HospitalInspections.org

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Based on record review, policy review and interviews the facility failed to: 1) ensure stabilization of an emergency medical condition (EMC) within their capacity and capability. Instead transferred an unstable patient to a facility where the Specialty Consult Services and stabilizing treatment of the EMC was known to not be available. Findings:

Record review from 11/13-16/17, of the Emergency Department (ED) registration and transfer logs dated from 5/1 - 11/11/17 revealed Patient #9 had been admitted to the ED on 10/26/17, transferred from the ED on 10/27/17 to JBER (Joint Base Elmendorf Richardson) and readmitted to the ED on 10/27/17, patient stabilizing treatment was delayed more than 24 hours.

Review of Patient #9's medical record, dated 10/26/17, revealed "Per Dr. [Rheumatolgist] note on 10/26/17: "[Patient #9] is at increased risk for ILD [interstitial lung disease] ... RNA Pol III confers an increased risk of scleroderma renal crisis ... I discussed the severity of the situation with the patient and recommended admission for further evaluation and treatment. I discussed the severity of the situation with the patient and recommended admission for further evaluation and treatment. I discussed the case with Dr. [name] ... at JBER .... He feels that the patient would be best served at ANMC. He is not sure that they are able to infuse IVIG or if they have it in stock at this time. No available inpatient rheumatology consults at JBER, Providence, or AK Regional Hospitals. This is a very rare, life threatening condition that will requiring ongoing evaluation and treatment by a rheumatologist therefore I feel it is in the patient's best interest to be admitted to ANMC, where the rheumatology consultation is available ... I have discussed this case and the recommendations above with, [Intensivist], [ED MD], and [Hospitalist]."


Review of the ED MD #3 Provider note, dated 10/26/17 at 5:02 pm, revealed a triage "Chief complaint: Pt sent from rheumatology clinic, hx systemic scleroderma. Has increased weakness and falls. History of present illness: ...presents with weakness, difficulty swallowing, breathing, strength, walking ... in the care of Rheumatology and is experiencing weakness to the point of falling and raising her head off the bed."

Further review of the ED MD Provider note revealed "Medical Decision Making Rationale: patient has highly technical and highly dangerous condition related to her systemic scleroderma and her Rheumatologist make sure the patient is going to get admission and IVIG and communicates frequently and helpfully and since the patient will need close monitoring for weakness leading to respiratory/ventilatory failure, admission to step down or ICU level is made."

Review of the "Out-of-Hospital Transfer Record," dated 10/27/17 at [11:45 pm] revealed the Patient was transferred to JBER at 00:30 am for "continuity of care with primary team."

Further review of the ED record revealed Patient #9 was transported by EMS to JBER on 10/27/17 at 12:55 am , and returned to the ANMC ED via EMS on 10/27/17 at 12:52 pm.

JBER: Admission H&P

Review of the JBER "Admission History and Physical," signed and dated 10/27/17 at 5:06 am, revealed "History was obtained from patient and review of records from ANMC send with patient upon transfer. Attempted to review record in AHLTA multiple times prior to and after arrival, however message received "unable to connect to server ...[patient] was being followed by Rheumatology at ANMC as none available here at JBER ... given she was a beneficiary here at JBER as well as a bed shortage which was noted and she was accepted for transfer here for further evaluation and treatment."

JBER Discharge/Transfer Note 10/27/17

Review of the JBER "Hospital Course/Narrative Summary dated 10/26/27 - 10/27/17 signed at 10:53" by a new JBER MD, revealed, "We requested records from ANMC and discovered very clear instructions from patient's Rheumatologist that the patient needs to be seen at a facility with inpatient rheumatology as well as receive IVIG. Unfortunately this was not communicated last night to our nocturnist. I spoke with Dr. [Rheumatologist] this morning who confirmed she highly recommends patient be transferred back to ANMC ..."

Interviews

During a Surveyor initiated telephone interview, on 11/14/17 at 5:55 pm, MD #1. [Rheumatologist] stated she discussed with the ED MD and the Hospitalist before transferring the patient to the ED, and explained the need for admission to ANMC for Rheumatology consult and the conversation she had with the Patient primary MD at JBER. In addition, she explained to the ED MD and Hospitalist how critical the Patient was and how quickly she could deteriorate.

During an interview on 11/14/17 at 1:35 pm, MD #3 stated because Patient #9 had been seen by the Hospitalist and was to be admitted, she provided a brief summary hand off report to oncoming MD #5 A transfer consent or handoff to JBER was not needed.

During an interview on 11/16/17 at 6:15 pm, MD #5 stated he provided a brief summary hand off report to MD #2 after being told by the Nursing Supervisor Patient #9 was not going to be admitted to ANMC, but was going to be transferred to JBER.

The MD also stated at the time the ED was very busy, the acuity was high, and he was not in a position to take the time to review the entire Patient medical record when he was told by the Nursing Supervisor he needed to call report to the receiving MD #2. In addition, he stated he had been told by MD #3 the Patient had been seen by the Hospitalist and waiting transfer to telemetry or ICU. He felt the transfer should have been given to the Hospitalist.

During an interview on 11/30/17 at 7:00 am, MD #2 stated she had not been informed of the Rheumatologist specific request for the Patient to remain at ANMC until the patient arrived, the ED provider notes had been reviewed, and the Patient had expressed her concerns with the transfer. The MD consulted with the morning Hospitalist, who initiated transfer back to ANMC after consultation with the Rheumatologist.

During an interview on 11/15/17 at 11:45 am MD #4 stated on 10/27/17 he does not recall having been consulted about the decision to transfer Patient #9 to JBER, but rather was told the Patient was being transferred to JBER by the Nurse Supervisor.

During an interview on 11/16/17 at 12:03 pm the Interim Chief Medical Officer (CMO) /Hospitalist Medical Director stated the decision to transfer was done collaboratively between the ED MDs, Hospitalist, or Intensivists when the census was high. She also stated if the Hospitalist or Intensivist had accepted admission of an ED patient, it would be them who should call the receiving MD to transfer care.

The CMO/Hospitalist Medical Director was also asked if she was aware of Patient #9's transfer to JBER with a return to ANMC less than 12 hours later due to JBERs lack of ability to provide the consulting services for Rheumatology. She stated yes, she had reviewed the transfer and stated it was an appropriate transfer; JBER has accepted the transfer and the Patient was stable. JBER MD had accepted the patient.

When asked if patients were ever held in the ED for an admission bed, to include ICU and telemetry, she stated yes. When asked if the facility had a policy on how the Transfer Call Center or Nursing Supervisors use to triage transfers, she stated they did not.

Out of Hospital Transfer Form

Review of the "Out of Hospital Transfer," form dated 10/26/17 at [11:45 pm], revealed under "Document specific risk/benefits to specific patient: Continuity of care with primary team." Consent was signed by MD #5.

Patient Interview

During Surveyor initiated telephone interview, on 11/20/17 at 2:10 pm, Patient #9 stated she was not told she was going to JBER hospital until about 30 minutes before the ambulance arrived. She stated she was told by the RN that there were no longer beds available for her at ANMC. The patient stated she had already been told she was going to be admitted to ANMC and questioned the RN if the Rheumatologist had been notified and the RN stated she was not sure.

The Patient also stated she was very concerned about going to JBER because of the discussion the Rheumatologist had with her today before the ambulance brought her to the ANMC ED. When asked if the risk and benefits of the transfer had been explained to her, she stated they had not. She said she was told by the RN she had to go because there were no beds available at ANMC.


Policy

Review of the hospital policy "EMS/EMTALA Transfer Procedure," dated 5/17/17, revealed "To ensure ANMC complies with its obligations under EMTALA ...;

Appropriate Transfer: ...individual is stable ... the individual will sustain no material deterioration in his or her medical condition as a result of or during the transfer to the receiving facility ... ANMC has provided medical treatment with in its capacity that minimizes the risks ..."


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Based on record review, interview and policy review the facility failed to ensure: 1) documentation of medical benefits and risk of transfer specific to the patient; 2) Consent for transfer had been signed by the patient or their representative; 3) documentation of qualified personnel and equipment needed for transfer; 4) medical records specific to transfer were available for the receiving hospital; 5) implementation of EMTALA policy. Findings:

Mode of Transfer

Record review from 11/4 - 17/17 of the following selected emergency department transfers revealed the "Out-of- Hospital Transfer
Record" did not identify the level of qualified personnel needed for transfer:

Patient #1: transferred on 10/7/17 with a diagnosis of Pneumonia revealed "Mode of Transfer: EMS."

Patient #2: transferred on 11/8/17 with a diagnosis of Occipital Stroke revealed "Mode of Transfer: Ambulance."

Patient #3: transferred on 10/30/17 with a diagnosis of STEMI revealed "Mode of Transfer: AFD."

Patient #4: transferred on 10/2/17 with a diagnosis of GI bleed revealed "Mode of Transfer: EMS ground."

Patient #5: transferred on 5/18/17 with a diagnosis of Sepsis revealed "Mode of Transfer: Ambulance."

Patient #6: transferred on 5/11/17 with a diagnosis of Sepsis revealed "Mode of Transfer: Blank."

Patient #7: transferred on 6/23/17 with a diagnosis of Pneumonia revealed "Mode of Transfer: Blank."

Patient #8: transferred on 11/9/17 with a diagnosis of Pneumonia revealed "Mode of Transfer: Stretcher."

Patient #9: transferred on 10/27/17 with a diagnosis of Scleroderma and weakness revealed "Mode of Transfer: Lifemed."

Patient #10: transferred on 9/15/17 with a diagnosis of COPD exacerbation revealed "Mode of Transfer: Lifemed."

Patient #11: transferred on 10/12/17 with a diagnosis of Asthma exacerbation revealed "Mode of Transfer: Lifemed/Ground."

Patient #12: transferred on 6/30/17 with a diagnosis of Renal failure/need of emergent dialysis revealed "Mode of Transfer: Lifemed."

Patient #13: transferred on 10/13/17 with a diagnosis of Hyponatremia revealed "Mode of Transfer: Lifemed."

Patient #14: transferred on 8/5/17 with a diagnosis of Vertebral Artery Aneurysm revealed "Mode of Transfer: Lifemed/guardian."

Patient #18: transferred on 8/19/17 with a diagnosis of cellulitis revealed "Mode of Transfer: (Air) Guardian."

Transfer Form/Consent

Record review from 11/4 - 17/17 of the following selected emergency department transfers revealed the "Out-of- Hospital Transfer."

Record did not identify medical benefits and risk of transfer specific to the patient and or had no documented consent to transfer:

Patient #3: transferred on 10/30/17 with a diagnosis of STEMI revealed no consent or Out of Hospital Transfer Form.

Patient #5: transferred on 5/18/17 with a diagnosis of Sepsis revealed no consent or Out of Hospital Transfer Form.

Patient #10: transferred on 9/15/17 with a diagnosis of COPD exacerbation revealed no consent or Out of Hospital Transfer Form.

Patient #15: transferred on 10/6/17 with a diagnosis of cellulitis revealed no consent or Out of Hospital Transfer Form.

Patient #16: transferred on 9/17/17 with a chief complaint of slurred speech, (per MD documentation patient was to be seen at another hospital) revealed no consent or Out of Hospital Transfer Form.

Patient #20: transferred on 10/19/17 with a diagnosis of COPD exacerbation revealed no consent or Out of Hospital Transfer Form.

Patient #21: transferred on 11/5/17 with a diagnosis of Pneumonia revealed no consent or Out of Hospital Transfer Form.

Patient #22: transferred on 10/19/17 with a diagnosis of Dysarthria revealed no consent or Out of Hospital Transfer Form.

Risk & Benefit

Patient #1: transferred on 10/7/17 with a diagnosis of Pneumonia revealed no risk or benefit of transfer specific to the patient.

Patient #3: transferred on 10/30/17 with a diagnosis of STEMI revealed no risk or benefit of transfer specific to the patient.

Patient #6: transferred on 5/11/17 with a diagnosis of Sepsis revealed no documented risk of transfer.

Patient #9: transferred on 10/27/17 with a diagnosis of Scleroderma and weakness revealed no risk or benefit of transfer specific to the patient.

Patient #12: transferred on 6/30/17 with a diagnosis of Renal failure/need of emergent dialysis revealed no risk or benefit of transfer specific to the patient.

Patient #13: transferred on 10/13/17 with a diagnosis of Hyponatremia revealed no documented risk of transfer.

Patient #17: transferred on 10/8/17 with a diagnosis of Cellulitis revealed no risk or benefit of transfer specific to the patient.

During an interview on 11/17/17 the Administrative/CMS Assistant confirmed he was unable to locate the Out-of-Hospital Form/Patient consent for the above listed medical records.

Review of the hospital policy "EMS/EMTALA Transfer Procedure" dated 5/17/17, revealed "Physician responsibilities: document the risks and benefits associated with the transfer, an assessment of whether the risks outweigh the benefits and why, and what treatment, personnel or equipment are needed prior to an during transport to minimize the risk of the transfer ..."

Transfer Log and EMTALA Policy Implementation

Record review from 11/13 - 17/17 of the 2 transfer logs provided by the Administrative /CMS Assistant revealed inconsistent transfer data.

"ED Discharge to outside May - Present" revealed:

May: 12 transfers

June: 14 transfers

July: 16 transfers

August: 16 transfers

September: 15 transfers

October: 24 transfers

"Disposition log" dated 5/1/17 - 11/14/17:

May: 11 transfers

June: 11 transfers

July: 15 transfers

August: 14 Transfers

September: 13 transfers

October: 20 transfers

Review of the EMTALA transfer audit log dated 5/1 - 10/31/17 revealed:

May: 13 charts were reviewed

June: 10 charts were reviewed

July: 16 charts were reviewed

August: 13 charts were reviewed

September: 14 charts were reviewed

October: 6 charts were reviewed

Review of the hospital policy "EMS/EMTALA Transfer Procedure" dated 5/17/17, revealed "To ensure ANMC complies with its obligations under EMTALA... ...Registered Nurse Responsibilities ... Verify the Emergency transfer record is complete ... House Supervisors Responsibilities ... verify that all EMTALA requirements have been met and all transfer forms are complete and accurate ..."

Record review of Patient #8 transferred on 11/9/17 at 4:35 am with a diagnosis of Pneumonia revealed a faxed "Request for Protected Health Information" from the receiving hospital dated 11/9/17 at 11:32 am. No nursing documentation was found in the EMR for transfer/discharge documenting the ER record had been sent with the patient.