HospitalInspections.org

Based on interviews and review of records, it was determined that the hospital failed to comply with CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Findings include:

As detailed in Tag 2409, it was determined that the hospital failed to assure that an appropriate transfer was effected for a medically unstable patient, Patient #1, and therefore, failed to comply with CFR §489.24.


Reference Tag 2409

Based on interviews and review of records, it was determined that the hospital failed to assure that an appropriate transfer was effected for 1 of 1 medically unstable patients whose records were reviewed, Patient #1. The hospital's failure to assure that the risks and benefits of transferring an unstable patient were explained to the patient and/or the patient's representative in writing, deprived the patient/representative of the right to be informed of the potential risks and benefits involved in the transfer of the medically unstable patient to another hospital.


Reference:
Online view of the Merck Manual on March 2, 2017 stated:

"What Is the Blood pH?
Acidity and alkalinity are expressed on the pH scale, which ranges from 0 (strongly acidic) to 14 (strongly basic or alkaline). A pH of 7.0, in the middle of this scale, is neutral.
Blood is normally slightly basic, with a normal pH range of 7.35 to 7.45. Usually the body maintains the pH of blood close to 7.40...
The body's balance between acidity and alkalinity is referred to as acid-base balance. The blood's acid-base balance is precisely controlled because even a minor deviation from the normal range can severely affect many organs..."

Findings include:

1.) The complainant stated in an email, and confirmed the written statement during a phone interview on February 21, 2017, that Swedish Medical Center - Cherry Hill (SMC-CH), had transferred an unstable patient to a receiving hospital. The complainant stated that the Emergency Department (ED) physician at SMC-CH transferred Patient #1 to the receiving hospital due to a lack of available Intensive Care Unit (ICU) beds at SMC-CH. The physician (MD#2) at the receiving hospital had reportedly accepted the patient with the understanding that the patient's condition would be further stabilized before the patient was transferred.

2.) Review of the medical record showed that Patient #1 was an 84-year-old person who was admitted to the SMC-CH ED via ambulance. The patient was intubated in the field and taken to the SMC-CH ED, where it was determined that the patient was in acute respiratory failure, had anemia due to a possible gastrointestinal bleed (GIB), a recent fractured hip and possible respiratory and systemic infections, in addition to other diagnoses.

3.) In the SMC-CH ED, the patient received multiple medical interventions, including being placed on a ventilator with setting adjustments, receiving intravenous (IV) fluids and multiple IV medications to treat fluctuating blood pressure, infections and pain, as well as to attempt to stabilize the patient's pH. The patient also received blood to treat the anemia, which was potentially due to the GIB.

4.) During an interview on February 23, 2017, at 10:30 a.m., MD #1 stated that she had determined that Patient #1 needed Intensive Care Unit (ICU) level of care that could not be provided in an ED. No ICU beds were available at any of the Seattle Swedish Medical Centers and a call was placed to the receiving hospital to see if they had available ICU beds. MD #1 stated that an ICU bed was available at the receiving hospital. She stated that MD #2 agreed to accept the critically ill patient, and requested that the patient be "hyperventilated" and the blood gas [pH] be rechecked prior to the patient's transfer. MD #1 stated that there was no request to call MD #2 back before the transfer, nor were there parameters set on acceptable vital signs or blood gas values.

5.) During an interview on March 1, 2017 at 8 a.m., MD #2 stated that she recalled Patient #1 and her conversation with MD #1. MD #2 stated that she had discussed the patient's treatment with MD #1 and wanted the patient's blood gas to be at 7.2 or better before the patient was transported. She stated that she did not get a call from MD #1 after the initial call and, when Patient #1 arrived at the receiving hospital, the patient was "coding".

6.) Review of the SMC-CH medical record showed that the last recorded set of vital signs taken in the SMC-CH ED was at 1705 [5:05 p.m.] and the last recorded blood gas value was 7.160, recorded at 1708 [5:08 p.m.] The ED Registered Nurse (RN) documented at 17:00 [5:00 p.m.] that MD #1 was aware of the vital signs and at 1705 [5:05 p.m.] that MD #1 okayed the patient for transfer. At 1710 [5:10 p.m.] report was given to the RN with the ambulance crew.

7.) Review of the medical record from the receiving hospital showed a history and physical from MD #2, which stated "...I requested that they [SMC-CH] get [Patient #1] pH improved prior to transport...on arrival [Patient #1] was in bradycardic cardiac arrest. Per the medics, they were unable to get sat readings on her during the entire transport to [the receiving hospital]. In the elevator coming to the ICU [s/he] became bradycardic with HR 40's and on arrival she lost her pulses...the patient was pronounced dead at 1833 [6:33 p.m.]

8.) During a phone interview on March 3, 2017 at 12:23 p.m., MD #3, an ED resident, confirmed that she had made the phone call to the family/responsible party of Patient #1. MD #3 stated that she had updated the family on the patient's status and treatment plan, but had not communicated the risks and benefits of the planned transfer.

9.) In an email received on March 3, 2017, the SMC - CH ED physician, MD #1, stated: "I do not think we can technically claim to have had the risk/benefit discussion with the [family]. We did our best to relay the severity of the situation and why we wanted to send to [receiving hospital].