HospitalInspections.org

Based on medical record reviews, Policy and procedure review, and Hospital Transfer Center Recordings, and staff interviews the facility failed to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized capabilities of the ENT (Ear Nose and Throat) on-call services, and the receiving had the capacity to treat 1 (Patient #24) of 24 individuals when the request was made by the referring hospital.

Refer to findings in Tag A- 2411.

Based on medical record reviews, Policy and procedure review, and Hospital Transfer Center Recordings, and staff interviews the facility failed to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized capabilities of the ENT (Ear Nose and Throat) on-call services, and the receiving had the capacity to treat 1 (Patient #24) of 24 individuals when the request was made by the referring hospital.

The findings revealed:

Medical Record Review Patient #24


Review of the medical record obtained from Hospital B (Referring Hospital) revealed the patient presented to the Dedicated Emergency Department (DED) on 01/19/2019 at 1015 with a chief complaint of sore throat. Nursing triage notes, documented at 1020, revealed the patient was sent to the DED from Urgent Care Center for evaluation of sore throat since Thursday (01/17/2019) with concerns of peritonsillar abscess (A collection of pus on one of the tonsils). Vital signs documented in triage revealed a temperature of 100.3 orally, heart rate 96, respiratory rate 18, blood pressure 116/68, oxygen saturation of 98% on room air and intermittent throat pain verbalized as an " 8 " on a scale of 0-10 (0 being no pain, 8-10 being worst/severe pain). Medical record review revealed current medications listed as Amlodipine (Treats high blood pressure), Eliquis (Anticoagulant, treats blood clots), Atorvastatin ((treats "bad" Cholesterol), Benazepril (Treats high blood pressure)and Metoprolol Tartrate (treats high blood pressure and angina). Past medical history revealed hypertension, stroke, deep vein thrombosis, atrial fibrillation and hyperlipidemia. Nursing assessment revealed the patient had angioedema present with no respiratory distress. Medical record review revealed the physician assistant ordered an intravenous line, labs to include: Complete Blood Count with auto differential, Sedimentation Rate, C-Reactive Protein, Hepatic Function Panel, basic Metabolic Panel, Urine Microscopic reflex culture, Mono Spot Test, Rapid Strep A Screen, Blood Cultures, Beta Strep Culture and x-ray/imaging studies which included a Cat-Scan of Neck with Contrast. Cat-Scan results revealed 1. Right peritonsillar abscess. 2. Prominent, inflamed uvula descends to the left hypopharynx. 3. Enlarged right level II lymph node, likely reactive. Medical record review revealed a medical screening exam was conducted by the physician assistant at 1038. History of present illness revealed onset of symptoms were gradual with aching pain, headache and fever. Physical exam revealed the patient appeared uncomfortable and " Posterior pharynx is injected, exudates are present in posterior pharynx, uvula deviated, to the left, oropharynx is injected, tonsillar hypertrophy, tonsillar erythema, exudate, evaluation of right side of the oropharynx show, swelling, right side asymmetry. " Medical record review revealed the patient received Clindamycin (An antibiotic)900 milligrams intravenously (antibiotic) at 1133, Dexamethasone sodium phosphate 10 milligrams intravenously (steroid) at 1117 and Normal Saline 1000 milliliters intravenous bolus at 1050. Review of " Doctor Notes " documented by the physician assistant at 1328 revealed " Discussed patient with MD #1 (Dr. Name) ENT provider at First Health Moore Regional Hospital (Hospital A). He states that he does not feel this is a life threatening condition and will not accept patient for transfer. I explained that I understand pt does not need immediate procedure but that he needs admission to facility with appropriate ENT (Ear, Nose, Throat) coverage. He continues to refuse acceptance of patient. " Review of " Doctor Notes " documented by the physician assistant at 1346 revealed " Discussed with appropriate consultants, discussed this case with Dr. (Name), Hospitalist, feel pt needs transfer to a facility with ENT coverage. " Review of " Doctor Notes " documented by the physician assistant at 1433 revealed " Patient accepted to (Named Hospital) Hospital C in Florence by Dr (Name). Pt refused to go by ambulance, he states his friend will drive him to the facility. Records will be provider (sic) in seal (sic) envelope. Pt agress (sic) with this plan and Dr. (Name) agrees with this plan. " Nursing note documented at 1440 revealed " Per (Name), PA, refuses to be transferred by hospital transport. Pt states he needs to go home first and he have (sic) a friend to drive him to (Named Hospital) Hospital C. AMA (Against Medical Advice) form signed by pt. " Discharge vital signs obtained at 1407 revealed temperature 99.0, heart rate 105, respiratory rate 19, blood pressure 130/63, oxygen saturation 96% on room air and Pain " 8 " .



Transfer Center Recording-1/19/2020

Review of Hospital A ' s transfer center refusal recordings on 02/05/2019 at 1545 revealed a call was received on 01/19/2019 at 1311 from Hospital B requesting a transfer for ENT services. Review of the call revealed the transfer center connected MD #1 from Hospital A with PA #2 from Hospital B. Recording revealed Hospital B requested to send a 65 year old male patient diagnosed with a 13 x 10 mm (millimeter) right peritonsillar abscess, with inflamed, deviated uvula, without airway compromise. Hospital B reported the patient was on an unknown blood thinner. MD #1 informed PA #2 that surgical intervention would be contraindicated and he recommended admitting to Hospital B and treating medically with antibiotics and steroids. MD #1 stated this was not an ENT emergency. PA #2 stated the hospitalist at Hospital B would not admit the patient due to no ENT coverage. MD #1 informed PA #2 that if the patient ' s condition worsened over the next 24 hours, he would accept the patient for transfer.


Interviews

Interview on 02/05/2019 at 1540 with MD #3 revealed he was the Medical Director for the Transfer Center at Hospital A. He stated all transfer refusals outside of capacity and capability were referred to him and the transfer center director.

Interview on 02/05/2019 at 1555 with MD #3 revealed he reviewed the refusal by the ENT on-call provider to accept the transfer of the patient with the peritonsillar abscess from Hospital B. Interview with MD #3 after reviewing the transcript recording revealed " If case (peritonsillar abscess) presented here (Hospital A) would not consult ENT. Interview revealed he concurred with MD #1 and felt the patient could have been admitted to Hospital B and medically treated with antibiotics and steroids. Interview revealed he spoke with the MD #4 from Hospital B and she " did not feel was emergent. "

Interview on 02/06/2019 at 1240 with MD #1 revealed he was the ENT provider on-call for Hospital A on 01/19/2019. Interview revealed he did refuse to accept the transfer from Hospital B. Interview revealed the patient was on unknown blood thinners and surgery intervention was contraindicated. Interview revealed PA #2 did not report any airway compromise and MD #1 didn ' t feel the patient needed urgent transfer for ENT services. Interview revealed he told PA #2 that if the patient was not doing better after 24 hours and 3 doses of antibiotics/steroids, he would be happy to accept the patient for transfer. Interview revealed the typical treatment for a peritonsillar abscess without airway compromise was medical therapy (antibiotics/steroids) and then surgical drainage if medical therapy not effective.

Interview on 02/06/2019 at 0900 with MD #4 from Hospital B revealed she did have communications with MD #3 from Hospital A. Interview revealed the patient could have been admitted to Hospital B and seen by ENT the next day, however this request was on a Saturday and they would not have ENT services until Monday. Interview revealed they do not have ENT coverage on the weekend. Interview revealed they have one ENT on staff and he typically is on call on Tuesdays or Wednesdays. Interview revealed the patient did have uvula deviation without airway compromise or respiratory distress.

Interview on 02/06/2019 at 0915 with MD #5 revealed she was the DED physician at Hospital B on 01/19/2019. Interview revealed she did not have any conversations with MD #1 from Hospital A.

Interview on 02/06/2019 at 0926 with PA #2 revealed she contacted the transfer center at Hospital A to request the transfer of a patient (#24) with a peritonsillar abscess, needing ENT services. Interview revealed she spoke with MD #1 at Hospital A. She stated she felt the patient needed a higher level of care, however didn ' t feel he needed immediate surgical intervention. Interview revealed MD #1 refused to accept the transfer. Interview revealed MD #1 recommended admission to Hospital B, treat with antibiotics and steroids and monitoring. Interview revealed the Hospital B DED physician was sitting by her side during the telephone conversation with MD #1 at Hospital A. Interview revealed the patient was transferred to Hospital C.




Hospital Policies and Procedures


Review on 02/05/2019 of Hospital A ' s EMTALA policy, last reviewed August, 2018, revealed " It is the policy of (Name) Hospitals that their physicians accept the appropriate transfer of patients from other facilities that require the specialized/emergency medical services that are within the capabilities and capacity of the facility. Where this hospital has the capabilities and capacity to treat the patient with an emergency medical condition, the on-call physician shall accept the patient ... 1. Patient transfers with emergency medical conditions (as defined by law) may be declined for the following reasons: a. Physician requested i. Lack of available capacity to accept and appropriately care for the patient. ii. Lack of current capability (e.g. only neurosurgeon on staff is in surgery) ... "

Review on 02/05/2019 of Hospital A ' s policy titled " Physician Refusal Policy " last reviewed June, 2018 revealed " ... The following will include examples of denials that are appropriated, but the list is not all inclusive. The decision of appropriated versus inappropriate denial will be made by the Administrative Review Committee according to governing regulatory agencies laws and standards. 1. High Census, appropriate level of care not available for the patient ' s medical condition. 2. Services requested by the referring facility not available at (Name). 3. Current caseload will prevent the accepting physician to care for the patient in a timely manner. 4. Services required for stabilization of patient are available at referring facility. 5. Patient/Family Request will all be reviewed by the Administrative Review Committee or at least the Administrative Director to determine appropriateness of transfer request. "


The hospital failed to ensure that their Policy and Procedure was followed as evidenced failing to accept from a referring hospital an appropriate transfer of Patient #24 on 1/19/2019. The facility also had the capability specialized services required ( ENT MD #1 ) and the capacity to treat patient #24 on 1/19/2019.