bedside, confirms suspicion of snake bite. Discussing case with Dr. (Physician D) for further opinion on administration of anti-venom. ...14:00 Dr. (Physician B) discussed case and consulted with hand surgeon on-call who declined, saying he does not treat snake bites. ...14:18 Dr. (Physician B), attending physician confirmed to start anti-venom. Cro-Fab ordered at this time. Patient remains stable with no respiratory distress - ordered IV fluids and IV morphine for pain. ...16:07 Consulted Dr. (Physician E) - general surgeon on call who states he declines coming to evaluate patient due to wound in upper extremity. He feels the patient should be transferred. ...1700 Consulted and discussed case with Dr. [Physician F] (IM) and Dr. [Physician G] (surgery) at (Hospital B) who suggested consulting trauma surgery before accepting. ...17:28 Consulted and discussed case with Dr. (Physician H), trauma surgery, who accepted patient for transfer. Patient updated with plan. At this time, patient reports improvement of pressure and swelling to right fingers with ROM improving. He does report mild [DIAGNOSES REDACTED] noted to anterior surface of forearm but no increase in swelling or pain to same area. No respiratory distress or chest pain noted at this time. Speaking in full sentences, alert and oriented. Crofab is still infusing. Patient is stable for transfer." Review revealed a clinical impression of snake bite and cellulitis. Condition: Stable. Disposition: (Hospital B). Electronically signed by PA #2 on 05/11/2017 at 2204 and Physician B on 05/12/2017 at 0304. The facility failed to ensure that their Medical Staff Bylaws and Rules and Regulations were followed as evidenced by failing to ensure that the on call physicians who were on call for duty on 5/1/2017, after the initial examination to provide treatment necessary to stabilize Patient #8 on 5/1/2017 (second ED visit), who had limb threatening hand injury. Review revealed the following Lab and Radiology studies ordered by the DED Physician and/or QMP: 1. 1135 - Complete Blood Count with Differential - WBC 12.0 H (high) [reference range 4.0-10.5]. 2. 1135 - Prothrombin Time (PT) / INR - PT 13.2 [reference range 11.4-15.4], INR (D) 0.97 Therapeutic Range (Thromboembolic Disease) [reference range 2.0-3.0]. 3. 1135 - Partial Thromboplastin Time (PTT) - 26.9 [reference range 23.5-35.8]. 4. 1135 - Comprehensive Metabolic Panel - Glucose 136 H (high) [reference range 75-110]. 5. 1125 - Blood Culture X2 - No growth in 5 days. 6. 1315 - Repeat PT/INR - PT 13.0 [reference range 11.4-15.4], INR (D) 0.96 Therapeutic Range (Thromboembolic Disease) [reference range 2.0-3.0]. 7. 1315 - Repeat PTT - 27.8 [reference range 23.5-35.8]. 8. 1315 - Fibrinogen - 531 H (high) [reference range 209-497]. 9. 1449 - Fibrin Degradation Products - less than 10 [reference range <10). 10. 1645 - Urinalysis - Ketones Trace H (high) [reference range Negative]. 11. 1755 - Right Hand 3 View X-ray - IMPRESSION: Negative Study of the right hand. No radiographic evidence of acute injury. Review on 05/17/2017 of Hospital A's "emergency room on -Call Schedule" for May 1, 2017 (revised at 1036) revealed, Physician D was on-call for Orthopedics and Physician E was on-call for General Surgery. Review of Physician D's Core Privileges that were granted 7/28/2016 revealed in part, "Core ...hand and wrist disorders, management of 6/30/2017 TO 7/28/2018 , Hand surgery 6/30/2016 TO 7/28/2018." Review on 05/17/2017 of Hospital A's Medical Staff Roster (dated 05/16/2017 at 1121), revealed Physician D's staff category was "active" and privilege status was "active" and specialty was "Orthopedics" and his re-privilege/credential date was 07/28/2018. Further review revealed, Physician D's staff category was "Locum Tenens" and privilege status was "Temporary" and specialty was "Surgery" and his re-privilege/credential date was 07/04/2017. Telephone interview on 05/18/2017 at 0909 with PA #1, revealed he was on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). He remembered the patient. He was the QMP who performed the patient's MSE. The patient presented with a possible insect or spider bite to his right hand. Upon initial assessment of the right hand he could not see any marks or bleeding. There were no wounds. After the hand was cleaned, he noticed a mark, "one" mark in the web between fingers. The area was warm and red with swelling present. It could have been an ant, insect, or spider. It did not occur to him to be a snake bite. It appeared to be a "localized inflammatory response" The patient was administered Solumedrol, Benadryl and Pepcid IV. The patient was offered a Tetanus shot but he refused. When reassessed, the patient's hand had improved. It was not as hot or swollen. After a second round of anti-histamines were given, there was "significant improvement" and "minimal redness" and did not look like cellulitis. The patient was prescribed antibiotics to cover for potential infection from the puncture mark on the hand. The patient was discharged . He had no fever or risk factors. The supervising DED physician on-duty was not consulted about the patient. There was no reason to admit the patient. If the patient's condition had worsened, he would have consulted the physician. If he had the same scenario and same presentation by another patient, he would not have changed his treatment plan and would have discharged the patient. Note: When asked to clarify his MSE documentation of the "Extremities: General upper extremity: other - right hand with (blank)" his response was: The hospital used dictation software for the providers to document their MSE in the medical record. The software must have failed to document his assessment. The software should have transcribed right hand with red mark in center of the webbing between the 4-5 digits, localized swelling around the dorsum of the hand with mild heat to the area extending up to the right wrist. Normal ROM. Normal Pulse. PA #1 was unaware his assessment of the right hand had not been completely documented. Further interview revealed the patient's symptoms were not systemic, there was no toxicity and vital signs were stable. If he had suspected a cat or snake bite he may have ordered an x-ray to see if there were any teeth left in the puncture site. If he had suspected a snake bite, or if the patient had diabetes, fever, or cellulitis he would have ordered PT/PTT/INR and CBC. It crossed his mind initially that it may have been a snake, but when he examined the right hand and only saw one mark, he stated he was not even thinking a snake bite. He stated he ruled out snake bite do to the patient's response to antihistamines. The patient was discharged in stable condition. The patient had an EMC on presentation; on discharge "not so much." He stated he would not change the treatment delivered based on the presentation. The next day he was made aware the patient had returned to the ED and was transferred to Hospital B on Crofab. He also stated he was made aware the patient had filed a complaint with the hospital within the last 48 hours. Interview confirmed he did not discuss the patient's care with the on-duty supervising DED physician. Telephone interview on 05/18/2017 at 0928 with PA#2, revealed she was on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). She recalled the patient. She was the QMP who performed the patient's MSE. The patient presented with increased swelling and redness to his right hand. The swelling did not extend past the elbow. The patient had full range of motion of the elbow and shoulder. Patient reported that when he was cleaning his hand in the morning, he noticed a second puncture wound. The patient reported a burning sensation traveling up his arm more than before. Labs were ordered and Dr. (Physician B) the attending DED physician on-duty was consulted. There was the possibility the patient would need antivenin. Physician B contacted poison control and determined the dose of antivenin to be administered. Discussed case with Physician B, he talked to the hand surgeon on-call, Dr. (Physician D). Physician D declined to evaluate the patient because he did not treat snake bites. CroFab administration was pending blood results to ensure lab values were within normal limits. Physician B confirmed to start the antivenin. She consulted Dr. (Physician E), the on-call General Surgeon, who was in a case? He declined to come evaluate the patient because he did not treat wounds/snake bites in the upper extremities. He felt the patient should be transferred. PA #2 then called Hospital B and consulted with Dr. (Physician F) [Internal Medicine], and Dr. (Physician G) [Surgeon]. They suggested she consult Trauma Surgery. She consulted Dr. (Physician H), Trauma Surgeon, who accepted the patient for transfer to Hospital B. PA #2, stated she nor Physician B consulted Hospital A's hospitalist because Physician B said the Hospitalist did not admit and treat snake bites. The decision was made to transfer the patient by Physician B. She stated the hospital's on-call physicians had turned the case down. The patient had an EMC. The patient needed to be monitored while on CroFab and monitored for [DIAGNOSES REDACTED]. The patient's condition was improved upon transfer, swelling, redness, and pain had decreased after the CroFab had been initiated. Telephone interview on 05/18/2017 at 1005 with Physician E, revealed he was the on-call General Surgeon when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). He was consulted by the ED providers, but was not requested to present to the ED. He declined to evaluate the patient because he "does not treat hands." He stated hand surgeons have a skill set. "I don't have the skill set, there was no point in evaluating the patient." Telephone interview on 05/18/2017 at 1030 with Physician D, revealed he was the on-call Orthopedist when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). Physician B, spoke with him regarding the patient. The patient had presented to the ED 24 hours earlier and returned for a snake bite to the hand. The hand was swollen. There were questions for the need of antivenin and admission. He stated he was not a snake bite specialist or hand surgeon. The patient needed to be admitted to the hospitalist services not orthopedics. There was not an orthopedic issue at the time, it was more of a medical issue due to the venom. He was not requested to present to the ED. Review on 05/18/2017 of Hospital A's current Medical Staff Bylaws, Rules and Regulations (dated March 31, 2016), revealed, "Article II ...2.2.2 Unassigned Call Service a. Unassigned Call Schedule: The Hospital is required to maintain a list of physicians or appropriate designees who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. Each Clinical Department shall provide the Emergency Department and the Medical Staff Services Office with a list of physicians and other practitioners who are scheduled to take emergency call on a rotating basis. Emergency call shall be from 0800 to 0800 the following day. Authorized allied health practitioners privileged through the medical staff can respond as first responder consistent with their collaborative agreements. b. Response Time: It is the responsibility of the on-call physician/practitioner to respond in an appropriate time frame. The on-call physician should respond to calls from the Emergency Department within thirty (30) minutes. If the on-call physician does not respond to being called or paged, the appropriate department policy with regard to the chain of command will be followed. Failure to respond in a timely manner may result in referral to the Medical Executive Committee (MEC) for appropriate action. c. Substitute Coverage: It is the on-call physician's responsibility to arrange for coverage and notify the Emergency Department through the switchboard if he/she is unavailable to take call when assigned. Failure to notify the Emergency Department of alternate call coverage may result in referral to the MEC for appropriate action and the physician will be considered to still be on call. Telephone interview on 05/18/2017 at 1040 with Pharmacy Director #1, revealed the hospital kept a stock of CroFab on-hand. There was a quantity kept in the ED and a back-up supply in the pharmacy. The hospital kept a sufficient supply for the initial dose and to get an additional dose the following day. If additional does were needed they would have to order them from the supplier or borrow from surrounding hospitals. CroFab was "a very expensive medication." The cost of an average does of 4 vials was $46,000. The administration of CroFab does not require any authorization or approval from the Pharmacy or Hospital administration. If there is the need and a physician's order the medication is administered regardless of insurance or payor source. In emergent type situations, CroFab is immediately accessible by staff for administration to the patient. Telephone interview on 05/18/2017 at 1345 with Physician A, revealed she was an attending physician on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). She was available for consult by PA #1. She had no contact with Patient #8. She only co-signed the chart. PA #1 did not consult her regarding Patient #8. She generally does not read the ED charts she just electronically co-signs them. Telephone interview on 05/18/2017 at 1410 with Physician B, revealed he was the atte

Based on current hospital policy and procedure review, medical record review, the hospital's "emergency room on -Call Schedule," the hospital's "Medical Staff Roster," Medical Staff bylaws, rules and regulations review, physician and staff interviews; the hospital's Dedicated Emergency Department's (DED) medical staff failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 1 of 24 sampled patients who presented to the hospital's DED with an EMC and were transferred to another facility. (Patient #8) Findings included: Review on 05/17/2017 of the hospital's policy "EMTALA (Emergency Medical Treatment and Labor Act): Medical Screening, Stabilization, and Transfer" (Revision Date: 12/2015), revealed "Purpose and Applicable Law: 1. To provide a medical screening examination to any individual who comes to the Emergency Department and requires examination or treatment to determine if an emergency medical condition exists (42 USC 1395dd(a))...2. If an emergency medical condition exists, to stabilize the condition or provide for an appropriate transfer of the patient to another facility (42 USC 1395 dd (b))...III. Definitions: D. Appropriate Medical Screening Examination - means a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists or whether a woman is in labor. The medical screening examination must be uniform for all patients who present with similar complaints. The screening examination must be performed by qualified medical personnel as designated by the medical staff bylaws." Hospital A, closed DED record review on 05/17/2017 for Patient #8, revealed the patient returned to the hospital's DED on 05/01/2017 at 1057 (visit #2). Review of a triage registration form revealed the reason for visit was "Bite." Review of PIVOT Triage Assessment documentation by an RN at 1109, revealed a chief complaint of "Hand Swelling" and a History of Present Illness of "Pt ambulatory to ER (emergency room ) with c/o (complaints of) swelling to the right hand. States seen yesterday and was thought to be and insect bite. States only one puncture site was seen last night. States today he can see 2 puncture sites. States he now thinks it was a snake bite." The patient was assessed as Awake, Alert, Appropriate. Respiratory Pattern Normal. Skin color normal. Review of initial triage vital signs at 1111 revealed BP 157/98, P 103, R 20, SpO2 95% on room air, and T 98.4° F. Pain was assessed using a numerical pain scale of 0 to 5 (0 no hurt, 5 hurts worst) with a reported pain level of 5. The patient was assigned a priority of 3H. Review of Triage documentation by an RN at 1122 revealed, "Triage - Hand/Wrist Injury" and "HPI - Hand or Wrist Injury" with Occurred - yesterday. Timing - constant. Distal pulses present no. Sensations intact no. Capillary refill less than 3 seconds. Notes - "Pt seen here last night for unknown bite to right hand. States swelling and discomfort has gotten worse today." Overall pain level - 5. Review of ED Nursing assessment documentation by an RN at 1211, revealed initial Assessment - awake, alert, appropriate. Patient oriented to person, place, time, and events. Glasgow coma assessment - eye opening spontaneous, verbal response oriented, motor response obeys commands. Score 15 (normal). Musculoskeletal - moves all extremities. Review of nursing documentation revealed: ~ At 1125 - Elevate right arm above your heart. ~ At 1129 - Immobilize right arm in arm sling. ~ At 1334 - Hourly rounding. Provider at bedside at this time. ~ At 1342 - Saline lock established. ~ At 1623 - Received patient at this time to room 10 with IV infusing. ~ At 1645 - Telemetry Monitor. Vital signs reassessed - BP 145/90, P 75, R 18, SpO2 98%. ~ At 1651 - "Pt resting in bed. Pt c/o 3/5 pain to right hand and forearm at this time. Pt on cardiac monitor. Wife at bedside. Call bell within reach. Will continue to monitor." ~ At 1700 - Vital signs reassessed - BP 130/82, P 81, R 19, SpO2 94%, T 97.7° F. ~ At 1747 - X-ray at bedside. ~ At 1801 - Vital signs reassessed - BP 121/80, R 18, SpO2 94%. ~ At 1817 - Vital signs reassessed - BP 138/77, R 17, SpO2 97%, T 97.7° F. ~ At 1821 - "Pt Crofab completed at this time. Pt c/o 4/5 pain to right hand at this time. Pt c/o rash to forearm at this time. Provider notified and new orders to follow." ~ At 1835 - Report called to (name) Vitalink (critical care transport service) at this time. ~ At 1840 - Report called to (name) RN, at (Hospital B) at this time. ~ At 1847 - "Pt states pain is a 2/5 at this time ..." ~ At 1901 - Vital signs reassessed - BP 149/80, P 85, R 18, SpO2 98%. ~ At 2000 - Hourly rounding. No needs at this time. Transport here ambulated to bathroom. Pain level 3. Vital signs reassessed - BP 141/85, P 65, R 18, SpO2 97% on RA, T 97.9° F. ~ At 2021 - Discharge documentation: Condition at discharge improved, IV removed no, Pain level 3. DC transport method: Vitalink. Patient discharged via: stretcher. Discharge instructions given to: report to transferring facility prior RN. Review revealed the following medications and nursing procedures completed by an RN as ordered by the DED Physician and/or QMP: ~ At 1125 - Elevate right arm above heart. ~ At 1129 - Immobilize right arm in arm sling. ~ At 1220 - Boostrix ([DIAGNOSES REDACTED], Tetanus, Pertussis) Vaccine 0.5 mL given. ~ At 1342 - Saline lock established. ~ At 1606 - IVF Normal Saline 0.9% 1000 mL bolus given. ~ At 1604 - Morphine 4 mg IV now given. ~ At 1605 - CroFab Antivenin 4 vials IV Bag given. ~ At 1825 - Morphine 4 mg IV now given. ~ At 1826 - Benadryl 25 mg PO now given. Review revealed an "ED Medical Screen (RME)" [rapid medical evaluation - performed at triage by QMP] was performed on 05/01/2017 at 1125 by FNP #1. RME documentation revealed, "General Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury ...Notes: [AGE]-year-old male seen last night with a bite while he was reaching under pine-needles to get a daffodil bulb at 6:30 PM has increased swelling past the wrist that is not pain out of proportion but it is tense and a second puncture mark showed up between the fourth and fifth base of the fingers. Dr. (Physician C) looked at it ..." Laboratory diagnostic studies were ordered by FNP #1. Review revealed an MSE was performed on 05/01/2017 at 1124 by PA #2. MSE documentation revealed, "Chief Complaint: Hand Swelling. Stated Complaint: Right hand pain/injury. Notes: Patient is a [AGE]-year-old Caucasian male who presents with right hand swelling, warmth, and pain that started yesterday. He sates he was workin [sic] on replanting his daffodils when he felt a sting between his fourth and fifth finger and then a burning sensation 'like gasoline' travel up his right arm. This occurred yesterday at 6:30 PM. He was seen here last night around 2100, only one puncture wound was visible, diagnosed with [DIAGNOSES REDACTED]. He states when he cleaned his hand this morning, he noticed a second puncture wound which made him suspicious of a snake bite. He did not see a snake ad has not seen any around his house. He is right handed. Denies any fever, chills, [DIAGNOSES REDACTED], numbness, tingling, chest pain or SOB (shortness of breath). ...Review of Systems ...Musculoskeletal: See HPI Skin: See HPI ..." Review of Physical Exam revealed: Constitutional: Alert and oriented, well-appearing and in no acute distress. HENT: normocephalic, atraumatic. Oropharynx clear without edema, [DIAGNOSES REDACTED], tonsillar exudate or malocclusion. Trachea midline. Uvula midline. Moist mucous membranes. EYES: Pupils equal round and reactive to light, EOM intact. Sclera anicteric, conjunctiva are normal. No entrapment. NECK: supple without lymphadenopathy. ROM intact. HEART: Regular rate and rhythm without murmurs. LUNGS: CTAB and equal. No wheezes, rales or rhonchi. GI: Normoactive bowel sounds. Nontender, non-distended. No organomegaly. No CVAT. BACK: nontender, no paraspinous spasm, 5+//5 strengths, DTRs 2+, SLR -. EXTREMITIES: Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis to forearm that is tender to palpation. Cap refill <3 seconds. NEURO: Cranial nerves grossly intact. Normal sensory/motor exams. PSYCH: Normal mood, normal affect. SKIN: Warm and dry. Normal turgor. No rashes or lesions noted. Review revealed, "Re-evaluation: 05/01/2017 12:38 Patient seen and examined. Right hand - tender to palpation along DIP, PIP and MCP joints with associated swelling. 2 superficial puncture wounds noted to dorsal surface of webbing between 4th and 5th digit without drainage or bleeding. Edema and faint ecchymosis extends from PIP joints of fingers to wrist with mild edema and ecchymosis to forearm that is tender to palpation. Cap Refill <3 seconds and distal pulses intact. Mild warmth to the touch but no streaking or [DIAGNOSES REDACTED] noted at this time. Patient has no respiratory distress. Tetanus was updated, initial labs drawn - mild leukocytosis (11.9). ...13:38 I have consulted with Dr. (Physician B) per (company name) APC guidelines who examined patient [sic] bedside, confirms suspicion of snake bite. Discussing case with Dr. (Physician D) for further opinion on administration of anti-venom. ...14:00 Dr. (Physician B) discussed case and consulted with hand surgeon on-call who declined, saying he does not treat snake bites. ...14:18 Dr. (Physician B), attending physician confirmed to start anti-venom. Cro-Fab ordered at this time. Patient remains stable with no respiratory distress - ordered IV fluids and IV morphine for pain. ...16:07 Consulted Dr. (Physician E) - general surgeon on call who states he declines coming to evaluate patient due to wound in upper extremity. He feels the patient should be transferred. ...1700 Consulted and discussed case with Dr. [Physician F] (IM) and Dr. [Physician G] (surgery) at (Hospital B) who suggested consulting trauma surgery before accepting. ...17:28 Consulted and discussed case with Dr. (Physician H), trauma surgery, who accepted patient for transfer. Patient updated with plan. At this time, patient reports improvement of pressure and swelling to right fingers with ROM improving. He does report mild [DIAGNOSES REDACTED] noted to anterior surface of forearm but no increase in swelling or pain to same area. No respiratory distress or chest pain noted at this time. Speaking in full sentences, alert and oriented. Crofab is still infusing. Patient is stable for transfer." Review revealed a clinical impression of snake bite and cellulitis. Condition: Stable. Disposition: (Hospital B). Electronically signed by PA #2 on 05/11/2017 at 2204 and Physician B on 05/12/2017 at 0304. Review revealed the following Lab and Radiology studies ordered by the DED Physician and/or QMP: 1. 1135 - Complete Blood Count with Differential - WBC 12.0 H (high) [reference range 4.0-10.5]. 2. 1135 - Prothrombin Time (PT) / INR - PT 13.2 [reference range 11.4-15.4], INR (D) 0.97 Therapeutic Range (Thromboembolic Disease) [reference range 2.0-3.0]. 3. 1135 - Partial Thromboplastin Time (PTT) - 26.9 [reference range 23.5-35.8]. 4. 1135 - Comprehensive Metabolic Panel - Glucose 136 H (high) [reference range 75-110]. 5. 1125 - Blood Culture X2 - No growth in 5 days. 6. 1315 - Repeat PT/INR - PT 13.0 [reference range 11.4-15.4], INR (D) 0.96 Therapeutic Range (Thromboembolic Disease) [reference range 2.0-3.0]. 7. 1315 - Repeat PTT - 27.8 [reference range 23.5-35.8]. 8. 1315 - Fibrinogen - 531 H (high) [reference range 209-497]. 9. 1449 - Fibrin Degradation Products - less than 10 [reference range <10). 10. 1645 - Urinalysis - Ketones Trace H (high) [reference range Negative]. 11. 1755 - Right Hand 3 View X-ray - IMPRESSION: Negative Study of the right hand. No radiographic evidence of acute injury. Review of the "Patient Transfer Form (EMTALA)" dated 05/01/2017 certified by Physician B at 1800, revealed "[check mark in box] Stable. The patient has an emergency medical condition, but the condition is stable. No material deterioration is likely to result from: (1) a transfer to another facility, or (2) discharge with instructions for appropriate follow-up care. ...Patient-Specific Benefits of Transfer: Admission to manage snakebite injury. Patient-Specific Risks of Transfer: worsening swelling of hand, increased pain. ..." Review revealed the patient's vital signs prior to transport were reassessed at 2002 as T 97.9? F, P 65, R 18, BP 141/85, SpO2 97% on room air. The patient was transported by critical care personnel to another hospital (B) where he was admitted as inpatient and treated. The patient departed the DED at 2021. Review on 05/17/2017 of Hospital A's "emergency room on -Call Schedule" for May 1, 2017 (revised at 1036) revealed, Physician D was on-call for Orthopedics and Physician E was on-call for General Surgery. Review on 05/17/2017 of Hospital A's Medical Staff Roster (dated 05/16/2017 at 1121), revealed Physician D's staff category was "active" and privilege status was "active" and specialty was "Orthopedics" and his re-privilege/credential date was 07/28/2018. Further review revealed, Physician D's staff category was "Locum Tenens" and privilege status was "Temporary" and specialty was "Surgery" and his re-privilege/credential date was 07/04/2017. Hospital B (Receiving Hospital), closed medical record review on 06/02/2017 for Patient #8, revealed the patient (MDS) dated [DATE] at 2147 and was direct admitted to an in-patient unit for observation with a diagnosis of [DIAGNOSES REDACTED]"Chief Complaint: Snakebite RUE. History of Present Illness: ...49 y. o. Caucasian male with no pmhx (past medical history) who reports a snakebite to Right hand. Patient states he was gardening and reached his hand under a board and felt a burning sensation. He did not see the snake. He states he knows this was a snake due to the two puncture marks over his 4th/5th digits. States he had some immediate swelling and went to the ED and was subsequently sent home. He then returned to (Hospital A) ED today with increased swelling and received one dose of crofab with improvement. Per (Hospital A) records, general surgery did not feel they could take care of wound and he was sent to (Hospital B) for further care. ...He states the dose of crofab improved the swelling such that now he is able to move his hand without intense pain. He has full sensation and motor function to RUE. He received tetanus at (Hospital A). Right hand XRay [sic] at (Hospital A) was negative for any injury. ...Assessment: ...male with recent snakebite to RUE with increased swelling. Received Crofab at (Hospital A). Will monitor for signs, symptoms of [DIAGNOSES REDACTED]. Admit to floor 2. IVFs 3. Pain control ...6. Will monitor for s/s (signs and symptoms) of [DIAGNOSES REDACTED]. ..." Review of a "Trauma Services Discharge Summary" dated 05/02/2017 at 0936, revealed " ... Hospital Course: After full trauma work up, primary and secondary surveys completed, including labs, xrays [sic], and CT scans the above listed injuries were identified. The patient was admitted for continued care. Had no issues while in the hospital, no fevers or reaction to the crofab or the bite. Labs were normal, medically clear to be discharged . This discharge is inclusive of a negative tertiary evaluation. Tertiary survey was completed and was negative for additional injuries. Disposition: The patient will be discharged to Home in Stable condition." Review revealed a discharge diagnosis of [DIAGNOSES REDACTED]" The patient was discharged on [DATE] at 1046. Telephone interview on 05/18/2017 at 0909 with PA #1, revealed he was on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). He remembered the patient. He was the QMP who performed the patient's MSE. The patient presented with a possible insect or spider bite to his right hand. Upon initial assessment of the right hand he could not see any marks or bleeding. There were no wounds. After the hand was cleaned, he noticed a mark, "one" mark in the web between fingers. The area was warm and red with swelling present. It could have been an ant, insect, or spider. It did not occur to him to be a snake bite. It appeared to be a "localized inflammatory response" The patient was administered Solumedrol, Benadryl and Pepcid IV. The patient was offered a Tetanus shot but he refused. When reassessed, the patient's hand had improved. It was not as hot or swollen. After a second round of anti-histamines were given, there was "significant improvement" and "minimal redness" and did not look like cellulitis. The patient was prescribed antibiotics to cover for potential infection from the puncture mark on the hand. The patient was discharged . He had no fever or risk factors. The supervising DED physician on-duty was not consulted about the patient. There was no reason to admit the patient. If the patient's condition had worsened, he would have consulted the physician. If he had the same scenario and same presentation by another patient, he would not have changed his treatment plan and would have discharged the patient. Note: When asked to clarify his MSE documentation of the "Extremities: General upper extremity: other - right hand with (blank)" his response was: The hospital used dictation software for the providers to document their MSE in the medical record. The software must have failed to document his assessment. The software should have transcribed right hand with red mark in center of the webbing between the 4-5 digits, localized swelling around the dorsum of the hand with mild heat to the area extending up to the right wrist. Normal ROM. Normal Pulse. PA #1 was unaware his assessment of the right hand had not been completely documented. Further interview revealed the patient's symptoms were not systemic, there was no toxicity and vital signs were stable. If he had suspected a cat or snake bite he may have ordered an x-ray to see if there were any teeth left in the puncture site. If he had suspected a snake bite, or if the patient had diabetes, fever, or cellulitis he would have ordered PT/PTT/INR and CBC. It crossed his mind initially that it may have been a snake, but when he examined the right hand and only saw one mark, he stated he was not even thinking a snake bite. He stated he ruled out snake bite do to the patient's response to antihistamines. The patient was discharged in stable condition. The patient had an EMC on presentation; on discharge "not so much." He stated he would not change the treatment delivered based on the presentation. The next day he was made aware the patient had returned to the ED and was transferred to Hospital B on Crofab. He also stated he was made aware the patient had filed a complaint with the hospital within the last 48 hours. Interview confirmed he did not discuss the patient's care with the on-duty supervising DED physician. Telephone interview on 05/18/2017 at 0928 with PA#2, revealed she was on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). She recalled the patient. She was the QMP who performed the patient's MSE. The patient presented with increased swelling and redness to his right hand. The swelling did not extend past the elbow. The patient had full range of motion of the elbow and shoulder. Patient reported that when he was cleaning his hand in the morning, he noticed a second puncture wound. The patient reported a burning sensation traveling up his arm more than before. Labs were ordered and Dr. (Physician B) the attending DED physician on-duty was consulted. There was the possibility the patient would need antivenin. Physician B contacted poison control and determined the dose of antivenin to be administered. Discussed case with Physician B, he talked to the hand surgeon on-call, Dr. (Physician D). Physician D declined to evaluate the patient because he did not treat snake bites. CroFab administration was pending blood results to ensure lab values were within normal limits. Physician B confirmed to start the antivenin. She consulted Dr. (Physician E), the on-call General Surgeon, who was in a case? He declined to come evaluate the patient because he did not treat wounds/snake bites in the upper extremities. He felt the patient should be transferred. PA #2 then called Hospital B and consulted with Dr. (Physician F) [Internal Medicine], and Dr. (Physician G) [Surgeon]. They suggested she consult Trauma Surgery. She consulted Dr. (Physician H), Trauma Surgeon, who accepted the patient for transfer to Hospital B. PA #2, stated she nor Physician B consulted Hospital A's hospitalist because Physician B said the Hospitalist did not admit and treat snake bites. The decision was made to transfer the patient by Physician B. She stated the hospital's on-call physicians had turned the case down. The patient had an EMC. The patient needed to be monitored while on CroFab and monitored for [DIAGNOSES REDACTED]. The patient's condition was improved upon transfer, swelling, redness, and pain had decreased after the CroFab had been initiated. Telephone interview on 05/18/2017 at 1005 with Physician E, revealed he was the on-call General Surgeon when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). He was consulted by the ED providers, but was not requested to present to the ED. He declined to evaluate the patient because he "does not treat hands." He stated hand surgeons have a skill set. "I don't have the skill set, there was no point in evaluating the patient." Telephone interview on 05/18/2017 at 1030 with Physician D, revealed he was the on-call Orthopedist when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). Physician B, spoke with him regarding the patient. The patient had presented to the ED 24 hours earlier and returned for a snake bite to the hand. The hand was swollen. There were questions for the need of antivenin and admission. He stated he was not a snake bite specialist or hand surgeon. The patient needed to be admitted to the hospitalist services not orthopedics. There was not an orthopedic issue at the time, it was more of a medical issue due to the venom. He was not requested to present to the ED. Review on 05/18/2017 of Hospital A's current Medical Staff Bylaws, Rules and Regulations (dated March 31, 2016), revealed, "Article II ...2.2.2 Unassigned Call Service a. Unassigned Call Schedule: The Hospital is required to maintain a list of physicians or appropriate designees who are on call for duty after the initial examination to provide treatment necessary to stabilize an individual with an emergency medical condition. Each Clinical Department shall provide the Emergency Department and the Medical Staff Services Office with a list of physicians and other practitioners who are scheduled to take emergency call on a rotating basis. Emergency call shall be from 0800 to 0800 the following day. Authorized allied health practitioners privileged through the medical staff can respond as first responder consistent with their collaborative agreements. b. Response Time: It is the responsibility of the on-call physician/practitioner to respond in an appropriate time frame. The on-call physician should respond to calls from the Emergency Department within thirty (30) minutes. If the on-call physician does not respond to being called or paged, the appropriate department policy with regard to the chain of command will be followed. Failure to respond in a timely manner may result in referral to the Medical Executive Committee (MEC) for appropriate action. c. Substitute Coverage: It is the on-call physician's responsibility to arrange for coverage and notify the Emergency Department through the switchboard if he/she is unavailable to take call when assigned. Failure to notify the Emergency Department of alternate call coverage may result in referral to the MEC for appropriate action and the physician will be considered to still be on call. Telephone interview on 05/18/2017 at 1040 with Pharmacy Director #1, revealed the hospital kept a stock of CroFab on-hand. There was a quantity kept in the ED and a back-up supply in the pharmacy. The hospital kept a sufficient supply for the initial dose and to get an additional dose the following day. If additional does were needed they would have to order them from the supplier or borrow from surrounding hospitals. CroFab was "a very expensive medication." The cost of an average does of 4 vials was $46,000. The administration of CroFab does not require any authorization or approval from the Pharmacy or Hospital administration. If there is the need and a physician's order the medication is administered regardless of insurance or payor source. In emergent type situations, CroFab is immediately accessible by staff for administration to the patient. Telephone interview on 05/18/2017 at 1345 with Physician A, revealed she was an attending physician on-duty when Patient #8 presented to Hospital A's DED on 04/30/2017 (visit #1). She was available for consult by PA #1. She had no contact with Patient #8. She only co-signed the chart. PA #1 did not consult her regarding Patient #8. She generally does not read the ED charts she just electronically co-signs them. Telephone interview on 05/18/2017 at 1410 with Physician B, revealed he was the attending physician on-duty when Patient #8 presented to Hospital A's DED on 05/01/2017 (visit #2). He received report from the PA (PA #2) and evaluated the patient. The patient had old ink drawn on his right hand that delineated swelling above the wrist. The patient now had swelling from his wrist to his elbow. There were two visible puncture marks on the dorsal of the hand at the 4th-5th web space, distal to the knuckle. When you only have one puncture mark the question is, is it a snake bite vs. spider bite? The patient reported after he cleaned up his hand, he saw little marks and the second puncture mark and returned to the ED. Knowing CroFab cost "thousands of dollars" and that the patient had no insurance, he performed an internet search to find out the value of administering CroFab twenty hours after an initial snakebite. He was unable to find any information. Dr. (Physician D) was on-call for Orthopedics. Physician D was consulted and stated he did not do snake bites and declined the evaluation. The PA called Dr. (Physician E) the on-call General Surgeon who stated he did not do upper extremities/hands and had never given CroFab; and declined to evaluate the patient. Physician E recommended the patient be admitted to medical for monitoring. Physician B stated he knew Hospital A's hospitalist did not admit and take care of snake bites. He attempted to call Dr. (Physician C), who had experience with snakebites, but was not on-call and was in New York; prior to calling Physician E. Based on his experience he believed the patient had been bitten by a cotton mouth or copperhead snake. . Interview on 05/18/2017 at 1020 with the CEO of Hospital A, revealed Physician E was a Locums Tenens physician with temporary privileges signed on 03/26/2017. In summary, patient #8 (MDS) dated [DATE] the patient returned to the hospital (11 hours later) with increased pain, swelling, redness, and warmth with distal pulses and sensation diminished. The patient informed the hospital staff there were "now" two puncture sites visible and he was concerned that he was bitten by a snake. The patient's arm was elevated and he was given a sling along with a hand consultation done by physician who stated he did not take care of snake bites. The patient was administered a snake antivenom and a general surgeon consult was done who also stated he did not take care of wounds to the hands and suggested a patient transfer. The patient was transported by critical care personnel to another hospital (B) where he was admitted as inpatient and treated. The review revealed concerns that the patient was not stabilized prior to transfer during the second DED visit to Hospital A on 05/01/2017 as evidenced by the hand surgeon refusing to accept the patient on their service or manage the patient in conjunction with an accepting medical team.

Based on review of medical records, policies and procedures, medical staff rosters, emergency room Call Schedules, and interviews the hospital inappropriately transferred and individual by failing to provide medical treatment that was within its capability and capacity to render care that minimized the risks to an individual's health who presented to the hospital's emergency department with a limb threatening injury for 1 (#8) of 24 sampled patients. Findings Included: Review of the facility's policy and procedure titled "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER. POLICY #509, effective August 6, 1999, last revision date 12/12, revealed in part, "G. Other EMTALA Provisions ...An improper transfer includes the following "D. Refusal of an on call physician to respond to a request from the emergency department for evaluation of a person believed to have an emergency medical condition ...or to provide stabilizing treatment to a patient with an emergency medical condition, when refusal cause the transfer of the patient to another hospital to receive stabilizing treatment." Review of Patient #8's "Patient Transfer Form (EMTALA)" dated 05/01/2017 certified by Physician B at 1800, revealed "[check mark in box] Stable. The patient has an emergency medical condition, but the condition is stable. No material deterioration is likely to result from: (1) a transfer to another facility, or (2) discharge with instructions for appropriate follow-up care. ...Patient-Specific Benefits of Transfer: Admission to manage snakebite injury. Patient-Specific Risks of Transfer: worsening swelling of hand, increased pain. ..." Review revealed the patient's vital signs prior to transport were reassessed at 2002 as T 97.9? F, P 65, R 18, BP 141/85, SpO2 97% on room air. The patient was transported by critical care personnel to another hospital (B) where he was admitted as inpatient and treated. The patient departed the DED at 2021. Review on 05/17/2017 of Hospital A's "emergency room on -Call Schedule" for May 1, 2017 (revised at 1036) revealed, Physician D was on-call for Orthopedics and Physician E was on-call for General Surgery. Review on 05/17/2017 of Hospital A's Medical Staff Roster (dated 05/16/2017 at 1121), revealed Physician D's staff category was "active" and privilege status was "active" and specialty was "Orthopedics" and his re-privilege/credential date was 07/28/2018. Further review revealed, Physician D's staff category was "Locum Tenens" and privilege status was "Temporary" and specialty was "Surgery" and his re-privilege/credential date was 07/04/2017. Hospital B (Receiving Hospital), closed medical record review on 06/02/2017 for Patient #8, revealed the patient (MDS) dated [DATE] at 2147 and was direct admitted to an in-patient unit for observation with a diagnosis of [DIAGNOSES REDACTED]"Chief Complaint: Snakebite RUE. History of Present Illness: ...49 y. o. male with no pmhx (past medical history) who reports a snakebite to Right hand. Patient states he was gardening and reached his hand under a board and felt a burning sensation. He did not see the snake. He states he knows this was a snake due to the two puncture marks over his 4th/5th digits. States he had some immediate swelling and went to the ED and was subsequently sent home. He then returned to (Hospital A) ED today with increased swelling and received one dose of crofab with improvement. Per (Hospital A) records, general surgery did not feel they could take care of wound and he was sent to (Hospital B) for further care. ...He states the dose of crofab improved the swelling such that now he is able to move his hand without intense pain. He has full sensation and motor function to RUE. He received tetanus at (Hospital A). Right hand XRay [sic] at (Hospital A) was negative for any injury. ...Assessment: ...male with recent snakebite to RUE with increased swelling. Received Crofab at (Hospital A). Will monitor for signs, symptoms of [DIAGNOSES REDACTED]. Admit to floor 2. IVFs 3. Pain control ...6. Will monitor for s/s (signs and symptoms) of [DIAGNOSES REDACTED]. ..." Review of a "Trauma Services Discharge Summary" dated 05/02/2017 at 0936, revealed " ... Hospital Course: After full trauma work up, primary and secondary surveys completed, including labs, xrays [sic], and CT scans the above listed injuries were identified. The patient was admitted for continued care. Had no issues while in the hospital, no fevers or reaction to the crofab or the bite. Labs were normal, medically clear to be discharged . This discharge is inclusive of a negative tertiary evaluation. Tertiary survey was completed and was negative for additional injuries. Disposition: The patient will be discharged to Home in Stable condition." Review revealed a discharge diagnosis of [DIAGNOSES REDACTED]" The patient was discharged on [DATE] at 1046. A telephone interview was conducted with Physician B on 5/18/2017 at 1410. Physician B stated he did have an issue with General Surgery. He thought the patient should have been taken care of at Hospital A and not transferred. He felt any General Surgeon should be able to treat a snakebite and that generally, Orthopedics do not. Given the hospital's resources, if a Surgeon was not comfortable treating a snakebite they should tell someone and not be staffing the ED. Physician B stated no hospitalist at Hospital A were consulted. Historically General Surgery has taken care of snakebites at the hospital and if needed a referral is made to Orthopedics. The facility failed to ensure that their own policies and procedures were followed as evidenced by the on call physician declining/refusing to come to the emergency department when notified by the emergency department physician that further evaluation and treatment was needed for patient #8 on 5/1/2017, when it was determined the patient had an emergency medical condition. As this resulted in an inappropriate/improper transfer of patient #8 on 5/1/2017.

Based upon hospital Medical Staff bylaws, rules and regulations review, policy reviews, medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 23 sampled DED patients (#18) who presented to the hospital for evaluation and treatment and was escorted out of the hospital's DED by Security personnel; and the DED Labor and Delivery (L&D) physician failed to certify in the medical record prior to discharge that a patient who presented to the hospital's DED L&D for contractions was in false labor and not true labor for 1 of 2 sampled DED L&D patients (#25); the hospital leadership failed to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate medical screening examinations (MSE) was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A). Findings included: 1. Review on 10/28/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy: 509, revised 12/2012, revealed "...II. PURPOSE AND APPLICABLE LAW: ...It is the policy of (Hospital A) to provide an appropriate medical screening examination, regardless of ability to pay, to persons requesting care or treatment on the hospital campus to determine the nature and extent of their injury, medical condition and/or pregnancy and to provide such additional care within the capabilities of the hospital and staff to stabilize the condition of the patient or to provide for an appropriate transfer. ...III. DEFINITIONS ...C. Emergency Medical Condition - a condition that manifests itself by such acute and severe symptoms that in the absence of immediate medical attention could reasonably result in serious jeopardy of the health of the individual (or an unborn child), serious impairment to bodily functions, or serious dysfunctions of any bodily organ or part. ...Examples of medical emergencies include: severe pain... D. Appropriate Medical Screening Examination - a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists. The medical screening examination must be uniform for all patients who present with similar complaints. ...IV. PROCEDURE: A. Patient Evaluation and Treatment ...1. EMTALA is triggered when a person 'comes to the emergency department' and a request is made by that individual or on his or her behalf for an examination or treatment of 'a medical condition'... 2. The medical screening exam will be provided within the capability of the hospital's emergency department and will include ancillary services routinely available to the emergency department. ...7. If the patient refuses to consent to a medical screening examination or to further stabilization treatment: a. Provide the individual with an explanation of the risks and benefits to the individual of the examination and/or treatment. b. Describe in the medical record the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. c. Take all reasonable steps to obtain the individual's....written informed refusal of the examination and/or treatment. The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. The document should be signed, if possible, by the individual....dated and placed in the individual's medical record. ...E. Medical Screening Examination A medical screening examination is provided to every presenting patient to determine within reasonable clinical confidence whether an emergency medical condition exists. This medical screening is uniform for all patients who present with similar complaints and within the capabilities of this hospital including ancillary services available to the emergency department. ..." Hospital A, closed DED record review on 10/27/2015 for Patient #18, revealed a [AGE] year old female presented ambulatory via private transportation to the hospital's DED on 09/17/2015 at 0931. Review of an "Emergency Services Triage Registration Form" revealed "Reason for Visit: Pelvic hurting, Rt (right) side hurting, lower back and leg pain (hand written by Patient #18)." Review revealed "If in pain please circle current level" with a circle around "5 Hurts Worst." Further review revealed "Vaginal Discharge Yellow" and "Odor" hand written on the left side of the form. Review of Triage documentation revealed the patient was triaged by RN #1 at 0933. Review revealed a "Stated Complaint: PELVIC PAIN, FLANK PAIN" and "Chief Complaint: Pelvic Pain." Review of Pivot Triage Assessment documentation at 0933 by RN #1 revealed, "Pain Level 5" (0 - no pain, 5 worst pain). Further review revealed "History of present illness PT (patient) reports pelvic pain for the past 2 weeks. Pt denies any urinary sx (symptoms). Pt reports yellow vaginal discharge with an odor. Pt able [sic] with a steady gait." Review revealed vital signs were assessed as Temperature (T) 98.5 degrees Fahrenheit (F), Heart Rate (HR) 92, Respirations (R) 20, Pulse Oximetry (P/Ox) 99% on room air (RA), Blood Pressure (BP) 130/81. Review revealed pain was assessed as 5, Quality was constant and achy. Review revealed the patient was triaged as a priority 3 (Emergency Severity Index 1-5, 1 most severe, 5 least severe). Review revealed the patient was placed into treatment room #9 at 0952. Review of Nursing assessment documentation at 1013 by RN #2 revealed, level of consciousness - awake, alert, and appropriate. Patient oriented to person, place, time, and events. Skin - dry, pink, intact, warm. Skin turgor - good. Respiratory - breath sounds clear, breathing is unlabored, respiration pattern normal, respiratory effort normal. Cardiovascular - normal peripheral pulses, regular rate, rhythm. Abdomen is soft, non-tender. Nausea/Vomiting - Yes. Bowel sounds normal active all quadrants. Review revealed "Pt presents to ED with c/o (complaints of) pelvic pain. Pt states she is having 5/5 constant aching pain in her pelvis and back radiating to legs. Pt has no tenderness with palpation. Pt c/o nausea denies vomiting, denies urinary symptoms. Review revealed at 1031, discharge documentation - condition at discharge "Unchanged." Patient discharged ambulatory. Verbalized understanding of discharge instructions "No." Review revealed "Pt dc'd (discharged ) to ED lobby escorted by security after attempting to assault Dr. (Physician A) name. Pt ambulated with fast paced gait stating 'Don't f....k with me.' Pt did not receive discharge instructions." (38 minutes after placement in treatment room #9). Review revealed an MSE was initiated by Physician A at 1010. Review of MSE documentation by Physician A, revealed "Chief Complaint: Pelvic Pain" and "Stated Complaint: PELVIC PAIN, FLANK PAIN." Review revealed "Notes: ...female presents with complaints of pelvic back pain chronic. pt denies any new concerns. Pt denies any fevers or chills" Review revealed a Past Medical History of hypertension, asthma, ovarian cysts, arthritis, musculoskeletal trauma. Review revealed a Past Psychiatric Medical History of anxiety, bipolar disorder, depression, and schizophrenia. Review of ROS (Review of Systems) revealed "...GASTROINTESTINAL: admits to abdominal pain. GENITOURINARY: Denies difficulty urinating, painful urination, burning, frequency, blood in urine, or discharge. FEMALE GENITOURINARY: Denies vaginal bleeding, heavy or abnormal periods, irregular periods. Denies vaginal discharge or odor. ..." Review of Physical Examination revealed, "GENERAL: Obese, angry female ...LUNGS: breathing with no difficulty ABDOMEN: Soft, nontender, nondistended abdomen. No guarding, no rebound. No masses appreciated. Female GU: deferred ...PSYCH: Angry...". Review revealed at 1030 "[AGE]-year-old female who was seen here very often for random pains presents with complaints of pelvic pain. Patient states that we must throughout [sic] her pain is from and that she does not have a primary care physician for [sic] I did explain to the patient that we would gladly evaluate her but that she needed OB/GYN to followup with. Lab work has already been ordered, I think the patient [sic] she will be receiving, [sic] and not narcotics at this point the patient became aggressive violent and began yelling, stood up and went to punch pain [sic] the face. I explained to the patient that she needs to calm down and sit down she again this patient [sic] in my face at which point for my own safety I left the room and had security escort the patient off the premise. IGiven [sic] that patient is here often, I expect her to return if there are any continued issues." Review revealed "Clinical Impression: Pain in pelvis Condition: Stable Disposition: HOME, SELF-CARE Additional Instructions: You have been removed off the premises and [sic] for aggressive behavior. When you have stopped threatening staff and stopped threatening to kill the physician you may return for further evaluation." Review revealed the following physician's orders were entered by Physician A for Patient #18 at 1012 and were canceled. (Patient discharged prior to collection.): 1. Tylenol 975 mg by mouth; 2. Complete Blood Count with Differential; 3. Comprehensive Metabolic Panel; 4. Hcg Qualitative, Urine (pregnancy test); 5. Lipase; and 6. Urinalysis. Further record review failed to reveal any available documentation the patient was given written discharge instructions for aftercare follow-up. Record review failed to reveal any available documentation the patient refused care or left against medical advice (AMA). Interview on 10/28/2015 at 1028 with Physician A revealed he had been on the medical staff for 14-15 months. Interview revealed he was employed by the hospital's contracted emergency physicians' group. Interview revealed he was the DED attending physician on-duty who performed the MSE on Patient #18 when she (MDS) dated [DATE]. Interview revealed "the patient had been in the ED 17-18 times in the past year." Interview revealed "she is a known narcotic abuser, always coming in with pain complaints." Interview revealed "I have known her from visits before." Interview revealed the patient came in with complaints of back and pelvic pain. Interview revealed she was in room 9 or 10. Interview revealed "I walked into the room. Introduced myself. She had chronic back/pelvic pain. I explained I can evaluate and treat her but she would have to follow-up with OB/GYN for pelvic pain." Interview revealed "I told her I would not be giving her narcotics and would be treating her with anti-inflammatories. She jumped out of bed and became violent. She took a swing at my face." Interview revealed "she was a big woman." Interview revealed "I stepped back. I was examining her at the time." Interview revealed "I was conducting a normal PE (physical exam), head to toe." Interview revealed "I did not get to listen to her lungs or heart, this is when the patient swung at me." Interview revealed the patient did not report any vaginal discharge or odors during the exam. Interview revealed "It (yellow vaginal discharge and odor) was documented on the original nurse's note." Interview revealed "she admitted on ly to abdominal, pelvic, and back pain." Interview revealed "I asked the patient to sit and calm down and she took a swing at me again." Interview revealed "I took her behavior to indicate I would not be doing a pelvic exam." Interview revealed the female genitourinary exam was deferred. Interview revealed "the plan was to do a pelvic exam." Interview revealed "if the patient had acted normal and cooperative a pelvic exam would have been performed." Interview revealed "the patient threatened me, said she was going to kill me." Interview revealed "I left the room, and called security after she tried to punch at me twice." Interview revealed "my physical exam and her vital signs is what I based my decision on, that she was stable and could be discharged ." Interview revealed "she had an exam, nothing was acute from her vital signs, so I discharged her." Interview revealed "I told the patient she could return when she was no longer violent towards the staff and threatening to kill me." Interview revealed the patient did not receive any written discharge aftercare follow-up instructions. Interview revealed "she stormed off." Interview revealed the patient was "escorted out by security." Interview revealed labs and Tylenol (for pain) had been ordered. Interview revealed "I ordered the labs before I entered the room." Interview revealed "I am not sure if they were collected and performed." Interview revealed the patient had been evaluated and "the labs would not have changed the treatment for the patient." Interview revealed "the exam showed no tenderness, no neuro deficits, and she was able to move around." Interview revealed "the patient was stable and did not have a emergency medical condition." Interview revealed "I called security for safety." Interview revealed "I do not recall if I asked the patient to be escorted out or if the patient stormed out." Note: Medical record reviews revealed transcription errors. Interview revealed the following clarification of the medical record by Physician A for his MSE entry dated 09/17/2015 at 1030 - "[AGE]-year-old female who is seen here very often for random pains presents with complaints of pelvic pain. Patient states that we must find out where her pain is coming from and that she does not have a primary care physician. I did explain to the patient that we would gladly evaluate her but that she needed OB/GYN to followup with. Lab work has already been ordered, I told the patient she would be receiving anti-inflammatories and not narcotics. At this point the patient became aggressive violent and began yelling stood up and went to punch me in the face. I explained to the patient that she needs to calm down and sit down. She again tried to punch me in the face at which point for my own safety I left the room and had security escort the patient off the premises. Given that the patient is here often, I expect her to return if there are any continued issues." Interview on 10/28/2015 at 1005 with RN #2 revealed she was a DED nurse. Interview revealed she was the primary treatment nurse for Patient #18 on 09/17/2015. Interview revealed the patient was at Pivot triage, then placed into treatment room #9. Interview revealed the patient complained of pelvic and back pain down her legs. Interview revealed the patient denied urinary symptoms and had no tenderness to her abdomen and back. Interview revealed the patient's pain was reported as a 5 out of 5, a constant achy pain. Interview revealed "Dr. (Physician A) had gone into do an evaluation." Interview revealed "I was in a room next door, when I heard the patient yelling." Interview revealed "I came out of the room and saw security walking beside her (Patient #18), kind of behind her. She was walking quickly." Interview revealed "She screamed 'Don't F....k with me." Interview revealed she did not witness any interactions between the patient and Physician A. Interview revealed the patient was "pleasant and cooperative with me." Interview revealed "I do not know why her mood changed." Interview revealed "she was cursing, but I don't know why." Interview revealed she did not know who called security or the names of the security guards who escorted the patient out of the ED. Interview revealed "I do not know why she was escorted out." Interview revealed "I do not know if the patient made the decision to leave." Interview revealed the patient did not receive any written discharge or follow-up instructions. Interview revealed labs had been ordered but nothing collected prior to the patient leaving. Interview revealed "Dr. (Physician A) told me he went into the room and explained to the patient that she would be getting some lab work and Tylenol and the patient became upset and tried to punch him." Telephone interview on 10/28/2015 at 1134 with RN #1 revealed she was a DED nurse. Interview revealed she was the Pivot triage nurse on 09/17/2015 when Patient #18 presented to the DED. Interview revealed she "vaguely" recalls the patient. Interview revealed the patient complained of pelvic pain, and yellow vaginal discharge with an odor. Interview revealed the patient reported her pain as a 5/5. Interview revealed she was triaged a priority 3. Interview revealed she recalled security escorting the patient out of the ED for causing a disturbance in back and posing a threat. Interview revealed she had no other interactions with the patient and did not witness any interactions between the patient and Physician A. Interview on 10/28/2015 at 1103 with Security Officer (SO) #1 revealed he was a security officer on-duty 09/17/2015 during the day shift (0530-1400). Interview revealed he received a call that a patient (Patient #18) had been discharged from the ED and did not want to leave the treatment room. Interview revealed SO #2 assisted and was the first security officer on-scene. Interview revealed when he arrived to the ED, the patient was at the treatment room doorway "on her way out." Interview revealed the patient stated that we did not have to follow her. Interview revealed the two security officers escorted the patient out of the ED to the greeter doors. Interview revealed the patient was talking on her cell phone. Interview revealed the patient was cooperative and complied with the request to leave. Interview revealed "nothing was said about an incident involving the patient being violent and aggressive." Interview revealed "It was my understanding the staff wanted the patient out of the room and the patient just did not want to leave." Interview revealed "there was no mention the patient had been violent or aggressive towards the physician." Interview revealed "we were asked to escort her out of the ED." Interview revealed he did not witness any aggressive or violent behaviors or use of profanity by the patient. Interview revealed when security is called for patients with violent or aggressive behaviors, "we talk with them and try to calm them down." If staff can not deescalate the situation, restraints can be used, or call police for assistance. Interview revealed "normally we try to handle it in-house." Interview revealed the incident was not recorded in the security log book because it was considered routine. Interview on 10/28/2015 at 1121 with SO #2 revealed he was a security officer on-duty 09/17/2015 during the day shift. Interview revealed he remembers the incident involving Patient #18. Interview revealed he was in the security office and received a phone call that security was needed in the ED. Interview revealed he went to the ED. Interview revealed "Dr. (Physician A) met me at the nurses' station and wanted the patient in room #8 or #9, escorted out of the building." Interview revealed "I was unsure of the events or why he wanted the patient escorted out." Interview revealed he was assisted by SO #1. Interview revealed the patient stated she did not need to be escorted out and was not worried about the hospital. Interview revealed the patient told us not to touch her. Interview revealed as the patient was walking out she called someone on her cell phone and was talking about the hospital. Interview revealed "the patient was angry and cussing as she was walking." Interview revealed the patient stated "you better not F....king touch me." Interview revealed the patient was cooperative. Interview revealed he did not witness any aggressive or violent behaviors from the patient. Interview revealed "Dr. (Physician A) was out of the room in the middle of the nurses' station when I arrived." Interview revealed "I was unaware the patient tried to assault Dr. (Physician A)." Interview revealed staff are trained on how to handle patients with violent and aggressive behaviors. Interview revealed staff are to try to deescalate the situation, can use restraints with a physician's order, or call the local police department for assistance. Interview revealed "we talk before we touch." Interview revealed the incident was not recorded in the security log because it was routine and did not involve any physical contact. Interview on 10/29/2015 at 1432 with Physician G revealed he was the DED Medical Director for Hospital A. Interview revealed he reviewed the patient's DED record for her 09/17/2015 visit in response to a grievance filed by the patient with the hospital. Interview revealed "the standard of care for the complaint (pelvic pain and yellow vaginal discharge with odor) is to have a pelvic exam done." Interview revealed "the patient should have received a pelvic exam, but there was extenuating circumstances by both parties." Interview revealed "a different approach of deescalating would have served useful." Interview revealed "when taken into context the totality of frequent visits and that the patient was a danger to our staff, I don't think there was an EMC at the time." 2. Review on 10/28/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy: 509, revised 12/2012, revealed "...II. PURPOSE AND APPLICABLE LAW: ...It is the policy of (Hospital A) to provide an appropriate medical screening examination, regardless of ability to pay, to persons requesting care or treatment on the hospital campus to determine the nature and extent of their injury, medical condition and/or pregnancy and to provide such additional care within the capabilities of the hospital and staff to stabilize the condition of the patient or to provide for an appropriate transfer. ...III. DEFINITIONS ...C. Emergency Medical Condition - a condition that manifests itself by such acute and severe symptoms that in the absence of immediate medical attention could reasonably result in serious jeopardy of the health of the individual (or an unborn child), serious impairment to bodily functions, or serious dysfunctions of any bodily organ or part. ...D. Appropriate Medical Screening Examination - a screening to determine, with reasonable clinical confidence, whether an emergency medical condition exists. ...G. Labor - means the process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta. A woman experiencing contractions is in true labor unless a physician, certified nurse midwife, or other qualified medical person (as defined in the medical staff bylaws) certifies that, after a reasonable time of observation, the woman is in false labor. ...E. Medical Screening Examination A medical screening examination is provided to every presenting patient to determine within reasonable clinical confidence whether an emergency medical condition exists. This medical screening is uniform for all patients who present with similar complaints and within the capabilities of this hospital including ancillary services available to the emergency department. ..." Review on 10/28/2015 of current facility policy "LABOR CHECKS", Policy: 6190-31, revised 02/20/2013, revealed "Patients at 20 weeks gestation or greater presenting to (Hospital A) with obstetrical complaints will be seen on the Labor and Delivery Unit. ...3. If patient is not admitted : ...c. Document medical diagnosis as ordered by M.D./C.N.M. ..." Hospital A, closed DED L&D record review on 10/28/2015 for Patient #25 revealed the patient presented to the L&D via wheelchair from home on 10/25/2015 at 1731 with a chief complaint of "Suspected Rupture of Membranes; Vaginal Bleeding." Review of triage nurse documentation at 1800 by RN #6 revealed, fetal movement - present, contractions - frequent, vaginal bleeding - normal show, vaginal discharge - present. Review revealed "Patient Complaints Contractions." Review revealed pain on admission was assessed as 3/5 (0 pain free, 5 worst pain), pain presence - intermittent, pain type - contractions, pain location - abdomen and back, pain related to contractions - yes. Review revealed membranes status - intact, speculum results - small amount bright red blood, mucous tinged. Review revealed dilatation 1-2 cm (centimeters), effacement (%) - 40-50 effaced, station - minus 3, consistency - soft, position - midposition, total Bishops Score 5 (5-8 = Small percentage of induction failure). Review revealed level of consciousness - fully conscious, DTR's (deep tendon reflex)/Clonus - DTRs 2 plus; No Clonus, extremity movement - full range of motion. Review revealed heart rhythm - regular, nailbeds - pink, capillary refill - less than 3 seconds. Review revealed respiratory effort - unlabored, regular rhythm, breath sounds (left and right) - clear and equal. review revealed skin color - normal for race, skin temperature - warm, moisture - dry. Review revealed Fetal evaluation - monitor mode - External US (ultrasound), FHR (fetal heart rate) baseline rate (bpm) - 145. Review revealed procedures - sterile vaginal exam. Review revealed at 1802, vaginal bleeding - normal show; vaginal Exam - dilatation 1.0 cm, effacement (%) - 50, station - minus 2, exam by - (RN #6). At 1830, contraction frequency 1.5-5 per minute, duration - 30-110 seconds, quality mild/moderate, FHR 145. At 1859, "Communication Provider orders received" and "Provider Notified....Dr. (Physician E)" and "Notification Reason Status Update; Fetal Status; Labor Status; Membrane Status; Uterine Activity; Pain; Bleeding; Lab/Diagnostic Study" and "Communication Comments Provider notified of negative fem results, sterile speculum exam, sterile cervical exam, reactive FHTs (fetal heart tracing), contraction pattern, maternal vital signs, vaginal bleeding, and urinalysis. Orders received to monitor vaginal bleeding for four hours with pad count and reassess after four hours." At 1900, contraction frequency 3-5, duration - 60-100 seconds, quality mild, FHR 140. Review revealed documentation by RN #4 at 1930, contraction frequency 3-5 per minute, duration 50-80 seconds, quality mild/moderate, FHR 145. At 2000, contraction frequency 2-5 per minute, duration 50-70 seconds, quality mild/moderate, FHR 150. At 2049, "Fetus A Comments Baby very active." At 2138, vaginal bleeding - small, vaginal exam - dilatation 1.0 cm, effacement (%) 0 (zero), station - minus 1, exam by (RN #4), Vaginal Exam Comments - "small amount of blood mixed with mucous noted on glove. Peri-pad is same pad has had one [sic]. Old blood noted with smears of fresher blood. No area of saturation noted. At 2145, "Dr. (Physician E) notified of u/c (uterine contractions) pattern, bleeding and repeat vag (vaginal) exam. Orders received." At 2201, "Pt d/c'd (discharged ) to home via w/c (wheelchair) with care notes on early labor. Instructed to keep appointment tomorrow in office." Review of a "Discharge Record Chart" at 2211 by RN #4 revealed, discharged to home, accompanied by husband, via wheelchair. Review revealed "Discharge Condition Stable" and "discharged By Dr. (Physician E)." Discharge pain 3/5. Review of a "Physicians Order Form" revealed a telephone order obtained by RN #4 from Physician E on 10/25/2015 at 2145 to "D/C home." Record review revealed no available documentation of an MSE conducted by Physician E. Record review revealed no available documentation of a medical diagnosis. Record review revealed no available documentation Physician E, a certified nurse-mid wife, or other qualified medical person acting within his or her scope of practice as defined in hospital medical staff bylaws and State law, certified that, after a reasonable time of observation, Patient #20 was in false labor upon being discharged from the hospital and not true labor. Telephone interview on 10/29/2015 at 1145 with Physician E revealed she was a locum tenens (temporary substitute) physician. Interview revealed her specialty was OB/GYN. Interview revealed 10/24-25/2015 was her "first coverage" for L&D at Hospital A. Interview revealed she was on-call for coverage when Patient #20 presented to L&D for evaluation. Interview revealed she did not come into the hospital to evaluate the patient at bedside. Interview revealed she consulted and communicated with the L&D nurses via telephone. Interview revealed she was not required to come in to evaluate the patient unless requested by the nurse. Interview revealed based on the information provided by the L&D nurse the patient's diagnosis was "False Labor" or "Latent Labor." Interview revealed she did not document any notes in the patient's medical record. Interview revealed she did not verbally give the nurse a medical diagnosis over the telephone to record in the medical record. Interview revealed "I assumed it would be reviewed in Medical Records (department) and a diagnosis would be given based on the nursing notes." Interview confirmed Physician E did not certify in the medial record that after a reasonable time of observation, Patient #20 was in false labor and not true labor. Interview on 10/29/2015 at 1445 with RN #4 revealed she had worked on the Labor and Delivery Unit for 4 years. Interview revealed RN #4 explained the responsibility of the RN performing a labor check as: "anything pertaining to pregnancy" like, intake history, give medications, perform vaginal checks, use amnisure (test strip) to rule out ruptured membranes, and perform speculum checks. Interview revealed nurses are checked off during annual competency by their peers in performing a quality amnisure test and vaginal exams. Interview revealed RN #4 described the steps in the labor check as assigning the mother a room, putting mother on the monitor to assess if the baby's heartbeat and activity is appropriate for gestational age, vaginal exam and call the physician if there is no change in the cervix. Interview revealed the physicians, "trust our vaginal exams and trust that we have a good fetal strip." Interview revealed the physician gives the nurse discharge orders and the nurse provides the patient with discharge (D/C) instructions. Interview revealed the physician may say "it does not sound like they are in labor," but, "we do not have a D/C diagnosis at discharge, it is not part of the discussion with the physician." Interview on 10/29/2015 at 1200 with Chief Nursing Officer (CNO) #1 revealed there was no available documentation in the medical record where Physician E certified that after a reasonable time of observation, Patient #20 was in false labor; and no available documentation of a medical diagnosis written by Physician E or verbally given by telephone to the L&D Nurse and documented in the medical record as of 10/29/2015. 3. Review on 10/29/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy: 509, revised 12/2012, revealed "...III. DEFINITIONS ...D. Appropriate Medical Screening Examination ...The screening exam is performed by qualified medical personnel as designated by the medial staff bylaws. ...G. Labor ...A woman experiencing contractions is in true labor unless a physician, certified nurse midwife, or other qualified medical person (as defined in the medical staff bylaws) certifies that, after a reasonable time of observation, the woman is in false labor. ...IV. PROCEDURE: A. Patient Evaluation and Treatment ...3. The individual shall be evaluated by qualified medical personnel that have been designated by the hospital in its medical staff bylaws or its medical staff rules and regulations. ..." Review on 10/28/2015 of Hospital A's current "Medical Staff Bylaws" dated 12/19/2013 and "Medical Staff Rules and Regulations" dated 04/11/2014 failed to reveal any available documentation of the definition or identification of the individual(s) who were determined qualifie

Based on policy review, closed medical record reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D)physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); and failed to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 4 of 4 sampled patients that were transferred with an EMC to other acute care hospitals (DED #13, #21, #3, and L&D #20). The findings include: Review on 10/28/2015 of current facility policy "EMTALA (EMERGENCY MEDICAL TREATMENT AND LABOR ACT): MEDICAL SCREENING, STABILIZATION, AND TRANSFER", Policy Number: 509, revised 12/2012, revealed "...II. PURPOSE AND APPLICABLE LAW: ...It is the policy of (Hospital A) to provide an appropriate medical screening examination, regardless of ability to pay, to persons requesting care or treatment on the hospital campus to determine the nature and extent of their injury, medical condition and/or pregnancy and to provide such additional care within the capabilities of the hospital and staff to stabilize the condition of the patient or to provide for an appropriate transfer. ...IV. PROCEDURE: A. Patient Evaluation and Treatment ...4. If it is determined that an emergency medical condition exists, (Hospital A) shall either: ...b. Appropriately transfer of the individual to another medical facility. EMTALA permits transfer of an unstable patient for only two reasons: medical indication and patient request. A medically indicated transfer is to a facility that can provide a higher level of care necessary to treat the patient's emergency medical condition that is not available at the transferring hospital. ...B. Transferring Physician and Facility 1. For a medically indicated transfer of an unstable patient, the hospital must: a. Certify that the benefits to the patient from transfer outweigh the risks. ...The transferring physician must certify, in writing, that 'based upon the information available at the time of transfer, the medial benefits reasonably expected from the provision of medical treatment at another facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting transfer.' ....A physician should certify the transfer as medically indicated only when the patient is being transferred to a facility that has equipment or physician resources not available at the transferring hospital. ...". 1. Hospital A (transferring facility), closed DED record review on 10/28/2015 for Patient #13 revealed a 7 month old male patient presented to the DED via private transportation carried by parents on 08/10/2015 at 1200 with a chief complaint of "Altered Mental Status." Review revealed the patient was pivot triaged (Triage #1) by a Registered Nurse (RN) at 1203. Review of triage RN documentation revealed "parents state that they found child just prior not responsive. Infant not following gaze initially upon arrival in ED but is becoming more alert. Parents stating he had similar episode of [sic] Friday and was here in ED for possible seizure. Reports at that time they found him unresponsive and did cpr (cardiopulmonary resuscitation)." Review revealed the patient was assigned a priority level 2 (1-5 scale with 1 most severe and 5 least). Review revealed the patient was reassessed by a triage RN (Triage #2) at 1206. Review revealed "pt (patient) presented to the ED with parents c/o (complaints of) seizure like activity at home approximately 45 minutes prior to arrival. pt woke from his nap 'started staring off into space then started shaking and vomiting' pt is lethargic at this time per mom. pt tearful while getting rectal temp. (temperature) parents report that he was seen here for a possible seizure this previous Friday." Review of ED Nursing Assessment documentation by an RN at 1233 revealed, "Mother reports pt is a normally developed 7 mo (month) old, reports pt was seen here Friday after being found blue and not breathing. PTA (prior to arrival) today pt vomited x (times) 5, was breathing but unresponsive, pt will now awaken and cry, open eyes, behavior not age appropriate at this time." Review revealed at 1250, "Pt held in father's arm, began to tremor, generalized over body, facial twitching, drooling, seizure like activity. Dr. (Physician D) called into room to see pt, ordered 2 mg (milligrams) valium (Benzodiazepine - used to treat seizure disorders) PR (per rectum), ok to give liquid inj (injection) form per Dr. (Physician D). ...Seizure lasted approximately 2 minutes. Mouth suctioned with bulb syringe, minimal secretions. Pt remains on monitor, Dr. (Physician D) at bedside speaking with pt. [sic]." Review revealed at 1551, "pt has seizure activity. generalized shaking with bilateral eye deviation to right upper. pt turned on left lateral side for safety. suction present. administered PR valium as ordered by dr. (Physician D)." Review revealed at 1152, "seizing completed. pt remains on left lateral side for safety..." Review revealed at 1650, "seizure activity noted again. dr. (Physician D) at bedside. orders obtained for additional 0.25 IVP (intravenous push) ativan (Benzodiazepine - used to treat seizure disorders) by dr. (Physician D). given as ordered." Review revealed at 1701, "pt remains on left lateral side in bed for safety. pt awake. pupils checked and are equal and reactive to light." Review revealed at 1711, "Dr. (Physician D) at bedside to update parents on pending transfer." Review revealed at 1806, "EMTALA signed by parent." Review at 1815 revealed, "Transfer Documentation" with Accepting Facility: (Hospital C), Accepting Physician: (Physician L), Transferring Provider: (Physician D), Diagnosis: Seizures, and Transfer crew at bedside at 1815. Review revealed at 1826, "Patient discharged via Stretcher." Further review revealed "Pt leaving ED via (Ambulance Service #1) transport enroute to (Hospital C)." Review of MSE documentation by Nurse Practitioner (NP) #1, revealed the patient was seen at 1210. Review revealed a chief complaint of "Altered Mental Status" and a stated complaint of "Possible Seizure." Review revealed "Notes: ...presents to ed for seizure like activity for 45 minutes. woke up from nap crying the [sic] was staring off in space off and on the [sic] would focus for a minute the [sic] stare off in space. projectile vomiting for 4 big amounts and 1 small amount. Parents [sic] he has been letargic [sic] the entire time. cries when BP (blood pressure) and temp done otherwise laying on shoulder eyes closed not moving around. ..." Review of MSE documentation by Physician D revealed the patient was seen at 1250. Review revealed a chief complaint of "Altered Mental Status" and a stated complaint of "Possible Seizure." Review revealed "Notes: Pt is 7 month 22 day old male who presents to ED secondary to possible seizure PTA today. Father states pt began 'shaking', staring off, and became unresponsive after waking up from nap 45 minutes PTA. Father states pt then became lethargic. Father denies fever, diarrhea, or rash. Father states pt was seen in ED Friday (8/7) secondary to being found cyanotic, and unresponsive by him. Pt was brought to ED for evaluation. (Hospital A) records show that pt had labs, CT (computed tomography) performed (Negative), then admitted for observation. Father states pt was discharged from (Hospital A) 8/8. Review revealed "GEN (General): Appears stated age. Patient is not awake. Parents holding the child most time. ...RESP (respirations): CTA (clear to auscultation) B/L (bilaterally), no wheezes, rales or rhonchi. Adequate Vt (tidal volume). CV (cardiovascular): RRR (regular rate rhythm) with no M/R/G (murmurs, rubs, gallops) MS (mental status): Non-rhythmic movement of extremities that are consistent with seizure activity. When not seizing there is no signs of trauma to the extremities. NEURO (neurological): Alert at times and looking apparent [sic]. He is nonverbal due to age. No obvious focal deficits but the exam is limited. CN (cranial nerves) 2-12 grossly intact. CGS [sic] (Glasgow coma scale) 15 (normal)." Review of re-evaluation revealed at 1630, "Another seizure noticed. This was not as strong as the other one I witnessed." Review revealed at 1709, "Talked with (Hospital C). Dr. (Physician L) will accept patient. Stated they can go higher doses on the Ativan even up to 1 mg (milligram) at a time. Will call me regarding the phenobarbital (barbiturate - used to treat seizure disorders) loading dose. ..." Review revealed at 1726 "Dr. (Physician M) called me about this child. She is peds neuro. Wants phenobarbital 20/kg (kilograms) over 10 minutes." Review revealed "Clinical Impression: Seizure" and "Condition: Fair." Review revealed "Disposition: (Hospital C)." Review of a "PATIENT TRANSFER FORM (EMTALA)" completed for Patient #13 on 08/10/2015 revealed the following pre-printed on the form "PART I (To be completed by Physician) I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer. The benefits relied upon for the transfer are: [check box left blank] Specialized Equipment at Receiving Facility [check box left blank] Specialized Services/Procedure at Receiving Facility [check box left blank] Continuity of Care Other __(line left blank)__. The risks of transfer are: [check box left blank] Transportation Risks which include traffic delays, accidents during transport, inclement weather, rough terrains or turbulence, limitations of equipment and personnel in transport [check box left blank] Deterioration in Patient Condition which includes a potential threat to the health and possible survival of the Patient Other__(line left blank)__." Further review revealed "Chief Complaint/Preliminary Diagnosis" with "Seizures" handwritten on a line. Review revealed "Reason for Transfer [check box left blank] Dialysis [check box left blank] Orthopedic Procedures [check box left blank] Neurosurgery Procedures [check box left blank] NICU (neonatal intensive care unit) [check box left blank] PICU (pediatric intensive care unit) [check box left blank] Interventional Cardiac Services [check box left blank] High Risk OB (obstetrical) [check box left blank] Trauma Care [check box left blank] Specialized MD Care [check box left blank] No ICU (intensive care unit) beds [check box left blank] Other [check box left blank] Specify__(line left blank)__." Review revealed "Facility Accepting Transfer" with (Hospital C) hand written on a line. Review revealed "Physician Accepting Transfer" with (Physician L) handwritten on a line. Review revealed "Transferring Physician's Signature" with Physician D's hand written signature on a line. Further review revealed the lines adjacent to the "Transferring Physician's Signature" for the date and time were left blank. Further review of the form revealed "PART III PATIENT CONSENT FOR TRANSFER (To be completed by the Patient) I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risk and benefits to transfer upon which this transfer is being made. I have considered the risks and benefits listed in Part I of this form and consent to transfer. ..." Review revealed the handwritten signature of the patient's father on the "Signature of Patient or Responsible Party" line dated 08/10/2015 at 1800. Review revealed the signature was witnessed by a RN. Review of the form and medical record failed to reveal any available documentation by the physician certifying the transfer indicating that the benefits and increased risks of transfer specific to the patient's emergency medical condition of Seizures were explained to the patient's parents. Further review revealed no available documentation of the date and time the transferring physician signed "Patient Transfer Form" (Physician Certification). Hospital C (Recipient Facility) closed medical record review on 10/30/2015 for Patient #13 revealed the patient was an emergency admit to Bed WT215 on 08/10/2015 at 2018 with an admitting diagnosis of [DIAGNOSES REDACTED]...presenting with new onset seizures during admission he was found to have non-hemorrhagic moderate-sized bilateral occipital lobe infarctions per MRI (magnetic resonance imaging). ..." Telephone interview on 10/29/2015 at 1122 with Physician D revealed he had been a locums tenens (temporary substitute) physician for the hospital for approximately 4 years. Interview revealed he was the physician who performed the MSE on Patient #13 on 08/10/2015. Interview revealed he was the physician responsible for the patient's transfer to Hospital C. Interview revealed Hospital A has limited resources and has no pediatric ICU beds or pediatric neurologist. Interview revealed he talked to the parents about the transfer. Interview revealed he does not document specific risks and benefits of transfer in the medical record. Interview revealed he only documents on the transfer forms. Interview revealed "the nurse usually hands the forms to me to sign. They hand me 4-5 forms to sign in all." Interview revealed specific risks for Patient #13 included "seizure activity, decreased level of consciousness, deterioration, airway compromise." Interview revealed specific benefits of transfer included "Peds Neurologist, Peds ICU, increased monitoring." Interview revealed "usually the nurse checks the boxes on the form." Interview revealed "I just put my signature on the form." Interview revealed "I typically do not date and time the form." Interview confirmed Physician D failed to document the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #13 at the time of transfer and failed to sign, date and time the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer. Interview on 10/29/2015 at 1200 with Chief Nursing Officer (CNO) #1 revealed the standardized pre-printed risk and benefits check boxes on the Patient Transfer Form dated 08/10/2015 for Patient #13 were left blank. Further interview revealed the date and time of the transferring physician's signature was left blank. Interview revealed there was no available documentation in the medical record where Physician D documented the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #13 at the time of transfer and documented the date and time the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer. 2. Hospital A (transferring facility), closed DED Labor and Delivery (L&D) record review on 10/28/2015 for Patient #20 revealed the patient presented to the L&D via wheelchair on 09/24/2015 at 2212 for "Cramping." Review revealed an EDC (estimated date of confinement) of 12/23/2015. Review revealed an EGA (estimated gestational age) of 27.1 weeks. Review of nursing documentation revealed the patient was triaged by a RN at 2308. Review revealed a chief complaint of "uterine cramping" and "dizziness." Review revealed contractions were irregular, onset 09/24/2015 at 1200. Review revealed pain was assessed as 0 (zero). Review revealed at 2330, contraction frequency was 2-4 per minute, duration 50-80 seconds, quality mild. Pain was reassessed as a 0 (zero). Review revealed "pt (patient) denies feeling cramping at this time." At 0000 (09/25/2015), contraction frequency 1.5-3 per minute, duration 50-80 seconds, quality mild. Review revealed pain was reassessed as 2 (0-5 scale - 0 pain free, 5 worst pain), pain presence intermittent, pain type cramping, and pain location abdomen. At 0006, "Notified Dr. (Physician B) of c/o (complaints of) dizziness and cramping. Pt (patient) ctx (contraction) pattern, FHT (fetal heart tones), ED Interventions. pt pain 2/5...". At 0030, contraction frequency 1.5-4 per minute, duration 50-80 seconds, quality mild. At 0100, contraction frequency 2-5 per minute, duration 50-90 seconds, quality mild. At 0130, contraction frequency 2-6 per minute, duration 60-80 seconds, quality mild. At 0200, contraction frequency 3-5 per minute, duration 50-70 seconds, quality mild. At 0219, "pt reports increased discomfort with contractions." At 0221, "Dr. (Physician B) updated on patient results. Dr. (Physician B) will come to unit to evaluate patient." At 0230, contraction frequency 2-4 per minute, duration 50-70 seconds, quality mild/moderate. At 0254, "Dr. (Physician B) at bedside." At 0300, contraction frequency 2-3 per minute, duration 50-70 seconds, quality mild. At 0302, "Dr. (Physician B) at bedside to discuss transferring patient to (Hospital B)." At 0311, "Discussed with [sic] POC (Plan of Care) with transfer. Patient agrees to go to (Hospital B) to transfer care. All questions answered (documented by a RN)." At 0330, contraction frequency 1.5-3 per minute, duration 50-180 seconds. At 0400, contraction frequency 3-5 per minute, duration 50-80 seconds, quality mild. At 0430, contraction frequency 2-7 per minute, duration 50-80 seconds, quality mild. At 0500, contraction frequency 3-4 per minute, duration 70-90 seconds, quality mild. At 0518, "(Ambulance Service #2) ambulance transport at bedside, report given, care relinquished." At 0524, "Pt off unit via stretcher by (Ambulance Service #2) ambulance transport for transport to (Hospital B)." Review of MSE documentation by Physician B dated 09/25/2015 at 0315 revealed the patient was G (Gravida) 2, P (Para) 0 with EDC of 12/23/2015 and EGA of 27.2 weeks. Review revealed "cc (chief complaint) - dizziness, CTx's (contractions)." Review of "Physical Exam" revealed "Other: + (positive) mild fundal tenderness" and "Contractions: q1-4" (every 1-4 per minute)" and "SVE (sterile vaginal exam): cl/50/^ (closed/50% effaced/High) soft." Review revealed "U/S --> VTX (ultrasound - Vertex)." Review of "Diagnosis" revealed "IUP (intrauterine pregnancy) @ (at) 27.2 (weeks) with preterm CTX's (contractions), ? (questionable) early chorio (chorioamnionitis - inflammation of the fetal membranes due to a bacterial infection)." Review revealed "Plan: ...Transfer to (Hospital B) - Dr. (Physician N) accepting physician." Review of a "PATIENT TRANSFER FORM (EMTALA)" completed for Patient #20 on 09/25/2015 revealed the following pre-printed on the form "PART I (To be completed by Physician) I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer. The benefits relied upon for the transfer are: [check mark in box] Specialized Equipment at Receiving Facility [check mark in box] Specialized Services/Procedure at Receiving Facility [check mark in box] Continuity of Care Other __(line left blank)__. The risks of transfer are: [check mark in box] Transportation Risks which include traffic delays, accidents during transport, inclement weather, rough terrains or turbulence, limitations of equipment and personnel in transport [check mark in box] Deterioration in Patient Condition which includes a potential threat to the health and possible survival of the Patient Other__(line left blank)__." Further review revealed "Chief Complaint/Preliminary Diagnosis" with "Preterm Contractions @ 27+ (plus) wks (weeks)" handwritten on a line. Review revealed "Reason for Transfer....[check mark in box] NICU (neonatal intensive care unit)....[check mark in box] High Risk OB (obstetrical)... ." Review revealed "Facility Accepting Transfer" with (Hospital B) hand written on a line. Review revealed "Physician Accepting Transfer" with (Physician N) handwritten on a line. Review revealed "Transferring Physician's Signature" with Physician B's hand written signature on a line. Review revealed "Date" signed "09/25/2015 (handwritten on line)" and "Time" signed "0330 (handwritten on line)." Further review of the form revealed "PART III PATIENT CONSENT FOR TRANSFER (To be completed by the Patient) I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risk and benefits to transfer upon which this transfer is being made. I have considered the risks and benefits listed in Part I of this form and consent to transfer. ..." Review revealed the handwritten signature of the patient on the "Signature of Patient or Responsible Party" line dated 09/25/2015 at 0345. Review revealed the signature was witnessed by a RN. Review of the form and medical record failed to reveal any available documentation by the physician certifying the transfer indicating that the benefits and increased risks of transfer specific to the patient's emergency medical condition of Preterm Contractions at 27.2 weeks and questionable early chorioamnionitits were explained to the patient. Further review revealed the date and time (09/25/2015 at 0330) of the physician's certification for transfer DID NOT closely match the date and time (09/25/2015 at 0524) of the patient's transfer. Review revealed Physician B signed the "Patient Transfer Form" (Physician Certification) 114 minutes prior to Patient #20's departure from Hospital A's L&D unit for transfer to Hospital B. Hospital B (Recipient Facility) closed medical record review on 10/30/2015 for Patient #20 revealed the patient was a direct admit to High Risk Antepartum Bed 3105-1 on 09/25/2015 at 0709 with an admitting diagnosis of [DIAGNOSES REDACTED]"...PLAN: ...No current evidence of preterm labor. ..." and at 1206 revealed "Plan: ...Discharge home today." Telephone interview on 10/29/2015 at 1045 with Physician B revealed she was on the medical staff of Hospital A. Interview revealed she had been on the medical staff for approximately 5.5 years. Interview revealed she was an OB/GYN (Obstetrical/Gynecology) physician. Interview revealed she was the attending physician who performed the MSE on Patient #20 on 09/25/2015 and transferred her to Hospital B. Interview revealed patients under 32 weeks are transferred and do not deliver at Hospital A. Interview revealed the patient was transferred due to pre-term contractions at 27+ weeks and questionable chorioamnionitits. Interview revealed the closest hospital to transfer the patient too was Hospital B. Interview revealed she arranged for the transfer. Interview revealed Hospital B had accepted the patient and had bed availability. Interview revealed the patient was transferred by ground ambulance. Interview revealed she completed the paperwork and signed the transfer form. Interview revealed she signs, dates and times the form "as soon as I get the ok and acceptance of patient information." Interview revealed the time of transfer depends on ambulance availability. Interview revealed "it can be as quick as 20 minutes and sometimes takes hours." Interview revealed if there is a delay in the time of transfer, she does not routinely go back and re-sign, re-date, and re-time the transfer form to closely match the actual time the patient is transferred from the L&D to the other hospital. Interview revealed she "lets the form stand." Interview revealed risk and benefits are usually explained to the patient and/or guardian by the physician. Interview revealed the nurses have the patient and/or guardian sign the transfer form. Interview revealed there was "no imminent delivery" but the patient was transferred for a "higher level of care." Interview revealed specific increased risks associated with the patient were "small risk of delivery of baby" and "abruption (of placenta)" and "becoming lightheaded and dizzy" and "health deterioration." Interview revealed specific benefits of transfer included "NICU availability, Ventilator management and maintenance, Staffing and Physicians' experience, equipment availability, and OB Services with increased support for mom." Interview revealed she does not routinely write specific risks and benefits related to the patient's emergency medical condition on the transfer form. Interview revealed "there are boxes to check, that are globally accepted so I just check them." Interview revealed "I usually put a check mark in the box, only." Interview confirmed Physician B failed to document the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #20 at the time of transfer and failed to sign, date and time the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer. Interview on 10/29/2015 at 1200 with CNO #1 revealed there was no available documentation in the medical record where Physician B documented the medical benefits and increased risks associated with the transfer for the specific EMC and condition of Patient #20 at the time of transfer and signed, dated and timed the Patient Transfer Form (Physician Certification) to closely match the actual date and time of the patient's transfer. 3. Hospital A (transferring facility), closed DED record review on 10/28/2015 for Patient #21 revealed a [AGE] year old male patient (MDS) dated [DATE] at 0838 with chest pain. Review revealed the patient was Pivot triaged (Triage #1) by a Registered Nurse (RN) at 0839. Review of triage nurse documentation revealed, "Pt (patient) presents to ED with c/o (complaint of) CP (chest pain)/SOB (shortness of breath) x (times) 6 hrs (hours), pt reports he started feeling numbness and sinus pressure around midnight reports taking allegra (allergy medicine) at 0300 then again later this am [sic]. pt reports chest tightness that began at 0745. pt states that he thought he was having an allergic reaction to something. EMS (emergency medical services) reports that the patient went Asystolic (absence of heart beat) under their care, reports that they initiated chest compressions. the EKG (electrocardiogram) performed by EMS shows sinus pause (irregular heart beat) of approximately 3 seconds. patient is alert and oriented. pt is pale at this time, pt is profusely shaking stating tha [sic] the [sic] is not cold that he is having an allergic reaction." Review revealed the patient was assigned a priority level 2 (Emergency Severity Index 1-5, 1 most severe and 5 least severe). Review of MSE documentation by Physician C revealed,the patient was evaluated at 0830. Review revealed, "ED Cardiac - General Stated Complaint: Possible Allergic Reaction... Mode of arrival: Medic, Information source: Patient, Emergency Med (medical) Personnel...". Review revealed at 0843, "Notes: This [AGE]-year-old male patient brought to the emergency room by EMS. ...Last night about midnight he noticed he had some numbness in his sinuses and took Allegra. He took an additional dose a 3 AM. He woke up this morning and reported that he told his wife that he was too nervous. He had tightness in his chest. He had some dry heaves. He felt very nervous. 911 was called. EMS arrived and found the patient with a normal sinus rhythm and ST elevation in V3 V4 (electrical views of the heart) probably early repolarization pattern. They gave the patient aspirin, Zofran (antiemetic) and nitroglycerin (vasodilator) and about 2 minutes later the patient lost consciousness and they [sic] unable to feel a pulse. They report the monitor showed a flat line rhythm, 15 compressions were administered before the patient woke up. They report the monitor then showed a pulse in the 30s that slowly increased to 40 and then 50. On arrival to the emergency room the patient still had some chest pressure, and he is shaking and shivering uncontrollably. He continues to seem to be very nervous. His past medical history is significant for high blood pressure and [DIAGNOSES REDACTED] (high cholesterol). ...Review of physical exam revealed, General Appearance: alert, anxious; In Distress: mild. Respiratory status: no respiratory distress, breath sounds normal. Cardiovascular: regular rhythm, heart sounds normal to auscultation, no murmur. Review revealed, "Discharge- Discharge Clinical Impression: CHEST PAIN, Asystole Condition: stable, Disposition: ...(Hospital C)." Review revealed at 1355, Accepting facility (Hospital C), Accepting physician - (Physician J) Transferring provider -... (Physician C), Patient transported to (Hospital C) via EMS. Review of a "PATIENT TRANSFER FORM (EMTALA)" completed for Patient #21 on 10/03/2015 revealed the following pre-printed on the form "PART I (To be completed by Physician) I hereby certify that based upon reasonable risks and benefits to the patient, and based upon the information available at the time of the patient's examination, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, to the individual's medical condition from effecting the transfer. The benefits relied upon for the transfer are: [check box left blank] Specialized Equipment at Receiving Facility [check box marked] Specialized Services/Procedure at Receiving Facility [check box left blank] Continuity of Care Other __(line left blank)__. The risks of transfer are: [check box marked] Transportation Risks which include traffic delays, accidents during transport, inclement weather, rough terrains or turbulence, limitations of equipment and personnel in transport [check box marked] Deterioration in Patient Condition which includes a potential threat to the health and possible survival of the Patient Other__(line left blank)__." Further review revealed "Chief Complaint/Preliminary Diagnosis" with "Chest pain, Asystole" handwritten on a line. Review revealed "Reason for Transfer [check box left blank] Dialysis [check box left blank] Orthopedic Procedures [check box left blank] Neurosurgery Procedures [check box left blank] NICU (neonatal intensive care unit) [check box left blank] PICU (pediatric intensive care unit) [check box left blank] Interventional Cardiac Services [check box left blank] High Risk OB (obstetrical) [check box left blank] Trauma Care [check box marked] Specialized MD Care [check box left blank] No ICU (intensive care unit) beds [check box left blank] Other [check box left blank] Specify__(line left blank)__." Review revealed "Facility Accepting Transfer" with (Hospital C) hand written on a line. Review revealed "Physician Accepting Transfer" with (Physician J) handwritten on a line. Review revealed "Transferring Physician's Signature" with Physician C's name handwritten in print on the line in the same handwriting as the nurse (RN #9) who completed the Part II Transfer Information section of the form. Review failed to reveal the handwritten signature of Physician C on the "Transferring Physician's Signature" line. Further review revealed the lines adjacent to the "Transferring Physician's Signature" for the date and time were filled in with a different handwriting than RN #9. Further review of the form revealed "PART III PATIENT CONSENT FOR TRANSFER (To be completed by the Patient) I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks

Based on hospital Medical Staff Bylaws, Rules and Regulations review, policy reviews, medical record reviews, physicians and staff interviews the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings include: 1. The hospital's Dedicated Emergency Department (DED) physician failed to provide an appropriate Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed for 1 of 23 sampled DED patients (#18) who presented to the hospital for evaluation and treatment and was escorted out of the hospital's DED by Security personnel; and the DED Labor and Delivery (L&D) physician failed to certify in the medical record prior to discharge that a patient who presented to the hospital's DED L&D for contractions was in false labor and not true labor for 1 of 2 sampled DED L&D patients (#25); and the hospital leadership failed to ensure individual(s) determined qualified and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction to provide appropriate MSE was defined by the hospital's Medical Staff bylaws or rules and regulations for 1 of 1 hospital's Medical Staff bylaws, rules and regulations reviewed (Hospital A). ~ Cross refer to §489.24(r) and §489.24(c) Medical Screening Examination - Tag A2406. 2. The hospital's Dedicated Emergency Department (DED) and/or Labor and Delivery (L&D) physician failed to ensure an appropriate transfer; by failing to complete a written physician's certification for transfer documenting the medical benefits and increased risks associated with the transfer for the specific Emergency Medical Condition (EMC); and failed to ensure the written physician's certification was signed and/or dated and timed by the transferring physician to closely match the time of transfer for 4 of 4 sampled patients that were transferred with an EMC to other acute care hospitals (DED #13, #21, #3, and L&D #20). ~ Cross refer to §489.24(e)(1)(2) Risks and Benefits, Tag A2409.