HospitalInspections.org

Based on review of Patient #2's Nursing Home medical record, ambulance trip report, Central Log, ED medical record, MEDICAL STAFF RULES, REGULATIONS AND POLICIES, AGREEMENT FOR EMERGENCY DEPARTMENT AND HOSPITALIST SERVICES, policies and procedures, observational tour, staff interviews, it was determined that the facility failed to provide an appropriate transfer for one (1) of 20 sampled medical records when the patient (Patient #2) presented to the Emergency Department on 09/26/18 with a chief complaint of low blood pressure and possible sepsis.

Findings were:

Cross refer to tag C-2409 as it relates to failure to provide an appropriate transfer.

Based on review of patient #2's NH record, ambulance trip reports, Central Log, ED medical record, MEDICAL STAFF RULES, REGULATIONS AND POLICIES, AGREEMENT FOR EMERGENCY DEPARTMENT AND HOSPITALIST SERVICES, policies and procedures, observational tour, and staff interviews, it was determined that the facility failed to provide an appropriate transfer by failing to ensure that: 1.) a physician certified in writing a certification for transfer for an individual; 2.) the receiving facility had available space and qualified personnel for the treatment of an individual; 3.) copies of the medical record was sent to the receiving hospital related to the individual's emergency medical condition; and 4.) the receiving facility had agreed to accept the treatment of an individual to provide appropriate medical treatment for one (1) of 20 sampled medical records when the patient (#2) presented to the Emergency Department on 09/26/18 with a chief complaint of low blood pressure and possible sepsis.

Findings were:

Medical Record Review from Nursing Home

Review of Patient #2's Nursing Home (NH) notes revealed that on 09/26/18 the patient condition changed. The NH nurse noted the following changes:
--decreased level of consciousness,
--not eating,
--difficulty swallowing,
--holding food in mouth,
--non-productive cough, and
--loose foul-smelling stools.

The NH notes indicated that the patient's past medical history included: stroke, abdominal pain, diabetes (high blood sugar), high blood pressure, coronary heart disease (narrowing of the major vessels of the heart), and pulmonary embolus (blood vessel in the lung that is blocked by a blood clot). The nurse noted the following medications: Trazodone (anti-anxiety) was discontinued, started Remeron (antidepressant), Prednisone (used to treat inflammation), and Eliquis (blood thinner). There was no indication as to when the last dose had been administered for any of these medications. The nurse noted that the patient's vital signs (temperature, pulse, respirations, blood pressure, and oxygen saturation) was 101.0 degrees Fahrenheit (normal 97.8 to 99.1)- 111 (normal 60-100) - 18 (normal 12 to 18) - 115/54 (normal 90-120/50-80) -93% (normal 94-100%), with a 98 (normal 70-100) blood sugar. The NH nurse further noted that the patient had a quarter size open area located on the roof of mouth. The nurse noted that he/she notified the patient's primary care physician (PCP) at 1:00 p.m. The nurse noted that the PCP's orders included: blood work, urinalysis, chest x-ray, and Zosyn (antibiotic) 3.375 grams to be administered intravenously (IV into a vein) every six (6) hours. The nurse also noted that the patient's family was notified. At 3:30 p.m., the nurse noted that a 22 gauge IV was inserted and the Zosyn 3.375 grams was administered as ordered. In addition, the nurse noted that the NH was awaiting lab results. At 4:20 p.m., the nurse noted that the lab results were received, and an order obtained from the patient's PCP to transfer the patient to the acute care hospital. The nurse noted that the patient's care was transferred to the ambulance attendants for transport to the acute care hospital. The nurse noted that the patient's discharge vital signs were 98.0-81-18-100/54, and that the patient was a full code.


Ambulance Trip Report

Review of the ambulance trip report dated 09/26/18 revealed the Emergency Medical Technicians (EMTs) responded to a call from the NH to transport a patient (#2) who had an abscess in the roof of the mouth. The trip report revealed the EMTs (#s6 and 7) arrived at the patient at 5:27 p.m. The trip reported noted that the patient had an infection and altered mental status (AMS). The patient's past medical history was listed as: dementia, diabetes, stroke, high blood pressure, and cardiomyopathy (thick/rigid, weakened heart muscle). The trip report further noted that the patient's home medications included Prilosec (used to treat acid reflux), Lisinopril (used to treat high blood pressure), and Glucophage (used to treat diabetes). The trip report indicated the patient was conscious but not alert and that staff reported that this was abnormal for the patient. The trip report indicated the NH staff reported that the patient usually fed himself/herself and was able to walk. The trip report further noted that the patient's arms were contracted, that the patient had a patent airway, and that there was a two (2) inch hematoma (clotted blood under the skin) above the patient's left eye that staff reported was from a fall approximately two (2) weeks earlier. At 5:42 p.m., the trip report noted that en route to the acute care hospital the patient's blood pressure was 64/40 and that the patient had weak radial (wrist) pulses. EMT #7 noted that IV fluids were connected to the IV site but due to the patient's contractures the fluids were not infusing properly. EMT #7 noted that he/she tried to start another IV but was unable to find a vein. EMT #7 noted that the decision was made to stop at the closest hospital and that upon arrival the EMTs (#s 6 and 7) were instructed to place the patient in room two (2). EMT #7 noted that upon arrival to the ED the patient became more responsive and stated, "let me go, please let me go". EMT #7 noted that physician #2 assessed the patient and after communicating with the patient's PCP, ED physician #2 informed the EMTs to put the patient back in the ambulance and continue to the acute care hospital. EMT #7 noted that hospital staff reported that the patient's blood pressure was 112/78. In addition, EMT #7 noted that a splint was applied to the patient's arm to keep it straight so that the IV fluids could be infused.

Central Log Review (Hospital A- Monroe County Hospital)

Review of the Central Log and Patient #2's ED medical record revealed the patient presented to the ED by ambulance at 6:00 p.m. on 09/26/18. The Central Log listed the chief complaint as AMS and the medical record listed the patient's chief complaint as low blood pressure.

Emergency Department Medical Record Review Hospital A

At 6:00 p.m., ED physician #2 noted that the patient's history was obtained from the EMTs (#s6 and 7) and the NH records. The physician noted that the chief complaint was possible sepsis (blood stream infection) and oral abscess. The physician noted that the patient's medical history included diabetes which is orally controlled, high blood pressure, coronary (heart) artery disease, and delusional disorder. Physician #2 noted that the NH staff had found that the patient had a severe oral abscess which was requiring evaluation by an Ear Nose Throat (ENT) Specialist and possibly oral surgery at a nearby acute care hospital. Physician #2 noted that the EMTs (#s6 and 7) were concerned that the patient's breathing pattern had changed en route and that they could only hear a blood pressure of 60s systolic (top number) so they (EMTs) diverted here. Physician #2 noted that the patient had recently been seen and treated by the patient's PCP. Physician #2 noted that the physical examination revealed: all systems negative except as noted, blood pressure 112/60 and respirations 20, alert and in no acute distress, mucus membranes (lining of the mouth) moist with a large abscess in the roof of the mouth. Physician #2 also noted that the patient was disoriented to person, place, time, and situation.

Registered Nurse (RN #3) noted that the patient was placed in room #2 at 6:05 p.m. There was no triage (assessment by a nurse to determine the priority in which patients will be seen based on the severity of their conditions) level noted. RN #3 noted that a call was received from the ambulance crew who reported that they were transporting a patient (#2) with a mouth abscess from the NH to a nearby acute care hospital and that the patient's blood pressure had dropped. RN #3 noted that EMT #7 reported that the patient's blood pressure was 60s systolic and that the EMTs (#s6 and 7) needed to bring the patient to the ED for stabilization. RN #3 noted that the patient's past medical history included diabetes, heart disease, high cholesterol, and high blood pressure. RN #3 also noted that IV fluids had been started prior to arrival.

At 6:20 p.m., Physician #2 noted that the patient was stating over and over "let me go", and that indicated that the patient had an adequate airway. In addition, the physician noted that the patient had bounding (forceful) pulses in the groin and good pulses in the top of the foot. Physician #2 further noted that since the patient needs ENT evaluation and possible oral surgery, after checking with the patient's PCP who agreed, the patient was sent on the way to the nearby acute care hospital. Physician orders revealed an order was written for the patient to be "Transferred". There was no documented evidence of the following:
--physician to physician communication between the ED physician and a physician at the acute care facility,
--accepting facility,
--accepting physician,
--nurse to nurse report,
--explanation of the risks and benefits associated with the transfer, and
--there the Transfer Form had not been completed.
Physician #2 noted that the patient's condition was guarded, and that the patient was being transferred by EMTs (#s6 and 7) to the acute care hospital. The Central Log noted that the patient left the ED at 6:25 p.m.

Ambulance Trio Report to Hospital B

At 6:29 p.m., EMT #7 noted that once in the ambulance the patient's blood pressure was 90/66 with fluids running wide open. EMT #7 further noted that the patient's blood glucose was 254. At 6:40 p.m., EMT #7 noted that the patient's blood pressure was 100/68. EMT #7 noted that during transport to the acute care hospital (Hospital B) the patient's blood pressure continued to improve slightly and that the patient became more alert, continued to moan and speak with confusion and incomprehensible words. At 6:45 p.m., EMT #7 noted that the patient's blood pressure was 100/72. EMT #7 noted that the patient was a non-emergent transfer without lights or sirens. At 6:55 p.m., EMT #7 noted that upon arrival at the acute care hospital (Hospital B) the patient was placed in room 25 and report was given to a RN.

Review of the facility's MEDICAL STAFF RULES, REGULATIONS AND POLICIES, last review and revision 09/25/18, revealed the following:
TRANSFER OF PATIENTS
Patients may be transferred from the hospital to another facility for services which are unavailable in our hospital or other reasons of medical necessity. The following protocol will be observed by physician and hospital staff in the event of necessary transfer:
--No patient will be transferred from the hospital to another hospital unless the attending physician has made an order and arrangements for the patient's care elsewhere.
--Willingness to receive the transfer must be obtained from the receiving hospital and the receiving physician and both acknowledged in the physician's documentation. --A copy of all pertinent medical records will accompany the patient.
--All patients must be assessed and stabilized prior to transfer.

Review of the AGREEMENT FOR EMERGENCY DEPARTMENT AND HOSPITALIST SERVICES, effective 08/05/2017, revealed the following:
II. DUTIES AND RESPONSIBILITIES OF CONTRACTORS (ED physicians)
A. STAFFING
1. To the extent permitted by law, Contractor shall supply independent contractor Physicians who are licensed to practice medicine in the State of Georgia ("Physicians"); who hold a current Drug Enforcement Administration/Narcotics license, who shall become a member in good standing of the medical staff of Facility with privileges to perform the services contemplated by this Agreement and who shall also be subject to the policies, rules and regulations of Facility, including, but not limited to, the medical staff by-laws, rules and regulations.

Review of facility policies included but was not limited to the following:
1. EMTALA, no policy, dated 07/01/13, revealed that an acute care, specialty or critical access hospital with an ED provide an appropriate MSE and any necessary stabilizing treatment to any individual, who comes to the ED and requests such examination to determine if an EMC exists. If an EMC is determined to exist, the hospital must provide either (i) further medical examination and any necessary stabilizing treatment within the capabilities of the staff and facilities available at the hospital or (ii) an appropriate transfer to another medical facility.
E. Transfer Obligations of Each Hospital
i. A hospital may transfer an individual with an EMC that has not been stabilized if the transfer is appropriate; and if
a. the individual (or legally responsible person acting on the individual ' s behalf) requests the transfer after being informed of the hospital ' s obligations under EMTALA and of the risks of such a transfer. Any such request must be in writing and must indicate the reasons for the requests as well as the risks and benefits of such a transfer;
b. A physician certifies in writing that based on the information available at the time, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or unborn child, from being transferred. A summary of the risks and benefits upon which the decision is based must be included; or
c. If a physician is not physically present in the ED at the time of transfer, a qualified medical person has signed a certification after a physician in consultation with the qualified medical person agrees with the certification and subsequently countersigns the certification. A summary of risks and benefits upon which it is based must be included.
ii. A transfer to another medical facility will be appropriate in those cases in which the receiving hospital can provide medical treatment within its capacity that can minimize the risks to the individual ' s health and, in the case of a woman in labor, the health of the unborn child; and the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to provide such care.
iii. The transferring hospital must send the medical records related to the EMC along with any history, preliminary diagnosis, results of diagnostic studies or telephone reports, and other medical records pertinent to the patient ' s presenting EMC, and the informed written consent or certification required for the transfer. Test results that become available after the individual is transferred should be telephoned to the receiving hospital, and then mailed or sent via electronic transmission consistent with HIPAA provisions on the transmission of electronic data.
iv. All transfers must be affected through qualified personnel and appropriate transportation equipment including the use of necessary and medically appropriate life support measures during the transfer.
v. The receiving facility must accept appropriate transfers of individuals with EMCs if the hospital has specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals.
vi. The CEO designee in conjunction with the Emergency Physician has authority to accept the transfer if the hospital has the capability and capacity to treat the individual. The CEO must designate in writing the hospital designee responsible for acceptance of transfers in conjunction with the Emergency Physician.
vii. A Transfer Center may facilitate transfers to and/or from sending or receiving hospitals at the Hospital ' s request. The Transfer Center may make no decision to accept or to refuse to accept a transfer request

2. External Patient Transfer, no policy number, effective 04/23/18, revealed the attending physician is responsible for the decision to transfer a patient to another facility based on EMTALA dictated criteria. The physician is also responsible for giving; a physician to physician report to the accepting physician. Once the patient is accepted, the ED or Medical/Surgical nurse will contact the receiving facility for transfer, assure completion of the documentation, completion of the "Patient Transfer to an outside Facility" form as per EMTALA, and any other electronic medical record documentation required for transfer of a patient. A patient report will be called to the receiving facility prior to transfer. In addition, the attending physician is responsible for determining the need for transfer; as well as ensuring EMTALA compliance in the decision to transfer.


Observational Tours and Interviews

On 10/15/18 at 9:30 a.m., a tour of the ED was conducted with the Director of Patient Care Services (#4 DOPCS). The DOPCS went on to explain that 70% of the ED patients present with urgent care complaints. The DOPCS said that only licensed physicians with privileges can perform the MSE to determine if an emergency medical condition exists, stabilizing treatment, and transfers to another hospital if a higher level of care is required.

During an interview on 10/15/18 at 12:00 p.m. in the Conference Room, the ED Medical Director (#1) explained that a MSE is to be performed by a physician for any patient that walks into the ED or presents on hospital property requesting a MSE. Physician #1 said that the general rule is that if someone needs help we will help them. The physician said that when he/she was informed of the incident involving the patient (#2) he/she had a bunch of questions and a lot of concerns regarding what happened. Physician #1 said that he/she questioned why there was no blood work obtained and no antibiotic administered. Physician #1 said that he/she had a discussion with ED physician #2 regarding "why there had been a rush to send the patient to the other hospital". Physician #1 explained that he/she then escalated the event to the ED physicians' (contracted group) upper management and "we all agreed that this was handled incorrectly and that there were potential problems with the transfer". Physician #1 stated the ED physicians group had completed EMTALA training sometime in August 2018 and that the group redid their EMTALA training again around the first of October 2018. The physician went on to explain that the EMTALA training is provided to the ED physicians group annually. Physician #1 further explained that he/she reviews all transfers for physician to physician communication and to ensure that the transfers are appropriate.

During an interview on 10/15/18 at 1:00 p.m. in the Conference Room, the ED physician (#2) stated he/she had been practicing medicine for over 30 years. Physician (#2) confirmed that he/she had provided care for the patient (#2) on 09/26/18 and that he/she remembered the patient well. Physician #2 explained that the patient (#2) was initially being transferred from the Nursing Home to a nearby acute care hospital by ambulance. Physician #2 said that the ED received a call from one (1) of the ambulance attendants and was informed that the patient (#2) was unstable. Physician #2 stated the EMTs diverted from the original plan and brought the patient to the ED to be evaluated. Physician #2 said that the two (2) ambulance attendants were Emergency Medical Technicians (EMTs are clinicians, trained to respond quickly to emergency situations regarding medical issues, traumatic injuries and accident scenes) not Paramedics (build on their EMT education and learn more skills such as administering medications, starting intravenous lines, providing advanced airway management for patients, and learning to resuscitate and support patients with significant problems such as heart attacks and traumas). The physician said he/she thought the Nursing Home should have requested an ambulance with more qualified staff for transporting the patient (#2). The physician explained that he/she thought the patient's (#2) primary physician wanted the patient to go to the nearby acute hospital that he/she (physician #2) needed to get the patient to that facility. In addition, physician #2 said that the patient kept repeating over and over "let me go" which told me (physician #2) that the patient had a patent airway and strong/bounding pulses in the lower extremities which told me that the patient had a good blood pressure that the concern was to get the patient to the nearby acute care hospital. Physician #2 went on to explain that the patient had a large abscess in the roof of the mouth that required more than blood work and antibiotics, the abscess needed to be drained and I (physician #2) could not drain the abscess. The physician said that his/her concern was not to delay the patient's care and that in retrospect he/she should have called the nearby acute care hospital.

During a telephone interview on 10/15/18 at 2:40 p.m. in the Conference Room, the RN (#3) said he/she recalls the incident on 09/26/18 regarding patient #2. The RN explained that on 09/26/18 he/she had been the ED Charge Nurse. The RN said that the ED received a call from a non-emergency ambulance crew informing the ED that they wanted to bring the patient (#2) to the hospital for an evaluation. RN #3 went on to explain that one (1) of the EMTs reported having concerns about the patient's (#2) blood pressure because he/she (EMT) was concerned that the abscess could have led to possible sepsis (is a life-threatening condition that arises in response to a blood stream infection). RN #3 explained that after receiving the call from the EMTs the ED was expecting an unstable patient. RN #3 went on to explain that the patient's (#2) vital signs were within normal limits, the patient was moving around, responding, verbalizing, and oxygenating well. The nurse said the ED physician (#2) checked the patient's (#2) lower extremity pulses. RN #3 explained that physician #2 had said the patient could continue on to the other acute care hospital. RN #3 said that he/she had not called report to the other acute care hospital because he/she thought the patient had been discharged. The nurse confirmed that the transfer form had not been completed, stating that the EMTs left with the patient within 20 minutes of their arrival in the ED.

During an interview on 10/16/18 at 10:10 a.m. in the Conference Room, the EMT (#6) explained that he/she has been an EMTB (basic EMT) for two (2) years. He/she explained that patient #2 is a regular EMT patient. EMT #6 said that on 09/26/18 he/she was driving the ambulance. EMT #6 explained that the NH called for transport of a patient to an acute care hospital. The EMT said that the patient was being transferred due to a mass in the roof of the mouth and that upon inspection the roof of the patient's mouth looked like it had a black hole. EMT #6 said that he/she helped the NH staff change the patient and that the patient did not respond when moved. The EMT said that the patient was loaded into the ambulance and that while enroute EMT #7 tried to get a blood pressure with the automatic cuff and it would not register so EMT #7 manually took the patient's blood pressure and it was extremely low. EMT #6 said that about two (2) miles from the facility his/her partner asked him/her to pull over and that after pulling over he/she got into the back to assist with the patient. EMT #6 said that the patient seemed to be rapidly declining and that while going down the road/bumps it was difficult to tell if the patient was breathing because the patient's respirations were shallow. EMT #6 said that IV fluids were started and that although the patient's oxygen saturation was normal the patient's breathing had changed. EMT #6 said that EMT #7 told him/her to divert to the facility because it was the closest hospital. EMT #6 said that EMT #7 called report to the ED and that when they entered the ED with the patient (#2) they were told to take the patient to room #2. EMT #6 said that the physician (#2) and a RN (#3) came in and evaluated the patient. The EMT stated that physician #2 said, I don't know why you didn't just take the patient to the acute care hospital like the PCP ordered. EMT #6 said that the physician #2 called the patient's PCP and then told us (EMTs #6 and 7) the patient was stable and to take the patient to the acute care hospital. EMT #6 explained, that the patient was stable enroute to the acute care hospital.

During an interview on 10/16/18 at 10:20 a.m. in the Conference Room, the EMT explained that he/she is an EMTA (advanced) and has been an EMT for a little over four (4) years. States he/she is familiar with the patient's (#2) transport on 09/26/18. Explained that we (EMTs #6 and 7) got called to a NH for transport to an acute care hospital because the patient had abnormal labs. EMT #7 explained that the other EMT (#6) had previously transported the patient. He/she said that upon arrival to the patient the patient was in a geri-chair, lethargic and not responding. EMT #7 said that the other EMT said this was abnormal and the staff confirmed it was abnormal. EMT #7 said the patient was placed on the stretcher and the NH staff provided their paperwork. EMT #7 said that the staff reported that while cleaning the patient's mouth they (NH staff) noticed an abscess in the roof of the patient's mouth. EMT #7 explained that the patient's mouth was agape, and that the patient definitely had some infection in the roof of the mouth. The EMT described the area as a nickel size pure white with yellow streaks and maybe some blackened areas and it looked like the skin had sloughed off. EMT #7 said that once in the ambulance he/she put the automatic blood pressure cuff and pulse oxygenation equipment on the patient but that they weren't picking up. The EMT said he/she then did a manual blood pressure but couldn't hear anything. The EMT went on to explain that he/she has taken manual blood pressures in the ambulance and that sometimes it is hard to hear but that if the blood pressure is anywhere near a 100 systolic (top number) it can be heard. EMT #7 said that he/she performed a sternal (over the breast bone) rub and the patient did not respond. The EMT explained that the patient had an IV that was inserted by the NH staff and that the patient's upper extremities (arms) were very contracted and that it wasn't surprising that the pulse oxygenation was not registering. EMT #7 went on to explain that the patient's breathing slowed and that he/she leaned over to see if the patient's chest was rising and if he/she could feel air on his/her cheek. EMT #7 said that he/she asked other EMT to pull over and we (EMTs #6 and 7) straightened the patient's arm and did a manual blood pressure which was in the 60s (systolic). EMT #7 said he/she did not recall whether the NH reported whether the patient had received any medications for sedation or the patient's blood pressure medication, but that the NH staff had reported that the patient was not eating and drinking and possibly was dehydrated. EMT #7 said that with the patient's low blood pressure, faint pulses, and slow respirations, he/she did not feel comfortable riding to the acute care hospital with a patient that was a full code with only himself/herself and another EMT. EMT #7 said that he/she started IV fluids to the IV site and made the decision to divert to this facility's ED. EMT #7 said that he/she called and gave the ED report and alerted them that he/she thought the patient might be septic. EMT #7 said that upon arrival in the ED the patient was placed in room #2 and physician #2 walked in and asked "why did you stop here instead of going on to" the acute care hospital. EMT #7 said that he/she gave the physician a verbal report and informed the physician (#2) that he/she had thought it best to stop and have the patient stabilized. EMT #7 stated the lab results from the NH were in the paperwork that was sent with the patient from the NH. EMT #7 said that he/she did not think he/she should have to feel bad about bringing a patient to a hospital that has an ED sign and that the physician (#2) did not make me feel like we were welcome. EMT #7 said that the physician (#2) asked if I had felt for a pedal (top of foot) pulse and told me, it's right there can you feel it now. EMT #7 said the RN (#3) rolled the manual cuff machine in and reported that he/she (RN #3) thought the blood pressure was 112/78 but was sure it was heard at 100 (top number). EMT #7 explained that the physician (#2) called the patient's PCP and told us (EMTs #6 and 7) that once before he/she (physician #2) had gotten in trouble for keeping the PCP's patient when the PCP wanted that patient to be sent to an acute care hospital. EMT #7 said that the patient's contracted arm was splinted so fluids could be run wide open and that the physician (#2) came back into room after talking with the patient's PCP and told us (EMTs) to put the patient back in the ambulance and take the patient to the acute care hospital. EMT #7 confirmed that the patient was loaded back into the ambulance with no discharge papers, no transfer forms, and that they (EMTs) were only given a face sheet from the ED. EMT #7 said he/she and EMT #6 were concerned and EMT #6 called their supervisor. EMT #7 confirmed that the patient started to moan after receiving some IV fluids and kept repeating "let me go". EMT #7 said the patient remained fairly stable enroute and was placed in a room once they arrived at the acute care hospital.