HospitalInspections.org

Based on interview and record review, the hospital (Hospital A) failed to ensure the on-call specialist responded to emergency medical conditions regardless of pay source for Patient 1, which resulted in Patient 1 transferring to another hospital for medical consultation, evaluation, and treatment.

Findings:

1. The clinical record for Patient 1 was reviewed on 5/23/11. The registration record dated 5/11/11, at 8:10 AM, indicated Patient 1 was a three-year-old child and complained of left knee pain. Emergency Department (ED) physician notes dated 5/11/11 and written by Doctor A indicated Patient 1's diagnosis was an acute closed spiral fracture of the left femur (a broken thigh bone that has not broken through the skin). Patient 1 was in pain and needed to have surgery to repair the fracture. This document read, "(Doctor B), I spoke with the on-call orthopedic surgeon, who requests transfer as he does not accept the patient's insurance. I spoke with (Doctor C) in the emergency department at (Hospital B) and she will accept the patient in transfer." Hospital A's transfer summary form dated 5/11/11 indicated Patient 1 was transferred by a paramedic ambulance to Madera, and the reason was "Higher lvl (Level) of Care."

During an interview with Doctor A on 5/19/11 at 9:15 AM, he stated he called Doctor B who was on call for orthoptics the night of 5/11/11. He stated, "I am not an orthopedic doctor and I felt this child needed to be seen by a specialist, but when I called Doctor B he asked me the kids insurance and when I told him, he said he did not take that insurance and then refused to take the case. I put the child needed a higher level of care on the transfer form because the orthopedic doctor refused to take the case and I could not provide the care he needed. I also sent him with a paramedic ambulance so the paramedics could give him pain medication through his IV (intravenous) because he was having pain." He also stated he had another similar case a year or so ago. At that time he called Hospital A's medical director to call the specialist to convince him to come in. After several hours, he gave up and transferred the patient. He stated, "This time I didn't want the child to have to wait because he was in pain, so I sent him as soon as possible without calling the medical director."

During an interview with the emergency department director (EDD) on 5/18/11 at 1 PM, he stated, "It's an EMTALA, no getting around it. It is what it is." He stated Doctor A should have called the medical staff and/or the chief of staff, but he did neither. He stated, "The nurses and the ward clerk should have caught it. We have had this problem with the on-call docs (doctors) before."

Doctor B's credentialing files was reviewed on 5/25/11 at 10 AM. A form titled "Request for Additional Privileges" indicated Doctor B was privileged to perform orthopedic surgery on children. This form also indicated Doctor B could treat fractures.

Hospital A's policy and procedure titled "On-Call Coverage" dated 9/10, read "An on-call Physician may not refuse a request from the dedicated emergency department physician to examine, treat, or accept the transfer of a patient on the basis of: The patient's health plan membership, insurance status, economic status or ability to pay."

Based on interview and record review, the hospital (Hospital A) failed to ensure the on-call specialist responded to emergency medical conditions regardless of pay source for four of 17 patient records reviewed (1, 8, 10, and 11), which resulted in these patients' transferring to other hospitals for medical consultations, evaluations, and treatment.

Findings:

1. The clinical record for Patient 1 was reviewed on 5/23/11. The registration record dated 5/11/11, at 8:10 AM, indicated Patient 1 was a three-year-old child and complained of left knee pain. Emergency Department (ED) physician notes dated 5/11/11 and written by Doctor A indicated Patient 1's diagnosis was an acute closed spiral fracture of the left femur (a broken thigh bone that has not broken through the skin). Patient 1 was in pain and needed to have surgery to repair the fracture. This document read, "(Doctor B), I spoke with the on-call orthopedic surgeon, who requests transfer as he does not accept the patient's insurance. I spoke with (Doctor C) in the emergency department at (Hospital B) and she will accept the patient in transfer." Hospital A's transfer summary form dated 5/11/11 indicated Patient 1 was transferred by a paramedic ambulance to Madera, and the reason was "Higher lvl (Level) of Care."

During an interview with Doctor A on 5/19/11 at 9:15 AM, he stated he called Doctor B who was on call for orthoptics the night of 5/11/11. He stated, "I am not an orthopedic doctor and I felt this child needed to be seen by a specialist, but when I called Doctor B he asked me the kids insurance and when I told him, he said he did not take that insurance and then refused to take the case. I put the child needed a higher level of care on the transfer form because the ortho doctor refused to take the case and I could not provide the care he needed. I also sent him with a paramedic ambulance so the paramedics could give him pain medication through his IV (intravenous) because he was having pain." He also stated he had another similar case a year or so ago. At that time he called Hospital A's medical director to call the specialist to convince him to come in. After several hours, he gave up and transferred the patient. He stated, "This time I didn't want the child to have to wait because he was in pain, so I sent him as soon as possible without calling the medical director."

During an interview with the emergency department director (EDD) on 5/18/11 at 1 PM, he stated, "It's an EMTALA, no getting around it. It is what it is." He stated Doctor A should have called the medical staff and/or the chief of staff, but he did neither. He stated, "The nurses and the ward clerk should have caught it. We have had this problem with the on-call docs (doctors) before."

Doctor B's credentialing files was reviewed on 5/25/11 at 10 AM. A form titled "Request for Additional Privileges" indicated Doctor B was privileged to perform orthopedic surgery on children. This form also indicated Doctor B could treat fractures.

2. The clinical record for Patient 8 was reviewed on 5/25/11 at 9:12 AM. The registration record dated 5/11/11 indicated Patient 8's insurance was a medicaid health management organization (HMO) and he was 14 years old. The ED physician notes dated 5/11/11 indicated Patient 8's diagnosis was acute appendicitis (inflammation of the appendix). The ED physician notes read, "Because of insurance reasons (Hospital E) was called. Patient was transferred to (Hospital E)." The form titled "Transfer Summary" dated 5/11/11 for Patient 8 read "Reason for transfer: Insurance." Doctor H was on-call on 5/11/11 for general surgery for Hospital A.

3. The clinical record for Patient 10 was reviewed on 5/25/11, at 9:40 AM. The registration record dated 12/3/10 indicated Patient 10's insurance was a medicaid HMO and he was 13 years old. The ED physician notes dated 12/3/10 indicated Patient 10's diagnosis was acute appendicitis. The ED physician notes read, "The patient had been seen and evaluated by (Doctor J, an ED physician). He had spoken with the on-call general surgeon, (Doctor S). The patient was to be transferred to (Hospital E)." Doctor S was on-call for general surgery on 12/3/10. The form titled, "Transfer Summary" dated 12/3/10, read "Reason for Transfer: Funding/insurance."

4. The clinical record for Patient 11 was reviewed on 5/25/11, at 9:50 AM. The registration record dated 1/4/11 indicated Patient 11's insurance was a medicaid HMO and she was 57 years old. The ED physician notes dated 1/4/11 indicated Patient 11's diagnosis was chest pain, unstable angina, and peripheral vertigo and she was transferred to Hospital E. The form titled "Transfer Summary" dated 1/4/11, read "Reason for Transfer: Insurance." Doctor K was on-call for cardiology on 1/4/11. There was no indication Doctor K was called.



28741

During an interview with the Emergency Department Unit Secretary (US), on 5/25/11, at 10:40 AM, she stated when the physician indicated an emergency patient was to be transferred to another acute hospital, she identifies the insurance "contract" hospital. She stated for Medi-Cal or a Medi-Cal managed care funding, the patient is transferred to a contract facility for higher level of care or to a contracting facility. When asked about the process for orthopedic consultations, she stated "they" (Hospital A) wait until the patient's pay source is identified and then determine if the patient will be transferred. If the patient is not going to be transferred to another hospital, they call the orthopedic doctor on-call.

During an interview with Doctor L, on 5/25/11 at 11 AM, he stated when he required an orthopedic consultation for an ED patient, he first determined whether the patient was going to be transferred to another acute care hospital or treated/admitted to Hospital A. If the patient was staying at Hospital A, he would call the on-call orthopedics for Hospital A. If the patient was being transferred to another acute care hospital, he would call the accepting hospitals physician. Doctor L stated he did not request orthopedic consultations for closed reductions or splinting of a fracture.

Hospital A's policy and procedure titled "On-Call Coverage" dated 9/10, read "An on-call Physician may not refuse a request from the dedicated emergency department physician to examine, treat, or accept the transfer of a patient on the basis of: The patient's health plan membership, insurance status, economic status or ability to pay."

Based on interview and record review, the hospital failed to ensure four of 17 patients transferred from its emergency department (ED) to other facilities were informed of the risk and benefits prior to their transfer(3, 6, 39, and 41). Such failure had caused the affected patients or their responsible parties unable to make sound decisions before consenting to the transfers.

Findings:

1. The clinical record for Patient 6 was reviewed on 5/23/11 at 2:10 PM. The registration record dated 4/24/11 indicated Patient 6 was a 12-year-old child brought in by an ambulance after he was involved in a car accident. He was a self pay for his medical care. The emergency department (ED) physicians notes dated 4/24/11 read "motor vehicle accident with blunt abdominal trauma rule out small bowel and mesenteric injury." The form titled "Trauma Care System Data Form - Pediatric" indicated Patient 6 was transferred to Hospital D. There was no documentation on the risk and benefits to the transfer were discussed with his patient or that consent was obtained for the transfer.

During an concurrent record review and interview with Registered Nurse (RN) A on 5/24/11, at 8:30 AM, she verified Patient 6's clinical record did not include risk and benefits to the transfer or a signed consent for transfer.

2. The clinical record for Patient 3 was reviewed on 5/23/11 at 4 PM. The registration record dated 1/3/11 indicated Patient 3 had the state medicaid insurance. The ED physicians notes dated 1/3/11 indicated Patient 3 had a history of asthma and chronic obstructive pulmonary disease (COPD-a disease that obstructs oxygen exchange in the lungs). She presented with increasing shortness of breath, productive cough, wheezing and pleuritic chest pain. The ED physicians notes read, "Will admit the patient to (Hospital C) for further evaluation and treatment." There was no documentation on the risk and benefits to the transfer were discussed with the patient or that she gave her consent for the transfer.

During an concurrent record review and interview with RN A on 5/23/11, at 4:20 PM, she verified Patient 3's clinical record did not include risk and benefits to the transfer or a signed consent for transfer.



28741


3. The clinical record for Patient 39 was reviewed on 5/24/11. The "Registration Record", dated 1/17/11, indicated Patient 39 was a 38 year old with chest pain. The "Emergency Department Activity Log" indicated Patient 39 arrived on 1/17/11, at 8:25 PM, via ambulance as "Urgent". He was transferred to Hospital E on 1/17/11, at 11:29 PM. The Emergency Department Physician Notes, dated 1/17/11, written by Doctor A, indicated "1/17/11 at 10:13 PM....I have spoken with the hospitalist covering for the patient's insurance, who will give admission order upon arrival to (Hospital E)." No "Transfer Summary" form was found in the clinical record that indicated the risk and benefits of transfer was provided to the patient.

During a concurrent record review and interview with Staff A, on 5/24/11, at 3:30 PM, she verified Patient 39's clinical record did not include risk and benefits to the transfer.

4. The clinical record for Patient 41 was reviewed on 5/24/11. The "Registration Record", dated 8/11/10, indicated Patient 41 was a 30-year-old with a right groin stab wound and was self pay for his medical care. The "Emergency Department Activity Log" indicated he arrived on 8/11/10, at 4:47 AM, as a walk-in with an acuity level of "very urgent." He was transferred to Hospital D on 8/11/10, at 8:55 AM. The physician notes, dated 8/11/10, written by Doctor Q, read, "trauma activation was being completed with all appropriate methods of trama activation to (Hospital D)." Doctor Q indicated Doctor R, the attending ED physician at Hospital D, accepted the patient. No transfer summary was found in the clinical record that indicated the risk and benefits of transfer was provided to the patient.

During an interview with the Emergency Department Unit Secretary (US), on 5/25/11, at 10:40 AM, she stated trauma activation transfers always went to Hospital D and were determined by the physician. She stated transfer summary forms are not completed for trauma activation patients.

The "Emergency Medical Services Trauma Care System Receiving Hospital Trauma Policies and Procedures" document, dated 7/1/08, indicated in section "VIII Trauma System Inter-facility Transfers: ... G. All patient transfers must meet the criteria listed in the California Code of Regulations - Title 22 - Article 5, COBRA requirements, and the California Health and Safety Code."