HospitalInspections.org

Based on clinical record review, staff interview and facility document review, it was determined the facility failed to report a suspected inappropriate transfer of an unstable patient (Patient #14) to the Centers for Medicare and Medicaid Services (CMS) or the state agency (SA).

Findings:

A review of the nursing notes from the receiving hospital from 12/05/2022 at 12:21 a.m. documented in part "Late Entry: Pt received from transport from [sending hospital]. Pt was febrile. Bradycardic [heart rate slower than sixty (60) beats per minute] and on 2L [liters] NC [nasal cannula] O2 [oxygen] upon arrival ..."

A review of the CCU (critical care unit) Progress Note from 12/5/2022 at 4:52 a.m. documented in part "...admitted to [receiving facility's] floor directly as a transfer from the [sending facility's] ED. [Patient #14] presented to the [sending facility] earlier today with confusion ... Upon arrival to the floor, [Patient #14] was febrile to 102.8 and confused... admitted to the ICU for management of septic shock ... [The patient] has had hypotension since admission yesterday evening...this patient is critically ill due to septic shock. [The patient] is at very high risk of acute decompensation requiring immediate lifesaving interventions..."

During an interview on 04/10/2023 at 1:53 p.m., Staff Member (SM) 6 stated that SM6 was made aware of the suspected "transfer concern" by SM9 on 12/09/2022. SM6 advised that the facility determined that there was no EMTALA violation, and thus the transfer concern did not need to be reported to CMS or the SA. SM6 provided no documented evidence to the surveyor concerning the facility's determination that the transfer was appropriate and thus did not need to be reported to CMS or the SA.

The facility's policy titled "Emergency Medical Treatment & Active Labor Act "EMTALA" Policy" states in part:...G. Reporting Suspected Unstable Transfers Received: In the event that any physician or staff personnel in the Hospital feels an inappropriate or unstable transfer has been received at the Hospital from another facility, such person shall notify a member of Hospital Administration as soon as reasonably possible. The Hospital will then make an appropriate investigation and determination as to whether such action must be reported to the Centers for Medicare and Medicaid Services (CMS). If the investigation confirms that the transfer was inappropriate, a report will be made to CMS within [sic] seventy-two [72) hours of receipt of the inappropriate transfer.