HospitalInspections.org

Surveyor: 30170
Based on review of the hospital's Emergency Department (ED) logs, review of medical records, interviews, and policy review, it was determined the hospital failed to comply with the provider agreement as defined in 489.24 by not:
*Confirming physician acceptance and bed availability for two of three sampled patients (6 and 11) that were transferred.
*Providing stabilizing treatment prior to discharge for three of twenty sampled patients (8, 13, and 16) prior to discharge or transfer to another healthcare facility.
Findings include:

1. Review of patient 6's and 11's ED records revealed:
*Patient 6 had arrived to the ED on 2/6/15 at 12:50 p.m. after threatening suicide by fire. Review of the transfer certification documentation revealed there was no accepting physician or confirmation of bed availability at the receiving hospital. Review of patient 6's ED record revealed the receiving hospital after his transfer had notified the provider there were not beds available for the patient.

*Patient 11 had arrived to the ED on 3/21/15 at 9:03 p.m. with complaints of uncontrolled abdominal pain. He had been transferred to another healthcare facility without completed transfer certification documentation, physician confirmation of acceptance at the receiving hospital, nor confirmation of bed availability.

Review C2409 findings 1 and 2.

2. Review of patients 8, 13, and 16's ED records revealed:
*Patient 8 arrived in the ED on 2/26/15 at 4:35 p.m.. She had fallen at the nursing home, bumped her head, and complained of right hip pain. She had rated her pain a 10 from a pain scale of 1 to 10 (10 the worst pain). The nursing staff had not addressed her pain during her ED visit or prior to discharging her back to the nursing home.

*Patient 13 arrived in the ED on 4/10/15 at 4:17 p.m. He had fallen at home and complained of left hip and left rib pain. He had been having difficulty with transferring and ambulation during the ED visit. The family had been concerned about the patient returning to his home because of his inability to ambulate or transfer. The nurses took one hour and twenty minutes to get him in the car after he had been discharged from the ED. The family had been instructed by the nurses to call the fire department to assist the patient in getting him out of the car and into his house. There had been no re-evaluation and no notification of the physician by the nurses in regards to his difficulty with transferring and ambulation or the family's concerns of the patient returning to his home.

*Patient 16 arrived in the ED on 5/18/15 at 11:40 p.m. He had developed left hip pain with nausea at home and was unable to control his pain with Tylenol. He had rated his pain a 14 on a pain scale from 1 to 10. He was administered Demerol (narcotic) for his pain. He had been given Demerol intravenous (in the vein) on 5/19/15 at 10:05 a.m. and transferred per private car to another facility for further treatment at 10:10 a.m. There was no documentation the nurses had given any discharge instructions to the patient or his wife regarding the administration of Demerol. There was no evaluation or assessment done by the nurses for the complaints of "light-headedness" after he had been give the Demerol prior to discharge from the ED.

Refer to A2407 findings 1, 2, and 3.

Based on record review, interview, and policy review, the provider failed to ensure 3 of 20 sampled patients (8, 13, and 16) were medically stabilized after being treated in the emergency department (ED) with a medical emergency prior to discharging or transferring those patients.
Findings include:

1. Review of patient 13's complete electronic ED record revealed:
*He had presented to the ED on 4/10/15 at 4:17 p.m. with left hip and left rib pain after a fall had occurred at his home.
*The patient had rated his pain an 8 out of 10 on a pain scale (10 being the worse pain you could feel).
*The patient's blood pressure (BP) was elevated at 202/89 (normal reading 120/80).
*The attending physician had ordered a left hip, pelvic, and chest x-ray. The following findings were:
-Subtle irregularity of the lower left ribs, consistent with undistracted fracture ? (question mark in dictation) costochondral (upper chest/rib area) calcification (accumulation of calcium salts in tissue or bone) in the left lung base.
*There had been tenderness over the left greater trochanter (hip region).
-No obvious fracture had been seen on the left hip and pelvic x-ray.
*The plan was as follows:
-The impression had been a left rib fracture and a contusion of the left hip or thigh.
-Disposition (where the patient had gone) was home with self-care and activity as tolerated.
*The attending physician had dictated the patient was discharged from the ED in stable condition without complication.

Review of patient 13's electronic nursing documentation from 4/10/15 revealed:
*He had been given morphine 2 milligrams (mg) IV (intravenous [directly into a vein]) for his left hip and left rib area pain at 1909 (7:09 p.m.).
*The nurse had rechecked his BP at 7:10 p.m., and the patient's BP was elevated at 202/89. The physician had been notified, and Vasotec (to reduce high BP) IV was ordered. He was to have been monitored for awhile before transferring home.
-At 1910 (7:10 p.m.) "Went to administer Vasotec IV per Dr. [doctor] order checked BP to get a base line of where he was at prior to giving the medication and BP had come down to 189/90, pt [patient] stated that he thought his BP had risen because he was getting dressed and had to use the urinal. I asked what his pressures typically run and he stated 146-160. Talked to Dr. to let him know that there had been a slight drop in BP and he decided to not have me administer the Vasotec. Pt. and family was informed of this. Pt was sat up on the cart to get into wheel chair for a ride to the car. Pt tolerated that ok [okay] but did not tolerate trying to stand, we got a walker and he was able to stand and bear weight after finally allowing us to assist him. Had him stand for a few minutes to catch his breath and he stood fine but when had had to move he was very guarded of that leg and did not want to let us assist him but also did not want to move it either. Stated pain was in the left hip area but would grab toward the muscles in the lower buttocks and back of the thigh not so much by the hip. Got him in the wheelchair after much encouragement. Pt daughter concerned how they can get him in to the house if we are having troubles getting him to stand for us to get to the wheel chair, family was told that we could call the FD [fire department] and ask for a lift assist. Daughter also stated that she had called the neighbor to see if he could assist at all. Ice pack sent home with pt and explained to him that he is going to be very sore for some time so take the pain medication as directed and we also did get him a script which he initially declined and ice his leg. A walker was sent home to use for him to stand to get in the house daughter states she will bring it back tonight or in the morning."
-At 2036 (8:36 p.m.) through 2157 (9:57 p.m.) "Pt did not want us to help him get into the car, he first wanted to go to the back seat, we attempted to stand him with 2 assist but he would start to stand and then tell us not to help and would sit back down, we tired this for approximately 30 minutes before it was decided that he thought he could get in the front seat better. Wheeled him to the passenger side in the front and same thing he would start to stand but would tell us to stop helping and when we let go he would sit back down, we were able to finally convince him to let us help and once we got him back up on his feet we moved the wheelchair out from behind him, he could stand and bear weight without complaint but did not want to pivot or move, he said if he stood it was ok and if just sits its ok but when he moves it hurts. After several attempts he did allow us to help him pivot and got seated in the car it took some times for him to allow us to assist him with scooting back into the seat and allowing us to help him lift his left foot into the car, we reminded him that it is going to be sore but he did tolerate and let us girls assist him would be less painful than tensing those muscles up, after much convincing he did allow us to assist him first to scoot back into the seat and then to gently lift his foot in. Pt was buckled in and a call was made to make sure that there was men there to help with a lift when he got home."
*According to the nursing documentation it took the nursing staff one hour and twenty-one minutes to get the patient into the car.
*There was no documentation the nursing staff had updated the physician on the patient's condition.

Interview with the director of patient care services during the above medical record review revealed:
*She was unsure as to the reason the nurses continued to attempt to get the above patient into the car.
*She agreed the patient clearly was having difficulty with ambulation, transferring, and the family had been concerned about taking the patient home.
*There should have been communication with the physician when the nurses discovered the patient was having difficulty even transferring into the vehicle.
*The patient probably should have been admitted to the hospital for further evaluation and care.

2. Review of patient 8's complete electronic ED medical record revealed:
*She had been seen on 2/26/15 in the ED after a fall at the nursing home.
*She had bumped her head and had been complaining of right hip pain.
*She seemed to have been uncomfortable.

Review of patient 8's 2/26/15 electronic nursing documentation revealed:
*From 1635 (4:35 p.m.) through 1654 (4:54 p.m.) "Pt here for Clinic treatment room from [long term care facility] for X-rays of hip and right pelvis per order [physician] from [long term care facility] nurses. Pt is in Tx [treatment] room 5 on cart for [name of the physician] to come and examine pt. Ice pack to pts left forehead on a bump that is bruised. Pt is stating that her left side hip is worse and the front is not bad but her mid [middle] back is severe pain rates at 10/10 [pain scale from 1 to 10 with 10 the worst pain]. Dtrs [daughters] here and state pt has Alzheimer."
*At 1740 (5:40 p.m.) "[physician] in to se pt and removed the slider board. Pt was assisted up to a w/c as ordered by [physician]. Pt tolerated transferring well with assist of gait belt [used for transferring]."
*At 1910 (7:10 p.m.) an addendum was made "Pt was changed to ER [emergency room] from clinical treatment room per [physician]order."
*At 1755 (5:55 p.m.) "Pt was taken back to [long term care facility] after [physician]) examined pt. Dtrs are here with pt. hospital personnel accompanied pt to nursing home via w/c [wheel chair]."
*There had been no documentation the nurse or physician had addressed patient 8's severe pain.

Interview with the director of patient care services during the record review of patient 8 revealed:
*The patient had been in the ED for one hour and twenty minutes without any pain control for her severe pain.
*She was unsure why the nurse or physician had not addressed her pain rating a 10 out of 10.
*The nurse should have communicated with the physician regarding the patient's pain. The nurse should have re-accessed the patient's pain prior to discharging her from the ED.

3. Review of patient 16's complete electronic ED medical record revealed:
*He was admitted to the ED on 5/18/15 at 2340 (11:40 p.m.).
*Patient had developed left hip pain at 9:00 p.m. He had nausea without vomiting. He had attempted Tylenol at home with no relief of the pain.
*He rated his pain a 14 on a pain scale of 1 out of 10. He was having severe pain.
*The patient was very restless and was unable to sit still.
*Computerized tomography (CT [specialized X-ray]) scan of the abdomen and pelvis had been done and revealed a renal calculus (stone) in the ureter (drains urine from the kidneys into the bladder) of the left kidney.

Review of patient 16's 5/18/15 through 5/19/15 electronic nursing documentation revealed:
*On 5/18/15 from 2340 (11:40 p.m.) through 0245 (2:45 a.m.) "Pt arrived ambulatory with c/o [complaint of] pain in hip area on lt [left] side with radiating to the middle. Assessed and examined by (physician assistant). Labs [laboratory] and CT ordered. Kidney stones identified in lt [left] side. Needs to be seen by another Dr. [doctor]. Will be held in ER until morning and a decision will be made as to transferring. Will receive fluids during the night and urine will be strained."
*On 5/19/15 from 0830 (8:30 a.m.) through 1104 (11:04 a.m.) "Patient resting comfortably. States he has no pain."
*At 0915 (9:15 a.m.) "Pt given Flomax (medication for prostrate enlargement)."
*From 1005 (10:05 a.m.) through 1110 (11:10 a.m.) "Patient being discharged to [hospital] to be evaluated by the urologist [kidney specialist] for a kidney stone. His blood sugar was 154 and was given Demerol [narcotic pain medication] 25 mg [milligrams]. Wife stated they are going to stop at home to pick up his medication and a change of clothes. Patient discharged via wheelchair because he was feeling light-headed [dizzy]. Vitals [blood pressure, pulse, and respirations] are stable."
*Pt was given Demerol at 1005 (10:05 a.m.) and discharged at 1010 (10:10 a.m.). There was no indication or documentation the nurses had given any discharge instructions to the patient or his wife regarding the administration of Demerol. There was no evaluation or assessment done by the nurses for the complaints of "light-headedness" after the administration of the Demerol prior to discharging the patient from the ED to transfer to another facility for further treatment. There was no documentation the patient or his wife had been instructed about not eating or drinking anything during the transfer to the hospital in a private car.

Interview with the director of patient care services during the above record review revealed:
*The nurses should have evaluated the patient complaints of lightheadedness after the administration of the Demerol and prior to discharge from the ED.
*There should have been discharge instructions given to the wife regarding the administration of the Demerol prior to leaving the ED.
*The nurses should have given instruction to the patient and his wife about taking nothing by mouth during the transfer to another hospital.
*The patient should have been evaluated in the ED longer than five minutes after the administration of a narcotic.

4. Review of the provider's 12/8/14 Nursing Process policy revealed:
*"Each patient's physical, psychological, and social status are assessed. The scope and intensity of any further assessment are based on the patient's diagnosis, the care setting, the patient's desire for care and the patient's response to care.
*Care and treatment are planned to meet the patient's needs.
*The RN [registered nurse] is ultimately responsible for assessment and planning based on data collected at the time of admission.
*During the initial assessment patients are screened to identify patients who require functional assessments by appropriate professionals.
*Assessment shall include medication reconciliation [count], pain assessment, fall risk assessment, and skin integrity [skin condition].
*The need for discharge planning is assessed at the time of admission.
*Patients are reassessed through the care process to determine the patient's response to care.
*At discharge unmet needs will be addressed. Referral, education, follow-up with the physician are examples."

Review of the provider's 12/8/14 Pain Management policy revealed:
*The purpose of the policy was to ensure optimal patient comfort through a proactive pain control plan, that was mutually established with the patient, family members, and members of the healthcare team.
*"Every patient's pain will be managed according to the patient's perception.
*To provide professional staff with standards of practice that will assist them in effective assessment, monitoring, and management of the patient's pain.
*All patients will be assessed for pain on admission with an appropriate pain rating scale based on age and communication skills.
*Pain can be managed with pharmacological (medications) and non-pharmacological methods.
*A pain management plan continues through the patient's care and when appropriate, includes a discharge pain management plan.
*Each patient's pain will be assessed at a minimum on admission, with each vital sign check and/or with any new report/signs/symptoms of pain.
*Reassess pain within 30 minutes after administration of IV pain medication.
*Document date, time, the patient's pain assessment and any pharmacologic and non-pharmacologic intervention.
*Document the effectiveness of the intervention.
*Discharge pain management needs will be identified at the time of admission and throughout the hospitalization."

Review of the provider's 12/8/14 Admission and Discharge of ED Patients revealed:
*"All patients who come to the Emergency Department (ED) will be assessed for appropriateness of admission/transfer or discharge for the ED.
*A patient is considered stable for discharge when it is determined that continued care could reasonably be performed as an outpatient."

Review of Potter A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 975, revealed:
*"During the planning step of the nursing process, you synthesize [combine] information from multiple resources. Critical thinking ensures the patient's plan of care integrates all that you know about the individual patient and key critical thinking elements. Professional standards are especially important to consider when you develop a plan of care. These standards establish evidence-based guidelines for selecting effective nursing interventions."

Based on record review, interview, and policy review, the provider failed to appropriately transfer two of three sampled patients (6 and 11) to another provider for further treatment. Findings include:

1. Review of the emergency department (ED) triage assessment for patient 6 revealed:
*He arrived at the ED on 2/6/15 at 12:50 p.m.
*His chief complaint stated:
"Parents brought patient to the ED as they were attempting to take patient to Sioux Falls Avera Behavioral Health when he stated 'I just finish the job before we get there,' then pulled out his lighter and attempted to light himself on fire. Dad took the lighter away from him and mom called the police who told them to bring him here and they met them in back and assisted to bring patient in to the facility and they will stay during his stay with us."

Review of patient 6's ED contact and arrival time note revealed physician A was notified at 1:05 p.m. Patient 6 had been seen by physician A at 1:25 p.m.

Review of patient 6's ED behavioral assessment completed on 2/6/15 at 1:00 p.m. revealed:
*Behavior - poor eye contact, agitated, depressed, tearful/crying.
*Cognition - able to follow directions and alert.
*Suicide - suicidal thoughts, suicidal plan, suicidal intent, self-harm behaviors.
*Suicide comment - has two plans in place.
*History of depression.
*History of self-mutilation - cuter last 2/4/15, left upper arm several cuts.

Review of patient 6's ED transfer document completed on 2/6/15 at 2:35 p.m. revealed:
*Accepting facility called - Avera Behavioral Health Services (BHS).
*Report called to "[RN] at McKennan ER as BHS said they had no rooms."

Review of patient 6's transfer instructions document completed on 2/6/15 at 2:35 p.m. revealed:
*Discharge to BHS or HSC (Human Service Center).
*Discharge transportation needs - ground ambulance.
*Agency name - Avera McKennan.

Review of physician A's emergency room visit note dated 2/6/15 at 10:45 p.m. revealed:
*ED course medical decision making - "patient deemed a harm to himself and emergency detainment applied. Administered 2 mg [milligrams] Ativan IV [intravenously] prior to EMS [emergency medical service] transporting patient."
*Plan:
-Primary impression - suicidal intent.
-Additional impression - "Self mutilating behavior. Major depressive disorder without psychotic features."
-Disposition - McKennan Mental Health.
*Additional information:
-"Spoke with [physician B], eEmergency physician regarding transfer. He accepted the transfer via EMS and indicated BHS might be full but would find accepting physician to medically clear prior to BHS admit."

Review of patient 6's physician certification for ambulance dated 2/6/15 revealed:
*Destination - Avera Behavioral Health.
*No documentation of the name of the physician ordering ambulance transfer.

Review of patient 6's Transfer Consent and Order dated 2/6/15 revealed:
*No documentation of patient's condition.
*No documentation of the patient's medical records being sent with the patient.
*Name of receiving facility had Avera Behavioral Health crossed out and Avera McKennan written above.

Review of patient 6's nurse's notes revealed on 2/6/15:
*At 3:45 p.m. - "Report being called to Avera Behavioral health and they are informing me that they do not have a bed for patient and that they do not have an accepting MD. [Physician A] called and he was also told by [physician C] that everything was in place for patient to be admitted there. He is going to call e-ER and see what we need to do. Ambulance was called and informed of this and they will keep in touch with me until they get there."
*At 4:15 p.m. - "Avera Behavioral Health called here stating that they do not have a bed available as the ambulance just contacted them with report. Informed them that our MD was talking with e-ER and we would work something out."
*At 4:30 p.m. - "[Physician A] called once again and he is waiting to hear from the e-ER MD on what to do."
*At 4:40 p.m. - "Received phone call from ambulance crew that they were waiting in the parking lot at Avera McKennan until we hear on what to do and where to go with patient."
*At 4:50 p.m. - "[Physician A] returned phone call and patient is to go to the ED at McKennan and be seen that way. Ambulance notified and nurse to nurse given to [RN] in the ED department."

2. Review of the ED triage assessment for patient 11 revealed:
*He arrived at the ED on 3/21/15 at 9:03 p.m.
*His chief complaint stated "patient had lithotripsy [treatment for the breaking up of kidney stones] on Tuesday March 18th and now he is having uncontrolled abdominal pain. He states this is the worst pain of his life and rates it at 10/10."

Review of patient 11's ED contact and arrival time note revealed physician D was notified at 9:05 p.m. Patient 6 had been seen by physician D at 9:05 p.m.

Review of physician D's emergency room visit note dated 3/22/15 at 12:30 a.m. revealed patient 11 would be transferred to Avera Medical.

Review of patient 11's medical record revealed no documentation the transfer consent and order form had been completed.

3. Interview on 6/3/15 at 4:00 p.m. with the director of patient care confirmed patient transfers should have been completely and accurately documented in patients' records.

Interview on 6/4/15 at 7:50 a.m. with the administrator regarding patient 6 revealed:
*Physician C had been his psychiatrist.
*The hospital staff had contacted physician C when he arrived in the ED.
*Physician C had made the arrangements for the transfer.
*When he had arrived at Avera Behavioral Health there had been no beds, and he had been transferred to Avera McKennan.
*He would have been transferred to Avera McKennan if there were no beds at Avera Behavioral Health because of the mental health issues of the patient.

Review of the provider's 12/8/14 Transfer Policy revealed:
*The provider would only transfer when:
-The receiving facility had available space and qualified personnel for the treatment of the individual.
-The receiving facility had agreed to accept the transfer of the individual and provide appropriate treatment.
-All medical information related to the emergency condition had been sent to the accepting facility.
*The decision to transfer a patient was the responsibility of the attending physician who would be designated as the referring physician.
*The referring physician would explain the risks and benefits of the transfer.
*The referring physician would contact the receiving physician to ensure acceptance of the patient.
*The Transfer Consent and Order included the reason, risks and benefits, the physician order to transfer, and the transfer method once it was signed by the physician. The form also included the patient consent to transfer and release of related medical information.