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Based on interview and record review, the hospital failed to provide stabilizing treatment to one of 23 sampled patients (Patient 19), and failed to ensure one of 23 sample selected patients (Patient 7) received and signed all the paperwork for Against Medical Advise (AMA) before leaving the facility.

The deficient practices had the potential to cause serious injury or death for Patient 19, resulting in immediate jeopardy, had the potential to cause serious consequences for Patient 7's health, and had the potential to recur for other patients.

Findings:

1. Refer to A-2407 regarding the hospital's failure to provide stabilizing treatment to Patient 19.

2. A review of Patient 7's "Outpatient/ER (emergency Room) Record" indicated Patient 7 arrived at the ER at 11:42 a.m., and left 1:18 p.m., on the same day.

A review of Patient 7's "Physical assessment" indicated Patient 7 left AMA and " ...AMA disclosure signed ..."

During a concurrent interview and record review on 4/24/24 at 3:00 p.m., with the Quality Nurse (QN), QN reviewed the chart for Patient 7 and could not find AMA and stated she could not find AMA documents for Patient 7.

During an interview on 2/25/24 at 10:15 a.m., with the Quality Director (QD), QD stated he could not find any AMA documents for Patient 7. Furthermore stated, it is important for the patients to sign the AMA forms because the facility want to make sure patients understand the possibility of outcome of leaving facility against medical advise.

A review of the facility's policy and procedure "AMA (Against Medical Advise) revised 06/2022 indicated " ... 5. The patient shall be requested to sign the form" leaving Hospital Against Advise." This form shall be to be kept in the patient's medical record ..."

Based on observation, interview and record review, the facility failed to have the required patient rights signage posted at the pedestrian and ambulance (a vehicle equipped for transporting sick or injured people to the hospital especially in emergencies) Emergency Department (ED) entrances on the first floor.

This failure had the potential for individuals to be uninformed of their rights to receive emergency medical care under EMTALA (Emergency Medical Treatment and Labor Act, law which required emergency departments to screen and provide stabilizing treatment to any individual coming to that department).

Findings:

During a concurrent observation and interview on 4/23/24, at 10:19 a.m. with Quality Analyst 1 (QA1) at the pedestrian entrance of the ED, there was no visible EMTALA sign. QA1 confirmed there was no EMTALA sign.

During a concurrent observation and interview on 4/23/24, at 10:24 a.m. with QA1 and the Emergency Department Manager (EDM) at the ambulance entrance of the ED, there was no visible EMTALA sign. QA1 and EDM confirmed there was no EMTALA sign.


A review of the facility's policy and procedures (P&P), titled "Emergency Medical Treatment & Active Labor Act (EMTALA)" dated 8/21, showed " ...General Policies: 1. Signage: A ...Signs shall be posted in the Emergency Department ...where patients may present for emergency services ..."

Based on interview and record review, the hospital failed to provide stabilizing treatment within its capability and capacity to 1 of 23 sampled patients (Patient 19). Patient 19 had a worsening subdural hematoma (bleeding between the layers of membranes surrounding the brain) and an elevated INR (international normalized ratio, a measure of blood clotting in which elevated values indicate poor clotting ability), but did not receive fresh frozen plasma (FFP, the liquid portion of blood used to treat clotting disorders) which had been ordered by the ED (Emergency Department) Physician (MD 1) prior to Patient 19's transfer to Hospital B over eight hours later. The deficient practice had the potential to cause Patient 19 to suffer brain damage or death, and had the potential to recur for other patients, resulting in immediate jeopardy.

Findings:

Review of Patient 19's medical record indicated Patient 19 was seen in the hospital's ED on 4/17/24. Patient 19's "EMERGENCY MEDICINE EVALUATION NOTE" dated 4/17/24 indicated, "He is currently non-verbal ... the patient appeared to be verbal as recently as March 18th on an emergency visit here ... INR 1.52 [a ratio indicating the prothrombin time, a measurement of how long blood takes to clot, is 1.52 times normal] ... The head CT [computed tomography, an imaging technique in which a computer constructs cross-sectional images from multiple x-rays] shows a large right-sided subacute [recent onset] versus chronic subdural hematoma with midline shift [a sign of blood squeezing the brain] ... of 1.5 cm [centimeters] ... The patient was seen most recently on March 18th in the emergency department here and was found to have a subdural hematoma ... today's CT is considerably worse. It does appear he was transferred to [Hospital B] for his last subdural ... Given the significant interval worsening in the subdural with midline shift, I spoke with the [Hospital B] transfer center to discuss transfer back to [Hospital B] given that we do not have neurosurgery available here ... I spoke with the accepting neurosurgeon ... She requests FFP given that the INR is elevated ... According to family the patient was walking as recently as 3 days ago with a walker but then became weak and could no longer walk. He was speaking at least somewhat until today. The family does give verbal consent for blood transfusion ... The patient presents with a very extensive subdural hematoma versus hygroma [when the fluid which normally surrounds the brain leaks between the membranes which normally surround the fluid] has evidence of midline shift. He is at risk of deterioration including death." Patient 19's nursing progress notes indicated, "Date and Time of Transfer: 4/17/2024 13:20".

Review of the "Order Chronology" in Patient 19's electronic medical record indicated an order for "BB FFP [blood bank fresh frozen plasma] (ORDER)x1" dated 4/17/24 was present. Review of the "ORDER INFORMATION" screen indicated Patient 19's "BB FFP" order was electronically signed by MD 1 on 4/17/24 at 4:47 AM and verified by an unspecified nurse at the same date and time. A field marked "Questions:" indicated, "Date of Transfusion Now Indications SDH [subdural hematoma], elevated INR". Review of the "ORDER HISTORY" screen indicated Patient 19's "BB FFP" order was assigned order number 1723512 and was completed on 4/18/24 at 2:23 p.m. (after Patient 19 had been transferred to Hospital B). Review of the "MEDICATION ADMINISTRATION RECORD" for "Date Range: 4/17/2024 04:00 - 4/25/2024 10:00" indicated there was no documentation the FFP had been administered.
Review of an undated printout from the hospital's Sunquest lab information system indicated for Patient 19's "BB FFP (ORDER) ORDER # 23512" ordered "4/17/2024 0447", two units of FFP had both been thawed, then "REL FROM ALLOC" (released from allocation).

In a concurrent interview and record review on 4/24/24 from 4:05 p.m. to 4:30 p.m., the Blood Bank Director (BBD) stated her records indicated that FFP was ordered for Patient 19, two units FFP were thawed by the Blood Bank and were available approximately 6:30 a.m. on 4/17/24 to be picked up by the ED Nursing staff, who were to be notified the FFP was ready. Review of the "Order Receipt/Modification" screen on the BBD's computer indicated an order to "TRANSFUSE FFP" dated 4/17/24 for Patient 19 was assigned accession number W6470. Review of the undated screen in the BBD's computer titled "Blood Order Processing - W6470" indicated the screen showed Patient 19's name, serial numbers for two units of FFP (unit numbers W 2006 23 882344 1 and W 2006 23 105356 0), and indicated both units had status "RL". The BBD stated the notations on the screen meant the two units were allocated to Patient 19 but were released from allocation. Review of two documents titled "Unit History" (printed 4/24/24), one each for FFP unit numbers W 2006 23 882344 1 and W 2006 23 105356 0, indicated each unit had been allocated to Patient 19 on 4/17/24 at 6:35 a.m., then released from allocation on 4/18/24 at 2:22 p.m. The documents indicated both units were discarded on 4/18/24. The BBD stated both units of FFP assigned to Patient 19 were discarded, and the most likely explanation was that they were never picked up from the blood bank. Review of the "Blood Bank Department Communication Log for Blood Components Issuance and Delay" indicated there were no entries between 4/16/24 and 4/21/24. The BBD stated blood products ready for pick-up were normally entered on the communication log. She acknowledged there were no entries for Patient 19's FFP on 4/17/24. The BBD stated she would speak with the staff member who processed Patient 19's FFP.

In a concurrent interview and record review on 4/25/24 at 12:59 p.m., the ED Manager (EDM) presented a second copy of the Sunquest printout regarding Patient 19's "BB FFP (ORDER)". The document had a hand written notation adjacent to "REL FROM ALLOC" indicating, "means wasn't transfused". The EDM stated the notation "REL FROM ALLOC" on the Sunquest printout meant the units had been released from allocation to a specific patient because they had not been given. The EDM stated the hospital had not been aware of the problem prior to the survey.

In an interview on 4/25/24 at 1:10 p.m., the Director of Quality (DQ) stated that the hospital had not done any quality analysis regarding Patient 19's "FFP issue" because it "only happened a week ago."

In an interview on 4/26/24 at 9:45 a.m., the BBD stated the lab technician who processed Patient 19's FFP on 4/17/24 did notify the ED the FFP was ready, but couldn't remember who he spoke with or explain why he didn't enter the communication on the log. The BBD stated there was no other documentation that the ED had been notified Patient 19's FFP was ready for pick-up. The BBD did not provide the name of the lab technician.

In an interview on 4/26/24 at 09:50 a.m., the DQ stated a failure to administer a transfusion of blood products on 4/17/24 would normally be reviewed by the Quality Committee on 4/29/24.

In an interview on 4/26/24 at approximately 11:15 a.m., the Chief Nursing Officer (CNO) stated MD 1 had refused to be interviewed, one of the two nurses involved in Patient 19's care was on leave, and the other nurse could not remember Patient 19.

Review of the UpToDate (an online medical reference) article "Subdural hematoma in adults: Management and prognosis" indicated, "Subdural hematoma (SDH) can be a neurologic emergency that may cause irreversible brain injury and death caused by hematoma expansion, elevated intracranial [inside the skull] pressure (ICP), and brain herniation [when pressure on the brain squeezes it through openings in membranes inside the skull or through an opening at the base of the skull]. Patients with SDH require urgent assessment of clinical status, the management of any antithrombotic [blood thinning] medications, and evaluation of the need for immediate surgery..."

The surveyors declared an immediate jeopardy situation on 4/25/24 at 4:34 p.m. in the presence of the DQ, the EDM, the CNO, and the chief health officer. On 4/26/24, the hospital submitted a removal plan stating the facility would retrain its ED and blood bank staff regarding their responses to blood product orders, that the hospital would modify its ED policies to require reassessments of patients awaiting transfer and retrain its ED staff on the policy changes, and that the hospital would monitor compliance. On 4/30/24, the hospital presented documentation that ED and blood bank employees were being retrained as they reported for duty. The surveyors therefore declared the immediate jeopardy removed on 4/30/24 at 12:18 p.m. in the presence of the DQ, the EDM, the CNO, and the chief health officer.