HospitalInspections.org

Based on the Emergency Medical Treatment and Labor Act EMTALA complaint investigation (PR00000646) , review of twenty medical records, policies/procedures manual, review of medical faculty by laws rules and regulations and documents related to the complaint, it was determined that the hospital failed to have policies and procedures in effect to ensure compliance with the requirements of 42 CFR §489.20 and §489.24.

Based on the Emergency Medical Treatment and Labor Act EMTALA complaint investigation (PR00000646), twenty records reviews (R.R) from 10/06/21 to 10/07/21, and interview with the Medical Director it was determined that the facility failed to report to CMS or the State survey agency any time it has reason to believe it may have received an individual who has been transferred in an unstable emergency medical condition from another hospital for 1 out of 20 record review (RR) (RR #5).

Findings include:

1.During review of the RR#5 on 10/07/2021 to 10/08/21 from 9:00 AM to 1:00PM it was found the following:

RR #5 is a 77 years old male, who visited the Emergency Room on 11/22/18. The patient was diagnosed with arterial obstruction, chronic Deep vein thrombosis (DVT) of left leg, arterial occlusion of both legs and sepsis.

On 11/22/18 at 12:40 PM the medical record provide evidence of the case was presented to Professional Hospital in Guaynabo; Case was accepted by MD#8 from the Professional Hospital at Guaynabo, on Sunday, on 11/22/18 at 12:43 PM a Internal Medicine consult to MD#6 at the Buen Samaritano hospital. The note was sign by MD#7 at the Buen Samaritano Hospital at 12:44 PM.

In the MD#10 of 11/22/18 at 8:31 PM it was found that after evaluation patient has not improved. "Condition is Restless but Stable. Have been presented in Professional Hospital in Guaynabo and accepted by MD#9 to be transferred on Sunday AM. Patient relocation to Intermediate care area and will be under the care of MD #10". The note was sign by MD#10 on 11/22/18 at 8:31 PM

In the disposition note on 11/25/18 at 1:42 AM it was found that the patient is asymptomatic and a follow up with primary care doctor recommended. The patient is tolerating intake by mouth. Medication reconciliation has been reviewed. Final diagnosis: Arterial obstruction and chronic DVT of the left leg. The note is signed on 11/25/18 at 1:42 AM by MD#7.

In the patient re-evaluation note on 11/25/2018 at 12:31 PM it was found that the patient arrives at the Professional Hospital and the physician on shift MD#8 indicted that he had not accepted the case because he did not have a vascular surgeon available. Refer that "I had said that the case should be presented again today or tomorrow Monday in case the patient it could be transferred". The doctor refer that even today he does not have a surgeon available and for that reason he return the case, refer that the leg is necrotic, with bullae, is septic and the leg have to be amputated, however he returns the case. We are waiting for the patient return to be present and sent to another institution. This note is signed by MD#11 on 11/25/18 at 12:38 PM.

In the progress note dated on 11/25/2018 at 3:46 PM it was found that the patient was evaluated initially by the fast track physician. MD#11 wrote in the note that he was not involve in the patient case until the patient is returned to the emergency room, and that he did not handled the patient transfer to professional hospital. He receives the patient at the emergency room from the Professional Hospital after been returned by there's doctor after having been previously presented and accepted by MD#8.

MD#11 notes state "When I get to the room, I proceed to examine the left leg, which looks ischemic, without a pulse, no palpable temperature. It has bullae disseminated in the leg and suppuration. Possible necessary amputation, Rt. Leg also with ischemia changes. Prognostic is fair, patient is septic with elevated WBC. The case is discussed with the wife and daughter and the severity of the case is explained, they are oriented. Labs will be repeated, Ct angio will be performed, analgesia and Lovenox will be given. Internal Medicine will be consult for evaluation".

In the Physical Exam and assessment plan is written that the leg have bullae, oozing without pulse. A Consult with the Referrals No. 23796 to MD#6, Internal Medicine with the date of Nov 25 2018 4:08 PM Referred by MD#11 with the diagnosis of arterial occlusion of both leg. In the comment section state, "Case discussed with MD#12" Electronic Signature: 11/25/18 4:09 PM MD#11.

2. During the survey, interview and record review from 10/07/2021 to 10/08/2021 it was identified that the facility sends the RR #5 transfer to Professional Hospital on 11/25/2021 at 9:10 AM as ambulance incident sheet and the patient was not accepted and the MD#8 returns the patient back. No documentation or evidence was found from Buen Samaritano Hospital calling Professional Hospital on the date of the transfer.

3. No evidence was found on the medical record of the transfer sheet and the medical evaluation made by MD#8 of the Professional Hospital before sending the patient back to Buen Samaritano Hospital.

4. On October 7, 2021 at 10:00 AM during interview with the Medical Director MD #1 stated "Regarding the case that you are asking questions it is important to inform that this case is sub judice ( pending judicial resolution ) and the recommendations of the hospital legal counselors is to not discuss or comment on anything related with the case. The only aspect that I can assure you is that the hospital did not renew the contract with the emergency room contractor company that was involved in this case".

Based on the Emergency Medical Treatment and Labor Act EMTALA complaint investigation (PR00000646), review of twenty records reviews (R.R) 10/07/21 to 10/08/21, and interview with the Medical Director it was determined that the facility failed to provide further medical examination and treatment as required to stabilize the medical condition until the condition ceases to be an emergency or until the individual is properly transferred to another facility for 1 out of 20 record review (RR) (RR #5).

Finding include:

RR #5 is a 77 years old male, who visited the Emergency Room on 11/22/18 at 3:56 AM. The patient was diagnosed with arterial obstruction, chronic Deep vein thrombosis (DVT) of left leg, arterial occlusion of both legs and sepsis.

During the EMTALA investigation, and record review from 10/07/2021 to 10/08/2021 the facility did not provide evidence of a continues medical examination and treatment due to the medical record did not have any notes from the physicians in charge of the patient during the shifts of 11/23/18 and 11/24/18. Patient Physicians notes are dated 11/22/18 and 11/25/18.

Based on the Emergency Medical Treatment and Labor Act EMTALA complaint investigation (PR00000646), twenty records reviews (R.R) from 10/07/21 to 10/08/21, and interview with the Medical Director it was determined that the facility failed to provide appropriate transfer to 1 out of 20 record review (RR) (RR #5).

Findings include:

1.RR #5 is a 77 years old male, who visited the Emergency Room on 11/22/18. The patient was diagnosed with arterial obstruction, chronic Deep vein thrombosis (DVT) of left leg, arterial occlusion of both legs and sepsis.

On 11/22/18 at 12:40 PM the medical record provide evidence of the case was presented to Professional Hospital in Guaynabo; Case was accepted by MD#8 from the Professional Hospital at Guaynabo on Sunday on 11/22/18 at 12:43 PM Consult to (MD#6) Internal Medicine at the Hospital Buen Samritano. The note was sign by Buen Samaritano MD#7 at 12:44 PM.

In the note of 11/22/18 at 8:31 PM it was found that "after evaluation patient has not improved. Condition is Restless but Stable. Have been presented to Professional Hospital in Guaynabo and accepted by its MD#9 to be transferred on Sunday AM. Patient relocation to Intermediate care area and will be under the care of MD #10". The note was sign by MD#10 of the Buen Samaritano Hospital on 11/22/18 at 8:31 PM.

In the disposition note on 11/25/18 at 1:42 AM it was found that the "patient is asymptomatic and a follow up with primary care doctor recommended. The patient is tolerating intake by mouth. Medication reconciliation has been reviewed. Final diagnosis: Arterial obstruction and chronic DVT of the left leg". The note is signed on 11/25/18 at 1:42 AM by MD#7 at Buen Samaritano Hopsital.

In the patient re-evaluation note on 11/25/2018 at 12:31 PM it was found that "the patient arrive at the Professional Hospital and the physician on shift MD#8 at the ER of the Professional Hospital indicted that he had not accepted the case because he did not have a vascular surgeon available. Refers "I had said that the case should be presented again today or tomorrow Monday in case the patient it could be transferred. The doctor refer that even today he does not have a surgeon available and for that reason he return the case, refer that the leg is necrotic, with bullae, is septic and the leg have to be amputated, however he returns the case. We are waiting for the patient return to be present and sent to another institution". This note is signed by MD#11 on 11/25/18 at 12:38 PM of the Buen Samaritano Hospital.

In the progress note dated on 11/25/2018 at 3:46 PM it was found that "the patient was evaluated initially by the fast track physician. MD#11 of the Buen Samaritano Hospital writes in the note" that he was not involve in the patient case until the patient is returned to the emergency room, and that he did not handled the patient transfer to Professional hospital. He receives the patient at the emergency room from the Professional Hospital after been returned by there doctor after having been previously presented and accepted by MD#8" of the Professional Hospital.

MD#11 note stated: "When I get to the room, I proceed to examine the left leg, which looks ischemic, without a pulse, no palpable temperature. It has bullae disseminated in the leg and suppuration. Possible necessary amputation, Rt. Leg also with ischemia changes. Prognostic is fair, patient is septic with elevated WBC. The case is discussed with the wife and daughter and the severity of the case is explained, they are oriented. Labs will be repeated, Ct angio will be performed, analgesia and Lovenox will be given. Internal Medicine will be consult for evaluation".

In the Physical Exam and assessment plan is written that "the leg have bullae, oozing without pulse. A Consult with the Referrals No. 23796 to MD#6 Internal Medicine with the date of Nov 25 2018 4:08 PM Referred by MD#11 with the diagnosis of arterial occlusion of both leg. In the comment section state, "Case discussed with (MD#12) Surgeon" Electronic Signature: 11/25/18 4:09 PM MD#11 from Buen Samaritano Hospital.

2. During the EMTALA investigation, interview and record review from 10/07/2021 to 10/08/21 from to 9:00AM to 1:00PM, it was identified that the facility send the RR #5 transfer to Professional Hospital and the patient was not accepted and the MD#8 from the Professional Hospital who return the patient back. No documentation or evidence was found from Buen Samaritano Hospital calling Professional Hospital on the date of the transfer.

3. On October 7, 2021 at 10:00 AM during interview with the Medical Director MD #1 of the Buen Samaritano Hospital, stated "Regarding the case that you are asking questions it is important to inform that this case is sub judice ( pending judicial resolution ) and the recommendations of the hospital legal counselors is to, do not discuss or comment on anything related with the case. The only aspect that I can assure you is that the hospital did not renew the contract with the emergency room contractor company that was involved in this case".