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Based on interview and record review the facility failed to ensure one of thirty sampled patients' (Patient 28) was assessed for pain initially, assessed for pain after medication was administered, and was stable for safe transfer to another hospital.

This deficient practice had the potential for a worsening condition during transport to a receiving hospital.

Findings:

On November 23, 2021 at 3:21 PM, during concurrent interview with Emergency Department Manager (ED Mgr.) and record review, dated September 25, 2021, Patient 28's ED records indicated the patient had a fractured left femur (large bone in the thigh).

The ED Mgr. stated Patient 28's vital signs at 11:13 PM, prior to the transfer to another hospital, was not stable with rapid heart rate and high blood pressure. The ED Mgr. stated Patient 28 was most likely experiencing pain from breaking a bone. The ED Mgr. stated Patient 28 was given pain medication, without first being assessed for pain. The ED Mgr. stated Patient 28's pain score was not assessed to evaluate the effectiveness after being given pain medicine. The ED Mgr. stated the nurse, who administered Patient 28's pain medicine, should have documented the patient's level of pain prior to giving the medicine and also after the pain medicine was given.

A review of Patient 28's ED record, dated 9/25/2021 at 11:13 PM, indicated that Patient 28 had an elevated pulse rate of 98 beats per minute (normal resting heart rate from 60 to 100 beats per minute), a respiratory rate of 20 (normal respiration rates at rest range from 12 to 16 breaths per minute), and a blood pressure of 147/68 millimeters of mercury (normal blood pressure range was under 140/90 mm Hg). There was no assesment of Patient 28's pain level.

A review of ED policy for Transfers from the ED, dated December 6, 2018, indicated a patient was considered stable if vital signs are in normal range for the patient.

A review of Patient Care policy for Assessment and Reassessment, dated September 17, 2019, indicated reassessment was the evaluation of the patient's response to treatment and care in order to determine the appropriateness and effectiveness of care. Reassessment includes reviewing the location, type and intensity of pain.

Based on interview and record review, the facility failed to ensure that prior to transfer to other facilities, a physician, or another qualified medical person in consultation with a physician, has completed and signed a certification that the benefits of transfer outweigh the increased risks for four (4) of thirty (30) sampled patients (Patients 9,11,13, and 25).

The deficient practice had the potential for patients transferred by the facility, whose emergency medical conditions have not been stabilized, without careful evaluation of the risks versus benefits to the patients or consideration of the increased risks that may be associated with transfer which could endanger health and safety of transferred patients.

Findings:

On 11/23/2021 at 10:20 AM, in the presence of the facility's Chief Quality Officer (CQO), electronic health records (EHR) of a selected sample of patients were reviewed with the assistance of the Emergency Department (ED) Auditor-Educator. The review included the patients face sheets, the ED Triage Form, laboratory reports, radiology reports and physicians notes as indicated.


A. Patient 9's ED Final Report indicated that the patient presented to the Hospital ED (Emergency Department) complaining of abdominal pain and had physical, laboratory, and radiographic findings suspicious for acute cholecystitis (inflammation of the gallbladder), was transferred to another hospital for surgical evaluation.

The ED Final Report for Patient 9 indicated that the primary care provider at the admitting facility consulted with the ER Physician at the receiving facility and Patient 9's ER (Emergency Room) to ER transfer was accepted. The ED note indicated that the ED provider had a detailed discussion with the patient and/or guardian regarding the need for further workup and treatment, and that the patient was agreeable with the plan of care and was stable at the time of transfer.

B. Patient 11's ED Final Report indicated the patient presented to the ED with complaints of vaginal rash and itchiness and subsequently exhibited suicidal ideations, required transfer to a psychiatric facility due to being a danger to self. The receiving behavioral health facility and the accepting physician were documented in the ED note. The note stated the patient was in stable condition and that the ED provider had a detailed discussion with the patient and/or guardian regarding the need for transfer to another facility.

C. Patient 13's ED Final Report indicated the patient presented with cramping during third trimester of pregnancy, was transferred to another hospital for obstetrics care. The ED note indicated that an OB/GYN (obstetrics/gynecology) physician from the receiving facility was consulted and had accepted the patient transfer, the patient's condition was stable, and the ED provider had a detailed discussion with the patient and/or guardian regarding the need for transfer to another facility.

D. Patient 25's ED Final Report indicated the patient presented with shortness of breath and confirmed positive for COVID-19, was transferred to another hospital for further care for pneumonia.

On 11/23/2021 at 10:20 AM, during review of these patients' records (Patients 9, 11, 13, and 25), the patient transfer document, "Acute Interfacility Transfer Consent/Physician Certification," was missing from the electronic records.

On 11/23/2021 at 10:20 AM, during concurrent interview, the Chief Quality Officer (CQO) stated the forms had not been scanned into the patients' EHR, that he would look for and present a hard copy of the document for surveyor review. Subsequently, the CQO reported he was unable to locate hard copies of the transfer form for Patients 9, 11, 13, and 25, and could not provide documentation of the physician certification for transfer of the four patients.

The hospital's Administration Policy 'LAK ADM.037, EMTALA', dated 9/12/2016, indicated, under Section 8: Transfer of Unstable Individuals, that the patient may be transferred if a physician or if a physician not physically be present at the time of the transfer, another qualified medical person in consultation with a physician, had certified that the medical benefits expected from transfer outweigh the risks.

The hospital's Emergency Department Policy 'LAK ED.060, Transfers Interfacilities from the ED', dated 10/15/2018, indicated the Charge Nurse will review documentation to assure the inter-facility transfer form was complete and signed.

The facility's Department of Emergency Medicine Rules and Regulations, dated September 2020, indicated that the transfer of any Emergency Department patient was the responsibility of the ED physician and these transfers will be arranged in accordance with all state and federal requirements and Hospital policies.