HospitalInspections.org

Based on a review of Emergency Medical Services Documents, Emergency Department (ED) logs, Medical Records, Medical Staff Bylaws, Medical Staff Rules and Regulations, Medical Staff credentialing files, On-Call Schedules and interviews, it was determined the facility failed to ensure one patient (#9) of 21 patient charts reviewed, was stabilized within the capacity and capability of the hospital, prior to transfer. Refer to 2407.

Based on findings from document review and interviews, the facility failed to ensure that one patient (#9), who presented with an Emergency Medical Condition (EMC), was stabilized within its capabilities prior to the patient's transfer to Hospital B. The Emergency Department (ED) has an average of 3018 visits per month and an average of 49 transfers per month.

Findings included:

1. Record review of Patient #9's discharged Emergency Department (ED) record, showed he presented by ambulance to the faculty's ED on 02/17/15 at 11:47 AM, with complaints of right shoulder pain and feeling "numb and tingly all over", after he fell on ice.

Record review of Staff D, ED Physician documentation dated 02/17/15, showed multiple entries between 12:22 PM and 4:58 PM, that:
- Patient #9 suffered a ground level fall, was unable to move his right arm and had right arm pain that was associated with neck pain.
- While the patient was in the ED, the patient progressed and developed a worsening paralysis (inability to move) affecting all extremities (arms and legs).
- Computerized Tomography (CT, detailed x-ray imaging) determined that the patient had a cervical spine (c-spine, specific to the neck bone, which extended into the upper portion of the back) fracture which resulted in a spinal cord injury (SCI, pressure or damage to the nerves, encased by the spine, that connect the brain to most all body parts).
- The patient was evaluated by Staff A, Neurosurgeon.
- Staff A arranged the patient transfer to Hospital B for further treatment, "due to availability of specialty care".

Record review of "Physician Group Coverage" dated 02/17/15, showed Staff A was on-call for Neurosurgery.

Record review of "Neuro Call Schedule" dated 02/17/15, showed a full roster of on-call staff for Neurosurgery.

2. During an interview on 03/18/15 at 1:40 PM, Staff D, stated that a CT of Patient #9's head and neck showed he had suffered a SCI, so Staff A was consulted for Neurosurgery. Staff A determined that the patient had a spinal fracture with SCI that was "too complex to manage here", so Staff A arranged for the patient's transfer to Hospital B. Staff D added that he had previously cared for a patient with spinal fractures that involved SCI in November 2014, but the patient was stabilized at the facility and not transferred.

3. Record review of Staff A's "Initial Patient Encounter" documentation dated 02/17/15 at 4:22 PM, showed that:
- Patient #9 suffered impaired (decreased) sensation to light touch and pin prick to all four extremities.
- The patient sustained multiple c-spine injuries, including SCI.
- Due to the severity of the injury, and with lengthy SCI rehabilitation needed, it was recommended that the patient be transferred to Hospital B for evaluation and treatment as soon as possible.

Record review of the Transfer Authorization Checklist for Patient #9, dated 02/17/15, showed the patient was transferred to Hospital B at 8:00 PM, for "Services not available at this facility: Complex Specialty, Spinal Cord Rehab (Rehabilitation)", and was signed by Staff A.

Record review of the facility's policy titled, "Transfer of Patients to other Facilities", dated 01/2015, showed that prior to transfer, appropriate medical treatment must be provided, within the capability of the hospital, to minimize the risk to the individual's health.

4. During an interview on 03/18/15 at 12:03 PM, Staff A stated that:
- He evaluated Patient #9 on 02/17/15 in the ED.
- The patient showed findings of an incomplete quadriplegic (partial damage to the spinal cord which can cause decreased sensation and or mobility to arms and legs, and can affect the ability to breath, swallow, and control bowel or bladder).
- The Magnetic Resonance Imaging (MRI, detailed x-ray images through use of magnets) showed unstable fractures at c-3/c-4 (level of the spine, pertaining to middle of the neck), damaged from the front and the back, with spinal cord injury.
- The patient also suffered fractures at c-6/c-7 (level of the spine, pertaining to the bottom of the neck), which did not affect the spinal cord.
- He felt the patient needed a complex spine surgeon, and told the family that it was in their best interest that the patient be transferred to Hospital B.
- He was concerned that the patient may lose his airway (ability to breathe on his own).
- He was concerned that the patient may go into spinal cord shock (vital signs fall out of normal range, such as blood pressure reaching dangerously low and life threatening levels), which would prevent the use of anesthesia (medically induced sleep to complete surgical procedures) and prevent the ability to surgically stabilize the patient.
- Spinal Cord Shock can last from two to seven days, which would prevent the patient from surgical stabilization during that time.
- When he tried to arrange emergency transportation for the patient transfer, it was snowing, freezing rain mixed with snow, and the roads were "very bad".
- It was a very busy day with other consults, and he continued to work after he arranged the patient's transfer to Hospital B.
- At 11:30 PM, he was notified that the patient transfer by ambulance was incomplete due to hazardous weather conditions, and the patient was enroute back to the hospital.
- Neurosurgery had a dedicated Operating Room (OR) team on-call, and the OR team that was called in were "our stars", "very experienced team of people helping me", and he had "no concerns about the competency of the team".
- The patient required anterior (front) and posterior (back) c-3/c-4 stabilization (surgical repair of spine, specific to the neck) to decompress (relieve pressure) from the spinal cord, for the patient's stabilization.
- He surgically completed a "anterior cervical diskectomy (removal of the disc, a round gel-like filled body which lies between the bones in the spine and provide shock absorption) and fusion (to join the spine bones together with a cement-like material) with intrumentation (medical appliance such /as screws, etc.) of c3/c4, which "I do all the time and it is a common surgical procedure".
- He surgically completed a "laminectomy (to surgically remove part of the spinal bone) with posterior instrumented fusion with lateral mass screws"at c-3/c-4, which was a common surgical procedure that he performed.
- He also surgically repaired c-6/c-7, which was not necessary to stabilize the patient.
- "If I felt I could have done as good of job as (Hospital B) could do, I wouldn't have sent him, but when he came back, I did the best I could do".
- He was credentialed to complete the surgical procedures that were done.
- The patient remained stable throughout the operation.
- The patient remained on a ventilator (provides artificial breathing for the patient) in the hospital with pneumonia and a fever, and was started on antibiotics.

5. Record review of Staff A's credentialing file showed an application (which was approved for reappointment on 12/19/14 for 01/01/15 through 12/31/16) for neurologic surgery privileges which included Laminectomy, spinal/fusion and diskectomy. The file also included "Diagnosis and Procedures from 04/01/13 through 10/31/14", which were completed by Staff A, and included:
- Vertebral (spine bone) fracture repair;
- Neck spine fusion;
- Insertion of spine fixation device (device which anchors two or more vertebrae (bones in the spine) together;
- Spine surgery procedures;
- Cervical laminectomy;
- Neck spine disk surgery;
- Cervical decompression of the spinal;
- Anterior Cervical Fusion; and
- Posterior Cervical Fusion.

6. During an interview on 03/18/15 at 2:35 PM, Staff C, ED Registered Nurse (RN) stated that she was present when Staff A came to examine Patient #9. She stated that Staff A "made it clear" that he could do the surgery here (Hospital A), but the patient would require spinal cord rehabilitation after surgery, which wasn't offered at Hospital A. Staff A explained to the family that Hospital B could manage the patient's case, which included the necessary surgery and rehabilitation, and left the decision up to the family. Staff C stated that Staff A never expressed to the family that the surgery was beyond his expertise.

During an interview on 03/17/15 at 2:45 PM, Patient #9's wife stated that "they" (referred to surgeon, but not by name) felt the surgery would go better at Hospital B. The wife stated that the transfer was not at the request of the family, "it was the hospital physician's decision", and stated that she "trusted the doctor to know what was best".
At the time of exit, Patient #9 was hospitalized in the intensive care unit on a ventilator.