Based on review of facility documentation, medical records (MR) and staff (EMP) interviews, it was determined the facility failed to provide stabilizing treatment within the capability of the hospital's Emergency Department in one of 20 medical records reviewed (MR1). Findings include: Review on May 9, 2018, of the facility policy "Hospital Treatment and Transfer of Individuals Who Request Emergency Services (EMTALA)" last reviewed April 2018, revealed, "...2. The Hospital will provide an individual with an emergency medical condition such further medical examination and treatment as required to stabilize the emergency medical condition, within the capability of the Hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below..." Review on May 9, 2018, and May 10, 2018, of MR1 revealed the patient was a [AGE] year old who was admitted to the Emergency Department at 9:40 am on April 28, 2018. ED SUMMARY revealed the patient "arrived via EMS after MVC. Pt was T boned by another car on drivers side + side airbag deployment. Pt no{sic} wearing a seatbelt." Additional NURSING ASSESSMENT revealed "Pt was T boned hit on drivers side. No seat belt. Side air bag deployment. Unsure if (name redacted) hit (name redacted) head, pt no{sic}on any blood thinners. C/O L sided rib/flank pain. Pt A&OX4 upon arrival to E.D." Vital signs on arrival were documented as B/P 80/56, P72, R18, Temp. 36.2 Pain assessment 8/10. Review of MR1 revealed that the patient was placed on oxygen at 0954. An IV was inserted/blood collected at 1001, but no fluid started until 1107, Cardiac monitor applied at 1003. The patient had CTs of the head, chest, c-spine, abdomen and pelvis. ED SUMMARY stated that "during CT scan, Pt diaphoretic. EMP6 made aware of same upon return to E.D." Upon return to ED patient's blood pressure was documented as 64/44, P75, R31, Sat 98% on 2L nasal cannula. A second IV was started at 1104 and two liters of Normal Saline was started at 1107, which was 87 minutes after admission to the emergency department. A call was made to outside facility for transfer at 1109. Results of the CT scan were called to EMP6 at 11:00 am and revealed, "Left 10 rib nondisplaced subtle fracture. Left 7th, 8th and probably 9th nondisplaced fracture deformities are also noted. Heterogeneous spleen density most likely complex laceration, perisplenic hyperdense fluid, most likely blood products. Also there is moderate perihepatic and pelvic dense fluid representing pneumoperitoneum..." At 1125, the patient complained of difficulty breathing, and EMP6 was at bedside to evaluate the patient. A central line was placed at 1132 and 2 units of packed cells were ordered and started at 1149. Vital signs at this time were BP 57/37, P76, R19, Sat 100% on 2L nasal cannula. The final documented vital signs was at 1153 and they were BP 61/34, P77, R24, Sat 100%. A third unit of packed cells was started at 1214 and patient was transferred via helicopter at 1215. ED SUMMARY indicated that a report was called to receiving facility by an RN. Review of EMERGENCY PROVIDER RECORD revealed "...hypotensive on arrival to ED, mentating normally, no evidence of hypotension -- sent to CAT scan...on returning from CT scan pt found to be hypotensive...IVF initiated via (2) 20g IV's RUE, minimal improvement in BP. Arrangement made to transfer pt to (name redacted)...pt...does not want to be transferred to (name redacted). Dr. (name redacted) and (name redacted) will accept pt.....2 units of PRBC's started in addition to 2 liters NSS BP continues to be 60-70 systolic...pt offering no complaints and is mentating normally. Decision made to airlift pt to (name redacted) for surgical intervention. Pt agreeable. Benefits outweigh risks @ this point, decision made for transfer to trauma facility." Interview with EMP6 on May 10, 2018, at approximately 12:30PM confirmed that the patient arrived hypotensive and awake and alert. EMP6 stated that "when (name redacted)got back from CT scan is when BP dropped, we started fluids, blood...we talked about choices and (name redacted) did not want to go to (name redacted). I would have recommended (name redacted) but the patient refused. EMP6 further stated that "they accepted (name redacted), the one thing they did say was to contact general surgery and I did. I spoke to (name redacted) on the phone. (Name redacted) thought the patient didn't require splenectomy and that embolization with IR was best." "I didn't document my conversation with (name redacted) in the chart." EMP6 confirmed that (name redacted) did not follow up with the receiving facility "because they got here quicker" EMP6 revealed the patient "didn't appear uncomfortable, (name redacted) was talking through the central line insertion." The patient was transferred to an outside facility with vital signs of BP 61/38, pulse of 81, respiratory rate of 24, and pulse ox of 100%. The patient was complaining of difficulty breathing prior to the transfer and was on the third unit of blood prior to transfer. The facility has general surgery, but the surgeon did not evaluate the patient.

Based on review of facility documentation, medical records (MR), and staff (EMP) interview, it was determined the facility failed to provide an appropriate transfer within the capability of the hospital for one of 20 patient encounters reviewed (MR1). Findings include: Review on May 9, 2018, of the facility policy "Hospital Treatment and Transfer of Individuals Who Request Emergency Services (EMTALA)" last reviewed April 2018, revealed, "...N. 1. with respect to an emergency medical condition, that the patient is provided such medical treatment of the condition is necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the patient..." Review on May 9, 2018, and May 10, 2018, of MR1 revealed the patient was a [AGE] year old who was admitted to the Emergency Department at 9:40 am on April 28, 2018. ED SUMMARY revealed the patient "arrived via EMS after MVC. Pt was T boned by another car on drivers side + side airbag deployment. Pt no{sic} wearing a seatbelt." Additional NURSING ASSESSMENT revealed "Pt was T boned hit on drivers side. No seat belt. Side air bag deployment. Unsure if (name redacted) hit (name redacted) head, pt no{sic}on any blood thinners. C/O L sided rib/flank pain. Pt A&OX4 upon arrival to E.D." Vital signs on arrival were documented as B/P 80/56, P72, R18, Temp. 36.2 Pain assessment 8/10. Review of EMERGENCY PROVIDER RECORD revealed "...hypotensive on arrival to ED, mentating normally, no evidence of hypotension -- sent to CAT scan...on returning from CT scan pt found to be hypotensive...IVF initiated via (2) 20g IV's RUE, minimal improvement in BP. Arrangement made to transfer pt to (name redacted)...pt...does not want to be transferred to (name redacted). Dr. (name redacted) and (name redacted) will accept pt.....2 units of PRBC's started in addition to 2 liters NSS BP continues to be 60-70 systolic...pt offering no complaints and is mentating normally. Decision made to airlift pt to (name redacted) for surgical intervention. Pt agreeable. Benefits outweigh risks @ this point, decision made for transfer to trauma facility." Interview on May 15, 2018, at approximately 9:00AM with OTH2 (receiving facility) confirmed that a call was received from (name redacted) to transfer a patient that was in a car accident. OTH2 revealed that the ED physician called and "said the patient was hypotensive and had a spleen laceration." OTH2 stated " I told them that if (name redacted) was responsive to fluid/blood then transfer but if (name redacted) was unstable...needs to go to the OR and then be transferred to ICU here." "We never heard from them until the patient arrived. I only spoke to them when they were calling to transfer the patient." OTH2 referred to ATLS guidelines to define "stable" and stated "persistent tachycardia, SBP < 90 or because (name redacted) was almost 60, SBP <110." Interview with EMP6 on May 10, 2018, at approximately 12:30PM confirmed that the patient arrived hypotensive and awake and alert. EMP6 stated that "when (name redacted) got back from CT scan is when BP dropped, we started fluids, blood...we talked about choices and (name redacted) did not want to go to (name redacted). I would have recommended (name redacted) but the patient refused. EMP6 further stated that "they accepted (name redacted), the one thing they did say was to contact general surgery and I did. I spoke to (name redacted) on the phone. (Name redacted) thought the patient didn't require splenectomy and that embolization with IR was best." "I didn't document my conversation with (name redacted) in the chart." EMP6 confirmed that (name redacted) did not follow up with the receiving facility "because they got here quicker" EMP6 revealed the patient "didn't appear uncomfortable, (name redacted) was talking through the central line insertion." History of Present Illness (Receiving facility): "This is a [AGE]-year-old (name redacted) who was involved in a MVC around 9:15a.m. It is unclear whether (name redacted) was an unrestrained driver, or unrestrained passenger...(name redacted) was initially seen at an outside facility...It had been discussed with the outside facility that the patient could be transferred if (name redacted) was stable and responsive to blood or fluid. Otherwise if not responsive, then (name redacted) should go to the operating room emergently at their facility and then could be transferred at a later time for continued care. I am unsure of the preceding events...the patient was then transferred to our facility. Enroute, (name redacted) was hypotensive. On arrival, (name redacted) was hypotensive. EMS did report blood pressure to the 90s- low 100s. The patient was awake and talking. (Name redacted) has received almost 3000ml of fluid and 3 of PRBCs at the outside hospital and during transfer...The patient denied any amnesia or loss of consciousness. (Name redacted) did have abdominal pain and distension." Course of hospitalization (Receiving facility): "The patient was hypotensive on arrival, hard to get an upper extremity blood pressure....(name redacted) was intubated...We opened the abdomen. (Name redacted) had lots of bleeding, an extensive amount of blood, difficult to tell exactly where it was coming from. We began packing the left upper quadrant for the known splenic injury...The patient lost pulses. We began CPR, finished packing the abdomen. The patient still had no pulses...We decided to do a resuscitative left thoracotomy...We started open cardiac massage...We noticed extensive bleeding from the left chest...chest tube had been placed...The patient had not had a pulse for over 20 minutes. No cardiac activity. We then called time of death at 1346 on 4/28/18." The patient was transferred to an outside facility with vital signs of BP 61/38, pulse of 81, respiratory rate of 24, and pulse ox of 100%. The patient was complaining of difficulty breathing prior to the transfer and was on the third unit of blood prior to transfer. The facility has general surgery, but the surgeon did not evaluate the patient. The patient did not go to the operating room and was transferred to a different facility.