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Based on staff interview, review of policies/procedures, documents, and patient medical records, the Critical Access Hospital (CAH) failed to arrange an appropriate transfer for an individual (Patient # 2) with an unstable emergency medical condition as required. The hospital identified an average of 37 emergency room transfers per month.

Failure to arrange an appropriate transfer for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of CAH policy/procedure titled "EMTALA Patient Transfer to Another Acute Care Facility", dated January 1, 2008, revealed:
a. "POLICY: The purpose of this policy is to assure the appropriate provision of medical screening, stabilizing treatment and, when applicable, safe transfer of a patient to another acute care facility for the purpose of continued care for the patient."
b. "Procedure: If a patient is not stabilized, the Hospital may not transfer the patient unless one of the following occurs: ...The Hospital is unable to provide the treatment necessary to stabilize the patient, and A physician signs a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at another medical facility outweigh the increased risks of the transfer to the patient ..."

2. Review of the statutorily required Quality Improvement Organization review conducted on 4/8/10 revealed patient #2 had an emergency medical condition that was not stable at the time of transfer. Patient #2 required transfer by ambulance to a higher level of acute care and not to Hospital B (a hospital without the appropriate capabilities to treat an acute case of poisoning).

3. Review of the medical record revealed patient #2 presented to the emergency department (ED) on 2/20/10 at 7:35 PM by ambulance accompanied by law enforcement. The EMS (Emergency Medical Services) Report revealed law enforcement summoned the hospital owned and operated ambulance to the scene of an accident (the result of a high speed car chase after patient # 2 eloped from Hospital B) because they thought patient #2 had sprayed de-icer in his mouth during the car chase. The ambulance crew documented in the EMS report that when they arrived at the scene and questioned patient #2, he "would not tell us much information." The EMS report specified that a law enforcement officer rode in the ambulance and upon arrival to the ED, the ambulance crew turned patient #2's care over to the ED nurse and physician. Page 1 of the Emergency Trauma Sheet revealed the ED nurse documented patient #2's chief complaint "Prestone deicer ingestion." (Prestone De-icer contains Methanol - a highly toxic product capable of producing severe metabolic acidosis, blindness, and even death after ingestion). The medical record contained information FAXed to the hospital from the Poison Control Center on 2/20/10 at 7:09 PM (just prior to patient #2's arrival) recommending: 1). Aspirin and Tylenol levels, a basic lab panel, and an ECG to check for QT/QRS prolongation or arrhythmias, 2). a full set of labs along with stat send out for methanol and ethylene glycol testing. [Two Iowa hospitals] have labs that can do these within few hours, 3). start Antizol (antidote for Methanol poisoning), "That will give you 12 hours to get labs and stat levels." 4). Check serum osmolarity. The FAX also contained specific information about the effects of Methanol poisoning ... "The onset of symptoms may be delayed for 18 to 24 hours after ingestion because Methanol is metabolized slowly" ... "There is a latent period of 12 - 24 hours from time of ingestion until the time symptoms develop." On page 2 of the Emergency Trauma Sheet, the ED nurse documented that she cleansed a laceration to patient #2's ear, that he remained on one to one observation while in the ED, and that at 9:20 PM (approximately 2 hours after presenting to the ED) patient #2 was discharged with police (Officer who pursued patient # 2 during a car chase) for transport back to Hospital B. Review of ED physician A's documentation revealed that patient #2 had a normal exam following a high speed car chase in which he crashed his car into a ditch. ED physician A documented that he discussed patient #2's case with law enforcement, with nursing and with the physician and medical personnel at Hospital B; and then arranged transport back to Hospital B by law enforcement vehicle. ED physician A did not document an assessment regarding patient #2's possible ingestion of Prestone De-icer or certify in the medical record whether the benefits of transfer to Hospital B outweighed the risks.

4. Review of the police report revealed the Officer (who transported patient # 2 back to hospital B) documented he observed patient # 2 consuming something from a white piece of paper or card during the high speed car chase. At approximately 7:13 PM the car chase ended with patient # 2's car in a ditch. The officer documented that patient # 2 was consuming something from a yellow can. As he approached the driver's side of the car, the officer documented he yelled at patient # 2 to get out of his car "but he ignored us and continued to consume from the can." The officer further documented that the yellow can contained 11 oz of Prestone De-Icer, that was almost empty, and that the local deputy advised him that the ambulance took the can and patient # 2 to Mercy Hospital. The officer reported that he was later summoned to pick up patient # 2 at Mercy Hospital and transport him to hospital B.

5. During an interview on 3/23/10 at 3:25 PM, ED Physician A stated there was some concern Patient #2 may have taken in some de-icer prior to arrival. Physician A stated he was told that there was de-icer in the car with patient #2 and that the patient had access to the de-icer but probably had not had time to use it or didn't think the patient would have drank it. Physician A stated the standard of care for a patient with de-icer ingestion would be to transfer the patient to a hospital with a higher level of care for further monitoring and treatment. Physician A stated that patient #2 had a normal exam after running his car off the road and that ED physician A did not entertain ingestion of de-icer. Physician A acknowledged the patient's medical record contained information from the Poison Control Center regarding de-icer ingestion at the time of his examination.

6. During an interview on 3/23/10 at 4:25 PM, EMT - PS C (Emergency Medical Technician - Paramedic Specialist) stated "we heard on the scanner the police said to get an ambulance, they thought the patient drank de-icer." "Dispatch paged out the ambulance and when we got to the scene, the police officers had the patient standing on the road." "We transported patient #2 to the hospital along with a police officer who was also an EMT." "During the ambulance ride, we asked patient #2 why he sprayed de-icer in his mouth but he did not have an answer." "We called in report to the hospital and told them that we thought the patient sprayed de-icer in his mouth." EMT-PS C stated they took patient #2 into ED room 1 on arrival and that Physician A was in the room with the nurse. EMT-PS C stated that he left the empty can of de-icer at the nurse's station.

7. During an interview on 3/23/10 at 10:30 AM, the ED Medical Director stated review of Patient #2's medical record revealed patient #2 had eloped from Hospital B and fled in a stolen car. Verbal report provided by the ambulance crew and law enforcement to the ED staff upon arrival to the ED, indicated patient #2 may have sprayed de-icer in his mouth. The ER Medical Director stated ED Physician A did not follow the standard of care and that patient #2 should have been transferred to a hospital capable of treating individuals with Methanol poisoning. The ER Medical Director said that patient #2 should not have been transferred back to Hospital B (a hospital without the capabilities to treat an acute case of poisoning).

Refer to tag C-2409 for further details.

Based on document review, staff interviews, and QIO (Quality Improvement Organization), the Critical Access Hospital (CAH) failed to arrange an appropriate transfer for an individual (Patient # 2) with an unstable emergency medical condition as required. The hospital identified an average of 37 emergency room transfers per month.

Failure to arrange an appropriate transfer for a patient with an unstable emergency medical condition could potentially delay the appropriate treatment for the patient and result in further complications including death.

Findings include:

1. Review of the statutorily required Quality Improvement Organization review conducted on 4/8/10 revealed patient #2 had an emergency medical condition that was not stable at the time of transfer. Patient #2 required transfer by ambulance to a higher level of acute care and not to Hospital B (a hospital without the appropriate capabilities to treat an acute case of poisoning).

2. Review of the medical record revealed patient #2 presented to the emergency department (ED) on 2/20/10 at 7:35 PM by ambulance accompanied by law enforcement. The EMS (Emergency Medical Services) Report revealed law enforcement summoned the hospital owned and operated ambulance to the scene of an accident (the result of a high speed car chase after eloping from Hospital B) because they thought patient #2 had sprayed de-icer in his mouth during the car chase. The ambulance crew documented in the EMS report that when they arrived at the scene and questioned patient #2, he "would not tell us much information." The EMS report specified that a law enforcement officer rode in the ambulance and upon arrival to the ED, the ambulance crew turned patient #2's care over to the ED nurse and physician. Page 1 of the Emergency Trauma Sheet revealed the ED nurse documented patient #2's chief complaint "Prestone deicer ingestion." (Prestone De-icer contains Methanol - a highly toxic product capable of producing severe metabolic acidosis, blindness, and even death after ingestion). The medical record contained information FAXed to the hospital from the Poison Control Center on 2/20/10 at 7:09 PM (just prior to patient #2's arrival) recommending: 1). Aspirin and Tylenol levels, a basic lab panel, and an ECG to check for QT/QRS prolongation or arrhythmias, 2). a full set of labs along with stat send out for methanol and ethylene glycol testing. [Two Iowa hospitals] have labs that can do these within few hours, 3). start Antizol (antidote for Methanol poisoning), "That will give you 12 hours to get labs and stat levels." 4). Check serum osmolarity. The FAX also contained specific information about the effects of Methanol poisoning ... "The onset of symptoms may be delayed for 18 to 24 hours after ingestion because Methanol is metabolized slowly" ... "There is a latent period of 12 - 24 hours from time of ingestion until the time symptoms develop." On page 2 of the Emergency Trauma Sheet, the ED nurse documented that she cleansed a laceration to patient #2's ear, that he remained on one to one observation while in the ED, and that at 9:20 PM (< 2 hours after presenting to the ED) patient #2 was discharged with a police officer (who pursued patient # 2 during car chase) for transport back to Hospital B. Review of ED physician A's documentation revealed that patient #2 had a normal exam following a high speed car chase in which he crashed his car into a ditch. ED physician A documented that he discussed patient #2's case with law enforcement, with nursing and with the physician and medical personnel at Hospital B and then arranged transport back to Hospital B by law enforcement vehicle. ED physician A did not document an assessment regarding patient #2's possible ingestion of Prestone De-icer or certify in the medical record whether the benefits of transfer to Hospital B outweighed the risks.

3. Review of the police report revealed the Officer (who transported patient # 2 back to hospital B) documented he observed patient # 2 consuming something from a white piece of paper or card during the high speed car chase. At approximately 7:13 PM the car chase ended with patient # 2's car in a ditch. The officer documented that patient # 2 was consuming something from a yellow can. As he approached the driver's side of the car, the officer documented he yelled at patient # 2 to get out of his car "but he ignored us and continued to consume from the can." The officer further documented that the yellow can contained 11 oz of Prestone De-Icer, that it was almost empty, and that the local deputy advised him that the ambulance took the can and patient # 2 to Mercy Hospital. The officer reported that he was later summoned to pick up patient # 2 at Mercy Hospital to transport him to hospital B.

4. During an interview on 3/23/10 at 3:25 PM, ED Physician A stated there was some concern Patient #2 may have taken in some de-icer prior to arrival. Physician A stated he was told that there was de-icer in the car with patient #2 and that the patient had access to the de-icer but probably had not had time to use it or didn't think the patient would have drank it. Physician A stated the standard of care for a patient with de-icer ingestion would be to transfer the patient to a hospital with a higher level of care for further monitoring and treatment. Physician A stated that patient #2 had a normal exam after running his car off the road and that ED physician A did not entertain ingestion of de-icer. Physician A acknowledged the patient's medical record contained information from the Poison Control Center regarding de-icer ingestion at the time of his examination.

5. During an interview on 3/23/10 at 11:20 AM, ED Nurse B stated the ED staff became aware that there was a high speed chase taking place due to traffic on the scanner. "Then our ambulance crew staff came through the ER, told us the person that had been stopped was in the ditch and was drinking antifreeze so the ambulance was paged out." The ambulance crew called in report to the ED that the patient had sprayed de-icer in his mouth. Nurse B said she heard on the scanner radio the police reported the person was drinking antifreeze so she directed ED Tech E to call Poison Control. Nurse B stated that Poison Control faxed information on antifreeze poisoning to the ED and "when we found out the patient had taken de-icer I asked ED Tech E to call Poison Control back and they faxed information on Methanol poisoning shortly after patient # 2 arrived." Nurse B said that ED Physician A examined the patient and that he had glass on him along with a small laceration anterior to his ear. Nurse B stated she was told the patient had a can of de-icer, would not get out of the car so the police officer broke out the side window with their nightstick. Nurse B saw the fax and said the antidote for de-icer was Antizol. Nurse B stated she checked the medication supply and found the hospital did not have the medication Antizol. Nurse B said she told Physician A the hospital did not have any Antizol but that Physician A did not respond. Nurse B said she told Physician A about the ambulance report and that patient # 2 had apparently sprayed de-icer in his mouth. Nurse B said that Physician A did not ask the patient anything about this when in Nurse B's presence. Nurse B stated ED Tech E stated they gave the report directly to Physician A. When Nurse B went back into patient # 2's room, the Poison Control Center's report was on the counter in the patient's room. Nurse B was in the patient's room and Physician A handed Nurse B a piece of paper and said the patient could go back to Hospital B and said we could cancel the ambulance.

6. During an interview on 3/23/10 at 4:25 PM, EMT - PS C (Emergency Medical Technician - Paramedic Specialist) stated "we heard on the scanner the police said to get an ambulance, they thought the patient drank de-icer." "Dispatch paged out the ambulance and when we got to the scene, the police officers had the patient standing on the road." "We transported patient #2 to the hospital along with a police officer who was also an EMT." "During the ambulance ride, we asked patient #2 why he sprayed this in this mouth but he did not have an answer." "We called in report to the hospital and told them that we thought the patient sprayed de-icer in his mouth." EMT-PS C stated they took patient #2 into the ED room 1 on arrival and that Physician A was in the room with the nurse. EMT-PS C stated that he left the empty can of de-icer at the nurse's station.

7. During an interview on 3/23/10 at 5:05 PM, ED Tech E stated the ED staff heard on the police scanner there was a high speed chase and there were a number of agencies chasing the car. "We heard them use stop sticks and then later we heard the police ran the car off the road and into a ditch." ED Tech E stated through listening to the traffic on the scanner, there was some talk that the patient in the car was drinking or had drank antifreeze so they called Poison Control and they said they would fax us information. "While we were waiting for the fax, there was more commotion on the scanner." ED Tech E said he gave the fax on antifreeze to Nurse B, and stayed at the desk and answered the telephone. ED Tech E stated there was an ambulance report called to the nurse and they said the patient sprayed de-icer in his mouth. The police officer said the patient was acting as if he was spraying de-icer in his mouth. We had that information faxed after that. That fax came soon after the patient got into room 1. ED Tech E took the fax, stapled it together and handed it to ED Physician A, who was standing at the foot of the patient's bed talking to the patient.

8. During an interview on 3/23/10 at 5:50 PM, Police Officer/EMT D stated they heard of a police chase coming their way so they responded to assist. Another police officer pitted the car to the ditch. Another police officer took the window out and dry stunned the patient with a tazer (the probes were not out). The police pulled the patient out of the car and they found the de-icer that the patient was huffing. The patient was conscious and cooperative. Police Officer/EMT D stated they rode in the back of the ambulance for the safety of the Paramedic. Police Officer/EMT D stated the information given to the ED staff included the bottle of de-icer the patient had huffed, the window was broken out so they could get the patient out of the car, and that the patient was tazed at the scene. Police Officer/EMT D said the hospital called Poison Control.

9. During an interview on 3/23/10 at 10:30 AM, the ED Medical Director stated review of Patient #2's medical record revealed patient #2 had eloped from Hospital B and fled in a stolen car. Verbal report provided by the ambulance crew and law enforcement indicated patient #2 may have sprayed de-icer in his mouth. The ED Medical Director stated ED Physician A did not follow the standard of care and that patient #2 should have been transferred to a hospital capable of treating individuals with Methanol poisoning. The ED Medical Director said that patient #2 should not have been transferred back to Hospital B (a hospital without the appropriate capabilities to treat an acute case of poisoning).

10. Review of Hospital B's medical record for Patient #2 revealed the patient arrived at the facility at 9:50 PM on 2/20/10 with discharge instructions from the ED that stated "Diagnosis: Normal exam after MVC [Motor Vehicle Crash], mental illness. Return to [Hospital B] to continue current treatment, shower tonight, expect to be more sore tomorrow, report any concerns to nursing." Documentation in the nursing notes on 2/20/10 at 8:30 PM specified "Received word that [patient #2] has been medically cleared and will be returning to [Hospital B] via authorities directly to unit. Will be placed on suicide precautions and escape precautions." Further review of the medical record documentation revealed that at 11:00 AM, patient # 2 was lethargic, sedate and had an increased blood pressure. Further documentation revealed that patient # 2 became unresponsive at 1:00 PM and orders were received for transport to the ED at Hospital C [an acute care hospital with greater capabilities] for evaluation.

10. Review of Hospital C's medical record revealed patient # 2 arrived by ambulance at 1:22 PM on 2/21/10 unresponsive. Documentation in the medical record revealed anesthesia intubated patient # 2 and that his laboratory studies revealed significant acidosis. Hospital C did not have Antizol available. At 2:45 PM Hospital C transferred patient #2 to Hospital D [an acute care hospital with greater capabilities].

11. Review of Hospital D's medical record revealed patient # 2 arrived via air ambulance to the ED at 3:02 PM unresponsive. Hospital D admitted patient # 2 to the intensive care unit for intravenous Antizol infusion, mechanical ventilation and dialysis for acute renal failure.