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Based on interview and record review, the hospital failed to maintain complete and accurate Transfer Logs for all transfer requests. This failure created the inability to determine patient status/outcomes, and the inability to monitor and respond to pending transfer requests for level of care, necessary resource availability, bed status and patient arrivals.

Findings:

The hospital's Case Management Log was reviewed. The log did not indicate if Patients 23 and 24 had been transferred to the hospital after the transfer requests were accepted.

During a concurrent interview with the Case Manager (CM) and review of the transfer log concerning Patient 23 and 24 which was incomplete on 1/30/14 at 8:45 AM, she stated, "I don't know what happened to the patients...there are not records of them being seen at the hospital...I guess they did not come for some reason." The CM stated, "The transfer logs should be reviewed and completed within the same month...the transfer logs have not been monitored...they should be completed and accurate."

The hospital policy and procedure titled "Transfers from Another Facility" dated 10/2011, read "A record of all transfers, accepted or not, shall be available in the...Case Management Transfer Logs... The transfer log will contain the following information: If the transfer request is denied or placed on hold because of the status of Kern Medical Center resources or refusal of the transfer by the accepting physician, a statement of current Kern Medical Center resources, and the reason for denying the transfer will be entered in the log.

Based on interview and document review, the hospital failed to:

1. Review the on-call schedule for attending physician oversight when resident physicians were on-call.

2. Investigate refusals of on-call physicians to accept patient transfers when beds and qualified staffing was available.

These failures had the potential to delay treatment and place patients at risk of harm.

Findings:

During an interview with Registered Nurse (RN) 19 on 1/28/14 at 8:50 AM, he stated he was one of the nurse managers and the transfer officer when he was working. RN 19 stated, "Sometimes the resident is the only one on call without an attending physician. The resident is asked who is there attending (physician)...sometimes they reply there's is not one, so I cannot accept a patient because the residents are not allowed to admit anyone.

During an interview with RN 13 on 1/29/14 at 3:45 PM, he stated, "The on-call doctor may refuse a case even if there is a bed and staff to take the patient if they don't feel qualified to take the patient...there is no process for monitoring when a doctor refuses to accept patients when beds and staff are available."

During an interview with RN 17 on 1/30/14 at 7:15 AM, he stated he was one of nurse managers and the transfer officer when he was working. RN 17 stated, "There are times when residents are placed on-call without an attending (physician)...an attending for coverage/acceptance is needed to accept a patient, residents cannot admit patients. Emergency Department (ED) to ED transfers sometimes occur and patients will then just hold (wait) in the ED till a bed is available and a doctor comes on who can later admit the patient."

During an interview with RN 13 on 1/30/14 at 9:50 AM, he stated, "I am the go between for Medical Staff and the Chief Medical Officer (CMO). On Monday (1/27/14) we spoke about the on-call list with the mid-levels (nurse practitioners, physician assistants) and residents coverage...as of today, the call schedule will need to be covered with someone who can admit (to the hospital)."

During an interview with the CMO on 1/30/14 at 3 PM, he stated, "I am not aware of allied health professionals (mid-levels) on-call, residents should not be taking call."

During an interview with the Chief of Surgical Services (CSS) on 1/30/14 at 3:40 PM, she stated the surgical attending physician should accept patients for transfer when there were requests for surgical services including ENT (Ears/nose/throat speciality physicians) transfers even if there was not an ENT physician on-call. The CSS stated the surgical attending physician would be available as needed for patients requiring ENT services, until the ENT specialist was available. She stated especially if the transfer request came from a critical access hospital because of their limited resources. (Critical access hospitals are located in rural areas and usually do not have specialized surgical care available. As a result, they must transfer the patient for them to receive specialized care.)

The hospital transfer log was reviewed. The following information was found:

1. Patient 34 with diagnosis requiring ENT physician on 7/29/13. No ENT staff was on-call so the patient was denied. An attending surgical physician was on-call.
2. Patient 35 with diagnosis of fractured joint was denied. The transfer log dated 12/7/12 indicated the transferring hospital was requesting a transfer for surgery.
3. Patient 36 diagnosis requiring ENT was denied. The transfer log dated 12/18/12, read "ENT residents only, not accepted, surgery not willing."
4. Patient 37 was at a Critical Access Hospital (CAH) with diagnosis of pregnancy and in labor. She was denied transfer on 11/3/13, by the on-call physician because of conflicting reports but even after the MD (medical doctor) to MD call which clarified her status, she was still refused transfer. Hospital records show she was discharged from the CAH and presented to the KMC's (Kern Medical Center) ED.
5. Patient 38 was requiring abdominal surgery. A CAH hospital requested transfer to KMC on 9/12/13 but was denied when the transfer coordinator attempted to contact the surgeon two times. The surgeon did not return the page.
6. Patient 39 had been assaulted. On 6/7/13, an area hospital request transfer to KMC for MD 10 specialized services and he was on-call for facial trauma/plastics/hands. The transfer log dated 6/7/13, read "(MD 10's name) does not accept."
7. Patient 40 needed a urologist (MD who specializes on the surgical and medical diseases of the male and female urinary tract system and
the male reproductive organs). The transfer log dated 1/29/13, read "Refused due to not a urologist O/C (on-call). The KMC Surgery Faculty Call Schedule for that date, indicated MD 11 was on-call for that speciality.

The hospital bylaws section titled "Basic Responsibilities of Medical Staff Membership" revised 1/31/12, read "Except for the honorary and retired staff, the ongoing responsibilities of each member of the medical staff include: Providing patients with the quality and efficiency of care meeting the professional standards of the medical staff of the medical center; abiding by the medical staff bylaws, rules, and regulations, and all standards and policies of the medical staff;...Properly supervising healthcare professionals under the member's supervision, including house staff (Resident doctors), medical students and allied health professionals (Nurse Practitioners, Physician Assistants);.. Participating in such emergency service coverage or consultation panels as may be determined by the medical staff and board; assisting the medical center in fulfilling its uncompensated or partially compensated patient care obligations within the areas of the member's professional competence and credentials; refraining from delegating the responsibility for diagnosis or care of hospitalized patients to a practitioner or AHP (allied health professional) who is not qualified to undertake this responsibility or who is not adequately supervised."

Based on interview and record review, the hospital failed to ensure the Emergency Department (ED) log information was correct, this had the potential for inaccurate tracking of the patients ED course, disposition, and need for follow-up.

Findings:

The ED clinical record for Patient 10 was reviewed. The document titled "Quick ID Form" dated 9/7/13, indicated Patient 10 arrived at the ED at 4:33 AM. The document titled "ED NSG (nursing) Rapid Triage" indicated Patient 10's arrival time was 4:38 AM The ED log dated 9/7/13, indicated Patient 10 arrived at the ED at 4:55 AM. A 22 minute difference between the earliest and the later. The ED log indicated MD (medical doctor) 5 was in charge of Patient 10's care but according to the ED History and Physical, Resident MD 6 and MD 7 were the treating doctors.

The ED clinical record for Patient 11 was reviewed. The document titled: "Quick ID Form" dated 9/19/13, indicated Patient 11 arrived at the ED at 7:47 AM. The ED log indicated Patient 11's arrived at 7:52 AM. A five minute difference between the above times. The ED log indicated MD 3 was in charge of Patient 11's care but the clinical record indicated Resident MD 8 and MD 9 were the treating doctors.

The ED clinical record for Patient 13 was reviewed. The document titled "Quick ID Form" dated 10/8/13, indicated Patient 13 arrived at the ED at 10:58 AM. The document titled "ED NSG Rapid Triage" indicated Patient 13 arrived at the ED at 10:55 AM. The ED log dated 10/8/13 indicated Patient 13 arrived at the ED at 11:02 AM. A seven minute difference between the above times.

The ED clinical record for Patient 14 was reviewed. The document titled "Quick ID Form" had a dated stamp that was unreadable but was part of the ED record for Patient 14's 11/8/13 ED visit. The document titled "ED NSG Rapid Triage" indicated Patient 14 arrived to the ED at 1:15 PM. The ED log dated 11/8/13 indicated Patient 14 arrived at the ED at 2:16 PM. A one hour and one minute difference between the above times.

The ED clinical record for Patient 16 was reviewed. The document titled "Quick ID Form" indicated Patient 16 arrived to the ED on 11/30/13 but the time was unreadable. The document titled "ED NSG Rapid Triage" indicated Patient 16 arrived at the ED on 11/30/13 at 12:35 PM. The ED log indicated Patient 16 arrived at the ED on 12/1/13 at 3:26 AM but the electronic record indicated this was the time the patient was admitted to the hospital not the time she arrived at the ED.

During a concurrent interview with the ED supervisor (Registered Nurse [RN] 15) and review of the above ED clinical records on 1/30/14, at 8:35 AM, RN 15 verified the findings. She stated she did not know the reasons for the discrepancies in the ED logs. She stated the ED logs should contain the correct information about the patients' visits to the ED.

Based on interview and record review, the hospital failed to ensure all persons presenting to the Emergency Department (ED) was registered and received a Medical Screening Examination (MSE) which had the potential for patients to leave the hospital with untreated emergency medical conditions. Because of the hospital's failure to have a system in place to assure persons presenting to the ED were registered and received a MSE, Immediate Jeopardy was called on 1/28/14 at 4:32 PM with the Chief Executive Officer and the Chief Nursing Officer.

Findings:

During an interview with the Chief Nursing Officer (CNO) on 1/28/14 at 11 AM, she stated some patients are discharged from other hospital EDs and told to follow up at Kern Medical Center (KMC). She stated the patients show up in the ED with paperwork from the other hospitals and wanting to be seen. So depending on the situation, the patient might be directed to a clinic for care and not receive a MSE when they present to the ED.

During an interview with Patient 1 on 1/28/14 at 9:25 AM, he stated, "I came to the hospital (Hospital B) with my wife for back pain. I was told I had kidney stones. They (Hospital B) did not have a kidney specialist so they gave me papers and told me to go the the other hospital (KMC). When I got there, the nurse wanted to see my transfer papers. Since I did not have them, the nurse told me to go to the clinic and make an appointment. I did not make an appointment, I returned to (Hospital B) when the pain came back." Patient 1 stated he did not sign in or see a doctor at KMC.

The transfer log and ED patient log for 12/2012 was reviewed. Per this log on 12/11/12, Hospital B requested transfer of Patient 1 for urology to KMC. The log indicated the KMC transfer coordinator refused the transfer because there were not beds available.

The ED patient log for 12/2012 did not show Patient 1 came to the ED to be seen and no records were found for any day in that month.

During an interview with Registered Nurse (RN) 20 (ED Quick Look nurse) on 1/28/14 at 11:28 AM, she stated, "We don't have a record on everyone that comes to the ED; it depends on what needs to be done."

During an interview with the ED Chairman (MD [medical doctor] 4) on 1/28/14 at 1:45 PM, he stated, "The process has always been for any patient to be referred to a clinic, they must be seen in the ED to determine what type of services they need."

The hospital policy and procedure titled "Medical Screening Examination" dated 1/2014, read "It is the policy of Kern Medical Center that all persons presenting to the emergency department for evaluation shall receive a medical screening examination within the capabilities of the emergency department and the ancillary services routinely available to the hospital, including examination, testing, treatment, and the services of appropriate on-call physicians where indicated."