HospitalInspections.org

Based on document review and staff interview, the critical access hospital (CAH) emergency department (ED) staff failed to follow their policies and procedures and did not arrange an appropriate transfer and provide treatment within its capacity to minimize the risks to one (Patient # 1) of 30 patients whose medical records were selected for review from 10/1/11 to 4/16/12. The CAH administrative staff identified an average of 732 patients per month that presented to the CAH, and requested emergency care. The CAH administrative staff identified an average of 30 patients that the CAH staff transferred to another hospital.

Failure to follow the CAH's policies and procedures regarding treatment to minimize the risks of transfer and arranging an appropriate transfer could result in the patient suffering an adverse event or death during the transfer.

Findings include:

1. Review of the policy "EMTALA GUIDELINES", revised 7/09, revealed in part on page 9 section E) "Appropriate Transfer In Unstabilized Emergency Medical Condition", 1) "Within the Hospital's capabilities, medical treatment must be provided that minimizes the risks to the individual's health ... " 4) "Qualified personnel and transportation equipment must be used for the Transfer, including any necessary and medically appropriate life support measures."

2. Review of the medical record revealed Patient #1 presented to the ED on 3/31/12 at 4:57 PM complaining of feeling hot, nauseated and sharp pain that she rated an 8 on a scale of 1-10 (10 being the most severe). At 5:30 PM ED Physician A examined Patient # 1 and documented she was pregnant, ill appearing, in moderate distress and had severe, cramping like pain with a sudden onset, located on the right side of her abdomen. At 6:00 PM blood and urine were collected from Patient # 1 for testing and to confirm her pregnancy. At 6:15 PM the ED nurse documented Patient # 1 was instructed not to eat or drink and that arrangements were made for her to go to Hospital B for an ultrasound. At 7:10 PM the ED nurse documented on the transfer form Patient # 1 was transported to Hospital B by car, was diagnosed with right lower quadrant pain with possible ectopic pregnancy (an emergency medical condition) and that the medical risks of transfer included a "Delay in receiving definitive treatment" and "Deterioration of condition up to and including death and disability." At 10:25 PM further documentation by the ED nurse revealed Patient # 1 returned from the ultrasound performed at Hospital B and that her pain remained unchanged. Untimed documentation by ED physician A "spoke with surgeon on call", recommended consult with an obstetrician/gynecologist. "Spoke with [gynecologist on call at Hospital B] - will see in [Hospital B]." At 11:35 PM the ED nurse documented that Patient # 1 returned to Hospital B by "private vehicle." Review of the transfer form revealed ED physician A certified at 11:35 PM the medical risks of transfer included "Delay in receiving definitive treatment" and "Deterioration of condition up to and including death." The medical record did not contain evidence that Patient # 1 received any treatment (pain medication, intravenous fluids, pre - transfusion blood testing, surgery, or transport by ambulance) within the CAH's capacity for her emergency medical condition.

3. During an interview on 4/17/12 at 9:00 AM ED Physician A stated Patient #1 presented to the ED complaining of abdominal pain. The CAH lacked the capacity to provide an ultrasound examination so Patient # 1 drove to Hospital B for the ultrasound examination. Afterwards, Radiologist E called ED Physician A and said that he believed Patient #1 had an ectopic pregnancy. ED Physician A then contacted on call Surgeon F. Surgeon F told ED Physician A he did not feel comfortable providing care to Patient #1, since Patient #1 had an ectopic pregnancy. ED Physician A arranged for Patient #1 to go to Hospital B by private vehicle to receive further care. ED Physician A stated Patient #1 had an unstabilized medical condition, and ideally would have ordered CAH staff to transport Patient #1 by an ambulance to Hospital B both times. However, the ambulance was occupied at the time and she wanted to send Patient #1 to Hospital B as quickly as possible. ED Physician A said she felt Patient #1 was stable for transport by private car to Hospital B the second time, since the patient had already driven to Hospital B once before that evening.

4. Review of Surgeon F's credential file revealed the CAH's Board of Trustees granted Surgeon F surgical privileges on 5/25/11. Surgeon F's surgical privileges revealed the Board of Trustees granted Surgeon F the privilege to perform a "salpingectomy" (surgical removal of a fallopian tube).

5. During an interview on 4/17/12 at 3:45 PM, Surgeon F stated ED Physician A called him about Patient # 1's ectopic pregnancy. Surgeon F stated he felt Patient #1 required the expertise of a gynecologist to perform the surgery. Surgeon F acknowledged he could perform the surgery to remove Patient #1's ectopic pregnancy. Surgeon F stated he had performed the surgery at least 10 times since graduating from surgical residency 5 years prior. Surgeon F stated he felt Patient #1 required transportation to Hospital B by an ambulance, since Patient #1 had an ectopic pregnancy, and if the ectopic pregnancy ruptured the fallopian tube, Patient #1 could experience life threatening complications.

Based on document review and staff interviews, the Critical Access Hospital (CAH) Emergency Department (ED) staff failed to arrange an appropriate transfer and provide treatment within its capacity to minimize the risks to one (Patient # 1) of 30 patients whose medical records were selected for review from 10/1/11 to 4/16/12. The CAH administrative staff identified an average of 732 patients per month that presented to the CAH, and requested emergency care. The CAH administrative staff identified an average of 30 patients that the CAH staff transferred to another hospital.

Failure to provide treatment to minimize the risks of transfer and arranging an appropriate transfer could result in the patient suffering an adverse event or death during the transfer.

Findings include:

1. Review of the medical record revealed Patient #1 presented to the ED on 3/31/12 at 4:57 PM complaining of feeling hot, nauseated and sharp pain that she rated an 8 on a scale of 1-10 (10 being the most severe). At 5:30 PM ED Physician A examined Patient # 1 and documented she was pregnant, ill appearing, in moderate distress and had severe, cramping like pain with a sudden onset, located on the right side of her abdomen. At 6:00 PM blood and urine were collected from Patient # 1 for testing and to confirm her pregnancy. At 6:15 PM the ED nurse documented Patient # 1 was instructed not to eat or drink and that arrangements were made for her to go to Hospital B for an ultrasound. At 7:10 PM the ED nurse documented on the transfer form Patient # 1 was transported to Hospital B by car, was diagnosed with right lower quadrant pain with possible ectopic pregnancy (an emergency medical condition) and that the medical risks of transfer included a "Delay in receiving definitive treatment" and "Deterioration of condition up to and including death and disability." At 10:25 PM further documentation by the ED nurse revealed Patient # 1 returned from the ultrasound performed at Hospital B and that her pain remained unchanged. Untimed documentation by ED physician A "spoke with surgeon on call", recommended consult with an obstetrician/gynecologist. "Spoke with [gynecologist on call at Hospital B] - will see in [Hospital B]." At 11:35 PM the ED nurse documented that Patient # 1 returned to Hospital B by "private vehicle." Review of the transfer form revealed ED physician A certified at 11:35 PM the medical risks of transfer included "Delay in receiving definitive treatment" and "Deterioration of condition up to and including death." The medical record did not contain evidence that Patient # 1 received any treatment (pain medication, intravenous fluids, pre - transfusion blood testing, surgery, or transport by ambulance) within the CAH's capacity for her emergency medical condition.

2. During an interview on 4/17/12 at 9:00 AM and 4:30 PM, ED Physician A stated that Patient #1 had abdominal pain. Patient #1 was pregnant and very tender, with right sided pain. ED Physician A thought Patient #1 had an ectopic pregnancy. The CAH doesn't have ultrasound capabilities on the weekends, or after 3:00 PM. The CAH didn't have ultrasound capabilities on 3/31/12 (Saturday). ED Physician A sent Patient #1 to Hospital B for an ultrasound, and told her to return to Mahaska for the results. ED Physician A talked to the radiologist, who was worried about an ectopic pregnancy. Once Patient #1 got back, ED Physician A talked with on-call General Surgeon F. General Surgeon F wasn't comfortable with providing care to Patient #1. General Surgeon F said they would do the surgery if ED Physician A had any problems getting a consult. General Surgeon F said they would see Patient #1 if ED Physician A couldn't get someone to see Patient #1. ED Physician A talked with on-call Gynecologist D, at Hospital B. ED Physician A told Gynecologist D the CAH didn't have GYN surgeons, and didn't have any other coverage if the general surgeon on-call wasn't comfortable. Gynecologist D accepted care for Patient #1. ED Physician A also talked with the ED Physician and the Nursing Supervisor at Hospital B. "I didn't have a surgeon who could [perform the necessary surgery]. I didn't think [the surgery] could wait, I thought the patient needed to be seen that night. We worry about rupture [of the fallopian tube]. That was why I thought she needed to be seen that night. If she ruptured a tube, she could have bleeding, and her [blood] pressures could drop. That can happen suddenly." ED Physician A stated Patient #1 had low belly pain. It was intermittent, from 8 to 10 on a scale of 1 - 10. ED Physician A explained that under ideal circumstances, Patient #1 would have received transportation to Hospital B, and back, in an ambulance. ED Physician A wanted Patient #1 transported to Hospital B as quickly as possible. ED Physician A did not order Patient #1 to receive transportation in an ambulance to Hospital B, because ED Physician A believed two ambulances had assignments to transport patients, and a third crew was only available for in-town 911 calls. ED Physician A believed they would have to wait for one of the transferring ambulances to become available. ED Physician A acknowledged Patient #1's medical record lacked documentation they ordered, or offered Patient #1 medication to relieve the pain. ED Physician A also stated Patient #1 did not have any reasons why they could not receive pain medication.

3. During an interview on 4/17/12 at 1:00 PM, ED RN C stated Patient #1 presented to the ED complaining of severe pain. ED RN C stated they evaluated Patient #1's pain by how Patient #8 rated their pain (8-10 on a 1-10 scale), the patient's appearance, and vital signs. ED RN C acknowledged they did not document offering Patient #1 medication to control the pain, and stated they normally advocated for pain control in patients.

4. During an interview on 4/19/12 at 10:00 AM, Hospital B Radiology Technician G revealed that someone from Mahaska called and said they were sending a patient for an ultrasound examination to rule out an ectopic pregnancy. Radiology Technician G stated they got the patient's name, and explained that the patient would need to go to admitting. Once the registration staff registered the patient, the registration staff would call in the ultrasound technician. Radiology Technician G stated that the patient would wait after the exam only if the orders said for them to wait for the results.

5. During an interview on 4/19/12 at 9:10 AM, Hospital B Ultrasound Technician H stated that Patient #1 showed up (at Hospital B), and admitting called them. Ultrasound Technician H performed the exam, and the patient returned to Mahaska Health Partnership. The radiologist called the report of the findings to the ED physician at Mahaska Health Partnership. Normally, the patient brings paperwork from the sending hospital that indicated what type of exam to perform, and if Ultrasound Technician H should keep the patient at Hospital B until the radiologist read the exam, or send the patient back to the other hospital. Patient #1's paperwork indicated for Ultrasound Technician H to send Patient #1 back to Mahaska Health Partnership.

6. During an interview on 4/23/12 at 8:10 AM, Radiologist E stated Patient #1 had a moderate amount of fluid in her pelvis, which was strongly suspicious of a right ectopic pregnancy. Radiologist E read the film about 9:25 PM. Radiologist E couldn't tell if the patient's [fallopian] tube had ruptured. "It may have ruptured because of the free fluid in the abdomen." Radiologist E got the ultrasound image via tele-radiology, on their home computer. Radiologist E told ED Physician A the findings, and ED Physician A said to send the patient back to Mahaska.

7. Review of Surgeon F's credential file revealed the CAH's Board of Trustees granted Surgeon F surgical privileges on 5/25/11. Surgeon F's surgical privileges revealed the Board of Trustees granted Surgeon F the privilege to perform a "salpingectomy" (surgical removal of a fallopian tube).

8. During an interview on 4/17/12 at 3:45 PM, on call General Surgeon F stated ED physician A called and asked for his opinion about a female with abdominal pain. The patient had an ultrasound at Hospital B. The ultrasound revealed an adenexal mass and thought Patient #1 might have an ectopic pregnancy. ED physician A wanted to know the best thing to do. "I told [ED physician A] if the patient is young, wants more babies, is stable, and doesn't have an acute abdomen, it is best to send them to an OB/GYN to try to preserve their fertility. I told [ED physician A] she was always welcome to ask me to do the surgery, if the patient didn't want to be transferred, or if [ED physician A] wanted me to see the patient. It was probably a 10 minute phone call. Ectopic pregnancies are usually within my realm of care. I can remove a fallopian tube. I have privileges here to do that. I can remove the fallopian tube if I'm not able to remove the products of conception. You can't determine when the tube is going to rupture. There aren't any obvious clinical signs without an acute abdomen. There isn't a set time where it will rupture, and there aren't any hard and fast rules. If a patient is going from hospital to hospital, they should go in an ambulance. At a minimum, a BLS ambulance (basic life support equipment on board). If the patient goes by car, they could get into an accident, choose not to go to the hospital, bad things can happen."

9. Review of Patient #1's medical record from Receiving Hospital B showed Patient #1 presented to Receiving Hospital B's ED on 4/1/12 at 1:10 AM, and requested Emergency Medical Care for the ectopic pregnancy.

10. During an interview on 4/19/12 at 8:30 AM, Hospital B on-call Gynecologist D stated they received a phone call around 11:00 PM about a patient with a probable ectopic pregnancy. Gynecologist D performed emergency surgery at about 3:00 AM. "It couldn't wait until the next regular OR (operating room) day. Mahaska has the capabilities to perform the same surgery. I don't know why they didn't do it."

11. During an interview on 4/16/12 at 4:00 PM, Patient #1 stated she went to the emergency room (ER) because she thought she had a urinary tract infection. "They got my blood and urine." "They told me they didn't have an ultrasound technician available, so they sent me to [Hospital B]. They called ahead, and said I could go in my own car. [Hospital B's staff] did the ultrasound, both external and internal. I was told to go back to Mahaska in Oskaloosa and [Hospital B's staff] would call the ER doctor [in Oskaloosa] with the results. The ER doctor [at Mahaska] said I had an ectopic pregnancy. She didn't have a surgeon on-call. She said if she had gotten the results sooner, she would have had me stay at [Hospital B]. I was told to go back to [Hospital B] and speak with the surgeon there. [Mahaska ER staff] asked if I had available transportation [to Hospital B]. They didn't offer me an ambulance. I was in severe pain. They didn't do anything for my pain. After surgery, my pain was resolved. I'm still recovering. The surgeon [at Hospital B] removed my fallopian tube for the pregnancy."