HospitalInspections.org

Based on review of records and interview, the facility failed to ensure that the appropriate transfer of patients with Emergency Medical Conditions were facilitated within a timely manner to ensure patients received treatment when it was determined a higher level of care was necessary for 4 (Patient #7, #27, #28, and #29) out of 18 patient transfers reviewed. Documentation showed that patients were left in the facility Emergency Department waiting indefinitely for bed availability at a hospital within their hospital system unless the family specifically requested another hospital outside of the system be used.

Findings included:

Patient #29's chart was reviewed on 11-3-2021. Patient #29 was 57 years old. The patient was found unresponsive at home and transported to the Emergency Department (ED) by ambulance. Review of the ED Course timeline of physician notes was as follows:

"Fri Oct 08, 2021
2201 (10:21 PM) Her hemoglobin is 5.0 type and crossmatch has been ordered her blood pressure is low so we will give her 1 unit of O-

2236 (10:36 PM) Ordered 2 units of typed specific blood to be transfused after the O-

2303 (11:03 PM) Calcium(!): 7.1

2330 (11:30 PM) Dr. ____ (receiving hospital system physician name) accepts the patient to IMC bed. (Intermediate Care - level of care not provided at Quitman location)

Sat Oct 9, 2021
0852 (8:52 AM) Patient care is transferred to me by Dr. _____ (ED physician name from off-going shift). Patient is moaning in bed, only responding to painful stimuli. I discussed this case with intensivist, Dr. ______ (On-coming receiving hospital system physician name). Patient is awaiting IMC bed at receiving hospital.

Sun Oct 10, 2021
0710 (7:10 AM) I discussed case with Drs. _____ (original receiving hospital physician contacted on 10-8-2021), ________ (Quitman physician), and ________ (Quitman physician) - all agree that patient can be kept here as inpatient as receiving hospital is still having no bed for her. Patient has improved significantly in the last 24 hours. She is now up, talking, and eating. VSS (vital signs stable)

0722 (7:22 AM) I spoke with patient daughter, ________ (daughter's name) at ________ (phone number), regarding patient clinical status. She is agreeable for patient to be admitted here."

Nursing notes documented on 10-9-2021 at 5:34 AM indicated, "Peri care provided at this time, large black watery stool noted in bed. Pt moans out with movement. Vital signs stable, 3rd unit of prbcs (packed red blood cells - blood) infusing." Black stool could be an indicator of a Gastrointestinal (GI) bleed. The chart indicated that the stool was sent to the lab and tested positive for blood in the stool, confirming a GI bleed.

Nursing Staff #61 documented:

10-9-2021
"07:15 (7:15 AM) Report received. Pt is waiting for transfer to IMC/ICU system facility. Pt remains minimally responsive, non-verbal. Pt appears icteric (affected by jaundice which causes a yellowing of skin), pale, and cool to touch. As reported by previous shift RN, pt has no NG tube (nasogastric tube place into the nostril and down to stomach in order to suction stomach contents or administer medications) after numerous attempts. Foley cath is patent with 1000ml urine in collection bag. Further orders pending.
...

08:40 (8:40 AM) Pt cleaned of moderate amount of black, tarry stool with foul odor. No change in mentation; does not follow commands or answer questions. NG tube attempted again to bilat nares (both nostrils); unsuccessful.
...

09:06 (9:06 AM) Pt remains obtunded (a depressed level of consciousness when a patient cannot be easily aroused), non-verbal, GSC of 9 (Glasgow Coma Scale of 9 - the GSC is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of the best eye response, verbal response, and motor response. A score of 9 correlates with a moderate injury to the brain.), ERMD (emergency room physician) notified. PO med (medications given by mouth) not given due to pt is not awake or responsive, does not swallow when instructed, and has almost continual black diarrhea stool. Nsg (nursing) staff not successful inserting NG tube safely. Pt does not follow commands or instructions. Pt does not answer any questions or speak to staff.
...

09:44 (9:44 AM) Pt continues to wait for transfer to critical care (system) facility. No change in assessment. GSC 9.
...

15:20 (3:20 PM) Pt continues obtunded; no verbal response. Family members calling ER after leaving bedside c/o having to wait for transfer and state she is not getting care here. Family members verbally abusive to nsg staff by phone. Charge RN aware; MD notified."


Staff #61 was interviewed by telephone on 11-4-2021 at 11:30 AM. Staff #61 stated that the patient's family was upset about how long the transfer was taking. She stated they requested that the patient be transferred to a hospital in Shreveport. The patient has family in Shreveport. She stated that a family member was yelling and cursing at her on the phone because the transfer was taking so long. Staff #61 was asked if the staff at the transfer center ever called back to let the hospital staff know what hospitals had been called to request they take the transfer or the results of those calls. Staff #61 stated the transfer center did call back and let her know that the Shreveport hospital had denied accepting an out-of-state transfer because the family had specifically requested that hospital. However, Staff #61 stated that the transfer center staff does not normally tell the ED staff what hospitals have been contacted in an attempt to transfer a patient or the results of those contact attempts. Staff #61 stated she doesn't believe the transfer center attempted to contact any other outside hospitals besides the one that the family requested.

Nursing Staff #23 was interviewed on 11-4-2021 at 11:07 AM about her involvement with the patient's family after the transfer was cancelled due to a lack of beds at the receiving system hospital. Staff #23 reported that the transfer center had initially been set up as a transfer center to coordinate internal transfers between system hospitals. In June 2021 the transfer center was given the responsibility of coordinating external transfers to hospitals other than system hospitals. Staff #23 advised that when a transfer is initiated, it is no longer under the local hospital's control. The local hospital is not authorized to call other hospitals and make transfer arrangements.

Patient #29's medical record documented on 11-8-2021 at 11:30 PM that the transfer center had secured an accepting physician at the system hospital, but there were no beds. On 11-10-2021 at 7:10 AM, the decision was made to admit the patient to the Quitman hospital because there were still no beds available at receiving system hospital. The patient had been left in the Emergency Department approximately 32 hours after the transfer center had secured an accepting physician; but no bed ever became available during the 32 hours wait.

On 11-4-2021 the transfer department transcripts for the transfer of Patient #29 were reviewed. The transcript showed that the transfer department never attempted to contact a hospital in local area when a bed was not available internally through the hospital system. The hospital in Louisiana was contacted only because the family specifically named that hospital and no other hospitals in the Shreveport area were contacted. Medical records and transfer department records did not document that the family was offered any other options than to wait for a bed at receiving system hospital.

On 11-5-2021 the ED Director was interviewed. The ED Director confirmed that once the transfer was initiated, the local hospital had to wait until the transfer center provided them with transfer information. Local staff were not allowed to initiate contact with other hospitals or arrange transport. The only recourse when staff believe a transfer was taking too long or becoming urgent was to have the ED physicians intervene if they could. The ED director confirmed that patient families became upset with the ED staff when ED staff could not provide information on the status of the transfer because the transfer center wouldm't provide local ED staff with updates on the status of the transfer.

The hospital was not able to provide a transfer log that recorded all transfers that were initiated and the result of those transfers (i.e.: completed, cancelled due to patient refusal/death/admission to local hospital, etc.). Staff #2 stated that the transfer center had that information and they were waiting on the transfer center to provide it. Until then, the hospital was able to provide copies of Memorandum of Transfer (MOT) for all completed transfers and a list of completed transfers. A record of all transfer requests (completed and cancelled) was never provided by the transfer center to the survey team. A review was made of MOTs for the time period 10-1-2021 to 11-1-2021. During that time frame, 72 transfers were completed. Twelve (12) transfers were to behavioral health hospitals for a remaining total of 60 medical transfers completed. Only 9 of the 60 remaining transfers were to hospitals outside of the hospital system.

Of those 9 transfers to hospitals outside of the hospital system, one was a pediatric patient that needed a pediatric orthopedic specialist and was transferred to a pediatric hospital in the Dallas area. Two (2) were documented to have been completed at the patient/family request. On 11-5-2021, the audio recordings for the transfer request for Patient #29 were reviewed. The physician was heard saying during the recording (as an incidental conversation with transfer center staff) that Patient #47 wants to be transferred to the Dallas area where he lives as he was only in the hospital's local area on vacation. The MOT was documented at the top as "Pt/Family Request".

Review of Patient #28's chart showed that a transfer was initiated on 10-5-2021 at 3:16 AM for the system hospital through the transfer center. According to transfer center transcripts an accepting physician was received at 3:50 AM. At 6:02, the family requested that another hospital be considered. Per MD notes, the family "says pt has not been treated at system hospital or ___(requested hospital) but a family member's recent experience would prefer to go to ____ (requested hospital). __________(transfer center) called."

During review of charts for transfer patients, Patient #7's and Patient #27's charts were reviewed. Both transfers were completed to the system hospital. Review of Patient #7's ED Course notes were as follows:

"Sat Oct 02, 2021

0859 (8:59 AM) Cxr (chest x-ray) shows infil (infiltrates) vs mass will get ct (computed tomography) pe (pulmonary embolism - blood clot in the lung) protocol

1114 (11:14 AM) I talked with Dr. ____ (physician name) and he recommended sending her to system hospital for oncology evaluation I call first come (sic) and talk to ____ (name) and he is going to get a hospitalist for me to talk to.

1121 (11:21 AM) I discussed her case with Dr. ______(physician name) and he accepts her in transfer

2000 (8:00 PM) I assumed care of this patient at 2000 (8:00 PM). Patient is awaiting transfer to _________ (receiving system hospital).

Sun Oct 3, 2021

0759 (7:59 AM) Discussed with and care to Dr. _____ (off-going ED physician)

0849 (8:49 AM) She is resting quietly with no new issues she is waiting on her ambulance to take her to receiving hospital or otherwise I was going to recheck her lab due to hyponatremia and elevated white blood count."

The CT Chest Pulmonary Embolism with contrast was completed and the report dictated on 10/2/2021 at 10:02 AM. The final results were as follows:
"1. Large pulmonary neoplasm (abnormal and excessive growth of tissue) in the left upper lobe. Bulky mediastinal and hilar metastatic adenopathy (lymph nodes with cancerous changes).
2. The mediastinal metastatic adenopathy is bulky enough that it nearly occludes the superior vena cava (the large vein that returns blood from the upper part of the body above the diaphragm to the heart) and right main pulmonary artery (a main artery that takes blood from the heart to the lungs).
3. No evidence of metastasis to the visualized upper abdomen.
4. Moderate to large pericardial effusion (an abnormal accumulation of fluid in the pericardial cavity - around the heart)."

Review of Patient #28's chart showed that the patient was transferred out of the facility at 9:47 AM on 10-3-2021. Review of the transfer record showed that Capacity Approval for a bed was secured on 10-3-2021 at 6:27 AM. No record was made of outside hospitals being contacted when a bed was not available on 10-2-2021 at 11:21 AM. No documentation was found in the patient's chart to show that the patient was told there may be a delay and that the patient was offered any other option than to wait indefinitely until a bed became available.

Review of Patient #27's chart was made on 11-5-2021. The patient had previously had a right hip replacement 2 months prior and was having bleeding and drainage from the incision site. He was diagnosed with a post-operative infection. Review of Patient #27's ED Course notes were as follows:

"Mon Oct 4, 2021
1303 (1:03 PM) Dr. ______ (physician name) consulted for transfer-Ref to hospitalist

1509 (3:09 PM) Dr. ______ (physician name) briefed and he accepted the patient

Tue Oct 5, 2021
0838 (8:38 AM) Signed out 0900 (9:00 AM)

Wed Octo 6, 2021
0755 (7:55 AM) Patient is ER hold and waiting for inpatient bed at _______(receiving system hospital). Patient clinical status remained uneventful during my shift. Care is transferred to Dr. _____(physician name).

2000 (8:00 PM) Discussed with and assumed car from Dr. _______(physician name). Awaiting transfer.

Thu Oct 7, 2021
2000 (8:00 PM) Discussed with and assumed care from Dr. ________ (physician name). Still waiting on transfer to ______(receiving system hospital)."

Nursing notes, Date of service 10-4-2021 at 10:46 AM, documented, "Pt states his leg has been swelling for a few days and he's been putting ice packs on it; bleeding and drainage started during the night. Right anterior thigh red, swollen and pitting from hip to knee."

Nursing notes, date of service 10-4-2021 at 8:00 PM, documented, "Pt wound weeping large amounts of purulent discharge from right hip surgical site. Pt denies any pain at this time. Complete linen changed at this time."

Nursing notes, date of service 10-4-2021 at 11:00 PM, documented, "Pt wound drainage seeped through dressing. Complete linen changed at this time."

Nursing notes, date of service 10-6-2021 at 2:18 AM, documented, "S/w (spoke with) _______ (staff name) at ___________(transfer center) about bed status; there has not been any change and we are still waiting on bed availability".

Nursing notes, date of service 10-6-2021 at 5:20 AM, documented, "Patient requested a shower, which was approved by ERMD. Supplies gathered, along with a wheelchair for transport to restroom and walker for transfer to bench seat in shower. Patient acc'd (accompanied) by ER tech for transfer assistance"

Nursing notes, date of service 10-6-2021 at 10:45 AM, documented, "Responded to call light. Pt has multiple requests frequently. Demanding heating pad to be warmed up. PSA gave her boundaries & informed her she is not able to do this all day. Pt agrees."

Records show that the patient was not transferred until 10-8-2021 at 1:30 AM. Review of the transfer record showed that between 10-4-2021 at 1:04 PM and 10-8-2021 at 1:30 AM, no other hospitals were contacted for possible transfer and acceptance of patient. No documentation was found in the patient's chart to show that the patient was told there may be a delay and that the patient was offered any other option than to wait indefinitely until a bed became available.

Review of a notebook of documents covering the transfer process was made. The "Transfer Algorithm" for all Quitman transfers contained the following decision tree:
"Is the patient transferring out of _____ (Hospital system) System?"

If the answer is no, the next step is "Consult with specialist when needed for placement or intervention." Then, "Consult with admitting provider for acceptance."

If the answer is yes, the next step is "Specific reason patient is transferring outside of facility?" Then, "Consult with admitting provider for acceptance."

Copies of all transfer policies were requested. Policy "Title: ______(transfer center)-Patient Transfers - ED to ED - DIV - ED; Policy Number: 52102.1; Effective Date: 11/26/2019" and policy "Title: ________(transfer center)-Patient Transfers-Inpatient - Admitted at another Facility- DIV-ED; Effective Date: 11/26/2019" were provided. These policies talked about the process for patients to be transferred to ___________ (hospital system)to "expedite the transfer process to enhance patient care" No policies were provided that outlined the process for ensuring transfers from ________(hospital system) hospitals were expedited when beds at the system hospital were not readily available, or the timeframe that a patient was expected to wait for a bed when a higher level of care was needed and not available at the current system hospital. The policies that were provided were put into effect when ________(transfer center) was responsible for internal system's transfers only and system hospitals were responsible for transferring to outside hospitals when no beds were available within the Hospital System.

Because a complete transfer log of completed and cancelled transfers was unavailable, it could not be determined how many patients, such as Patient #29, had thier transfers cancelled due to the lengthy wait for a bed. These could have been cancelled due to patients leaving/discharging because of the wait or changes in patient condition.

Delay in transfer of a patient indefinitely due to no bed availability without checking other hospitals when a higher level of care was required for the patient condition has the potential for the patient's condition to worsen. No evidence was presented that showed the patients were provided with information necessary to choose another transfer location.