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A. Based on review of clinical records, review of Hospital Bylaws, Rules and Regulations, Emergency Department (ED) logs, and staff interview, it was determined the Hospital failed to ensure an appropriate transfer process was followed for all patients that presented to the ED, refer to A2409.

Based on record review and interview, Red Lake Hospital failed to maintain an on-call list of physicians who are either on staff or part of a community call plan to provide any specialized treatment necessary after the initial examination to stabilize individuals with emergency medical conditions. This could potentially affect all patients with an emergency medical condition.

Findings include:

1) According to "Bylaws of the Medical Staff of the USPHS Indian Hospital (Red Lake IHS Hospital), Red Lake, Minnesota, Effective June 6, 2011, "The call schedule provides for General Practice coverage, and does not provide for specific primary care coverage, e.g. Family Medicine, Internal Medicine or Pediatrics, nor for specialty coverage, e.g. Surgery, Obstetrics, or Orthopedics."

2) During interview with Physician A on 09/28/2011 at 3:00 p.m., he stated that on-call specialty physicians are "accessed" through the recipient hospital's emergency room as needed, for specialty coverage that is not available at Red Lake Hospital. The Clinical Director verified that Red Lake Hospital does not maintain its own list of physicians who are on call for duty after initial examination to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.

3) Hospital Wide policy entitled "Physician Coverage", effective: May 2010, states, "Medical Staff Members, consistent with clinical privileges and employment duties, participate in a call schedule designating a Medical Officer of the Day to provide coverage for the Inpatient Service in the absence of the Attending Physician, and clinical consultation for issues regarding outpatients in the absence of their respective primary care providers, and clinical consultation for the Emergency Room and Urgent Care Department." Hospital policy does not address situations in which a particular specialty is not available or the on-call physician cannot respond because of circumstances beyond the physician's control.

Based on record review and interview, Red Lake Hospital failed to demonstrate agreement by the recipient hospital to accept transfer of the individual and to provide appropriate medical treatment for 4 of 20 patients (Patient #1, Patient #2, Patient #3, and Patient #4). This could potentially affect all patients who are transferred with emergency medical conditions.

Findings include:

1) Review of "Hospital Wide" policy entitled, "Discharge Planning and Transfers" Effective: October 2010, states, "3. The accepting facility will receive information appropriate to the care and treatment including: The reason for the transfer; The patient's physical and psychosocial status; A summary of care, treatment, and services provided and progress toward goals; and Community resources or referrals provided to the patient. . . 5. Transfer facility and/or receiving physician must be contacted and accept the patient in transfer. . . 12. Documentation of transfer to include: Condition on admission, history, physical, diagnosis, treatment, consultants/facility transferred to, records and personnel that accompany condition at time of transfer, and time of transfer. . . 13. A Registered Nurse call the receiving facility prior to patient transfer and gives a complete nurse to nurse report."

2) Review of the emergency department record for Patient #1 on 09/28/11 at 3:44 p.m. revealed that the physician's assessment was "CVA, left sided upper and lower extremity weakness" with "Disposition: Transfer to Another Facility." Interview with the Acting ER Supervisor on 09/28/11 at 3:44 p.m. revealed that the receiving hospital called to say that no physician-to-physician call was made.

3) Review of the emergency department record for Patient #2 on 09/28/11 at 5:13 p.m. revealed that the physician's assessment was "headache; acute" with "Plan: transfer to (Hospital A) by ems." The transfer record was missing documentation of the certifying physician's signature or name, the patient's condition on transfer, acknowledgement and name of receiving facility, time of contact for physician accepting transfer, mode of transportation for transfer, and time of request for transfer. These findings were verified with the Acting ER Supervisor on 09/28/11 at 5:13 p.m.

4) Review of the emergency department record for Patient #3 on 09/28/11 at 5:22 p.m. revealed that the physician's assessment was "headache; Concussion without LOC; Nausea and vomiting" with "Plan: transfer to (Hospital A) via ground ambulance. Dr. B accepted at (Hospital A)." There was no transfer form with documentation of the patient's condition on transfer, notifications, documentation sent with the patient, risk of transfer, benefits of transfer, treatment enroute, or physician or qualified medical person's certification for transfer. These findings were verified with the Acting ER Supervisor on 09/28/11 at 5:22 p.m.

5) Review of the emergency department record for Patient #4 on 09/28/11 at 5:30 p.m. revealed that the physician's assessment was "acute coronary symdrome (sic)" with "Plan: trasfer (sic) to (Hospital B)." The "Notification" was missing the "Name of Physician Accepting Transfer" and "Time Contacted." These findings were verified with the Acting ER Supervisor on 09/28/11 at 5:30 p.m.