HospitalInspections.org

Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate transfer for 1 patient (#1) of 31 Emergency Department (ED) patients reviewed.

The findings include:

Please refer to C-2409 for failure to provide necessary stabilizing treatment.

Based on review of facility policy, medical record review, and interviews, the facility failed to provide an appropriate transfer for 1 patient (#1) of 31 Emergency Department (ED) patients reviewed.

The findings included:

Review of facility policy Emergency Medical Treatment and Labor Act (EMTALA) (Screening, Stabilization, and Management of Emergency Transfers), last revised 2/2017, revealed "...appropriate transfer means a transfer of an individual with an Emergency Medical Condition that is implemented in accordance with EMTALA standards as follows...the transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition for which the individual presented..." Further review revealed "...facility property means the entire campus includes facilities that are within 250 yards of the [facility) building which are operated under...including sidewalks, parking lots, and driveways..." Further review revealed "...the transferring physician is responsible to determine whether an individual is stabilized, and the means, personnel and equipment for the transfer...the transferring facility shall bear the cost of the transfer..."

Medical record review revealed Patient #1 was admitted to the ED at Hospital A on 4/26/19 at 7:15 PM with a chief complaint of a cyst on the right shoulder. Continued review revealed the patient was discharged on 4/26/19 at 7:50 PM (35 minutes after arrival).

Medical record review of an ED Progress Note at Hospital A dated 4/26/19 at 7:27 PM revealed the transfer center at Hospital A contacted Hospital B regarding a transfer of Patient #1.

Medical record review of an ED Time Line (summary of hospital stay) at Hospital A dated 4/26/19 at 7:30 PM revealed Patient #1 presented to the ED with complaints of an abscess to the right shoulder for 1 week. The patient's vital signs were: temperature 99.2 (degrees) Fahrenheit; Pulse 55 per minute; Respirations 18 per minute; and oxygen saturation was 100% on room air. Continued review revealed Patient #1 indicated her pain score was 9/10 (indicating intense pain). Further review revealed the patient was triaged with an Emergency Severity Index (ESI) of 3 indicating an urgent need for emergency care.

Medical record review of an ED Physician's Progress Note at Hospital A dated 4/26/19 at 7:33 PM revealed Patient #1 presented to the ED with pain to the right shoulder and arm. Further review revealed "...painful, redness and swelling to the right supraclavicular [neck]...aching and hot...duration 1 week...progression: worsening, it gets better, it is bigger and closer to the surface..." Further review revealed "...recurrent abscess from shooting substances into neck, pt. [patient] not sure if this is same spot...has been trying leftover abx [antibiotics]...no antipyretics [medication for a fever]. Pt. would prefer that I not lightly touch the site...do not think that we will get any IV [intravenous] access. Pt. admits at end of triage that she shot up there about weeks ago..." Continued review revealed the physician order the following laboratory tests at 7:34 PM: Complete Blood Count (CBC); Urinalysis (UA); Urine Drug Screen (UDS); Blood Culture, and a Comprehensive Metabolic Panel (CMP).

Medical record review of an ED Physician's Progress Note at Hospital A dated 4/26/19 at 7:37 PM revealed "...[named surgeon] at [Hospital B] accepts..."

Medical record review of an ED Physician's Progress Note at Hospital A dated 4/26/19 at 7:38 PM revealed the laboratory tests were canceled by the physician.

Medical record review of an ED Physician's Progress Note at Hospital A dated 4/26/19 at 7:46 PM revealed "...patient/mom opt to leave now since they don't have gas money and we [Hospital A] don't know of a way to meet ambulance necessity; they opt to make scene call [patient called] to EMS [emergency medical services]..."

Medical record review of an ED Timeline at Hospital A dated 4/26/19 at 7:50 PM revealed Patient #1 was discharged "...AMA [against medical advice]/LWBS [left without being seen]..."

Medical record review of the ED record at Hospital A revealed no documentation of discharge instructions or a transfer form to Hospital B for Patient #1.

Review of an EMS Specialty Care Transport form (medical necessity form for EMS transport), not dated, revealed the transfer form was available to the facility and was used for the transfer of a patient from Hospital A to another healthcare facility by EMS. Continued review revealed the form was not completed on Patient #1. Further review of the form revealed "...Medical Necessity...this patient (check all that apply) Higher Level of Care...is being transferred to a facility for higher level of care/specialty care not offered at transferring facility..."

Medical record review of an EMS Prehospital Care Report (run sheet) dated 4/26/19 at 8:17 PM revealed "...pt. [patient] is a 26 year old female that had come to EMS station needed ride to [Hospital B] ER [emergency room] due to abscess on rt. [right] side of neck...it had been there for about a week, red, warm, very large...pt. alert...transported to [Hospital B] ER..." Further review revealed the patient's vital signs were: blood pressure 108/85; Pulse 130; Respirations 18; oxygen saturation 99%...pain score 8/10..." Further review revealed "...type of service requested 911 response..." Further review revealed the transport of Patient #1 was initiated at 8:17 PM and arrived at Hospital B at 9:20 PM..."

Medical record review of an ED Time Line revealed the patient was admitted to Hospital B on 4/26/19 at 10:23 PM.

Medical record review of an ED Physicians Record from Hospital B dated 4/27/19 at 1:18 AM revealed "...patient presents with abscess to right side of neck...history of IV drug abuse and had injected in that side of her neck in the past...this abscess has been progressively worsening for about 1 week...patient was initially seen at [Hospital A]...states that she was told [she] did not meet criteria for ambulance transport even though she was accepted [at] this hospital by surgery...states she was told to go in the parking lot and called 911 so that she can be transported by ambulance here...sits [states] she had no other way to get here...patient was transported by ambulance here [Hospital B] from [Hospital A] parking lot...had a very large right sided abscess. Ultrasound was used but it is difficult to establish how deep the abscess goes. Is approximately 6 cm [centimeters] in diameter. Fluctuant and indurated. Surgery was consulted to evaluate...the patient states is not tolerating manipulation of the area well and that she would not likely tolerate bedside drainage of the abscess. They [surgery] state they would take the patient to the Operating Room tomorrow...was started on Vancomycin [antibiotic] in the ED and had no evidence of sepsis [life threatening infection] at this time...Internal Medicine will admit..."

Medical record review of an Admission History and Physical from Hospital B dated 4/27/19 at 1:34 AM revealed the patient was admitted with a right side abscess to the neck and was given Vancomycin and Zosyn (antibiotic). Further review revealed surgery was consulted for an Incision and Drainage (I&D) of the abscess.

Medical record review of an Operative Note from Hospital B dated 4/27/19 at 11:02 AM revealed an I&D was performed on Patient #1 under general anesthesia.

Medical record review of a Discharge Summary from Hospital B dated 4/29/19 at 6:30 AM revealed the patient's blood cultures were positive for Methicillin-resistant Staphylococcus Aureus (MRSA) (staph infection resistant to some antibiotics). Continued review revealed Patient #1 was started on intravenous antibiotics and was transitioned to oral antibiotics. Further review revealed the patient was discharged home on 4/29/19 with follow-up appointments.

Interview with Registered Nurse (RN) #1 at Hospital A on 9/6/19 at 9:40 AM, in the Administrator's office, revealed Patient #1 presented to the ED with an abscess to her right neck. Further interview revealed the physician examined the patient's wound and told the patient she needed to be transferred because the wound was infected. Continued interview revealed the transfer center was called and the patient was accepted at [Hospital B]. Further interview revealed the patient stated she did not have the money to be transported by ambulance and the physician told the patient she did not meet the criteria for ambulance transport. Continued interview revealed "...normally EMS would transport these patients to the other hospital...the patient told the physician she would call EMS herself..." Further interview confirmed the patient was discharged AMA/LWBS there were no records sent to the receiving facility and the transfer form was not filled out..."

Telephone interview with ED Physician #1 at Hospital A on 9/6/19 at 9:50 AM revealed the patient presented to the ED with an abscess to the right side of her neck. Further interview revealed "...the patient needed additional workup related to the wound and it looked infected. She wanted oral antibiotics to fix this and I told her that oral antibiotics would not fix this. When I saw the wound I knew it needed surgical intervention. Initially I ordered a workup for the patient but canceled the orders when she left. I called the transfer center to get her transferred and she was accepted. By the EMS necessity form she would have met the criteria related to being transported to a higher level of care but I was concerned if the transfer would be approved and the cost of the EMS transport. The patient wanted me to call EMS right then and get her transferred and I explained to her that I could not do that without prior authorization..." Continued interview revealed "...she said 'you mean you can't call EMS from here and get me transported and I can go the parking lot and call EMS and they [EMS] would take me'...I told her that was a possibility...I told the patient she was accepted at [Hospital B] and she needed to go immediately...she left the ED..."

Telephone interview with EMS Paramedic #1 on 9/6/19 at 3:45 PM revealed "...the patient came to our building which is right beside [Hospital A] and said she did not have the gas money to drive to [Hospital B] and said 'I am not sure why they would not transfer me from there'...she said the physician did not want her to go by ambulance and said she could go by private vehicle...she looked sick..." Continued interview revealed "...we elected to do the transport as a scene call from the EMS building...this would not require a medical necessity form...we transported her non-emergency. Her pulse was 130 but otherwise her vitals were stable..." Further interview confirmed the patient would have met medical necessity for transfer by EMS because she was transferred to a higher level of care and had an accepting physician at Hospital B.