HospitalInspections.org

Based on medical record review, document review and interview, in one (1) of 20 records reviewed, the facility failed to ensure an appropriate transfer for a patient with an unstable emergency medical condition, after the patient/family requested a transfer.


Findings:
On 5/25/21 at 12:04 AM, Patient #1, a 64-year-old female, arrived via EMS to the facility's Emergency Department (ED). Her chief complaint was noted as acute left sided weakness to the upper and lower extremities which started at 11:00 PM while brushing her teeth. She was seen and evaluated, and a Stroke code was called on 5/25/21 at 12:06AM. CT scans of her head and neck were performed and the results revealed a right frontal bleed, additional lesions worrisome for metastasis, and a right frontal lesion likely represented a hemorrhagic metastasis.

A Neurology Assessment/Recommendations was completed and documented on 5/25/21 at 1:04AM which noted, physical exam and.," goals of care; patient would benefit from admission to SICU, as per hospital protocol, for acute intracranial hemorrhage; obtain records from patient's oncology team at Facility A. Rest of management as per team. Above discussed with attending."
A Neurosurgery consult on 5/25/21 at 1:50 AM noted the physical exam and plan: ... Subsequent CT revealed multiple masses with right IPH. CT Stroke Protocol: Right frontal bleed, additional lesions worrisome for metastasis. Right frontal lesion likely represents a hemorrhagic met ... Physical exam: awake, alert, no acute distress, oriented x 3, follows commands, eyes open spontaneous PERRL, EOMI, positive left side weakness. Plan: spoke in depth with family who absolutely does not want any care with this establishment; family states patient is been treated at Facility A and would prefer all care be continued there. MRI, BP< 140, Decadron, Keppra, NPO, discussed with attending."

On 5/25/21, at 4:17AM, the ED Resident provider (Staff O) documented: "Patient see's Dr. R. at Facility A and the patient and patient's family would prefer that patient be transferred to Facility A for further treatment. Patient and patient's family decline any further intervention from CIH despite understanding of patient's current intracranial pathology and potential risks for worsening of condition.
Contacted Facility A and patient was accepted by ED attending Dr. K. Per attending, Facility A does not have a transfer service that will send transportation for the patient and sending hospital would be responsible for sending patient.
Per the documentation in the medical record, the ED Resident Contacted facility's transfer center and was informed by operator that they would not be able to perform the transfer and was provided with the number for EMS vendor, to arrange transport for patient ourselves. After multiple attempts, the ED Resident was unable to secure transport.

Per the ED Resident documentation on 5/25/21, at 4:17AM, patient agreed to sign out AMA and procure private transportation to Facility A with family. Patient with capability to make their own medical decisions. Patient and patient's daughter were informed, and voiced understanding of the risks involved with leaving AMA given current condition and were still willing to sign out AMA. Patient voiced understanding of instructions and agrees to discharge plan.

Per the last nursing note on 5/25/21 at 3:34AM, the "Patient. and her daughter signed out AMA. Patient able to sign the paper herself. Pt. is Alert and Oriented x 4, the patient's daughter and patient's son will take the patient to Facility A hospital for treatment. Staff X and I assisted the patient to the car with the help of the family as well. Patient left the ER with all her property, her daughter and son. Heplocks removed. Dr. L. explained all the risks of signing out AMA. Pt and family verbalized understanding."

Per interview of the transfer center and facility staff, 9/16/21 the facility failed to successfully provide a transfer for the patient due to a breakdown in communication with the Health and Hospital Cooperation (HHC) network transfer center staff and the inability of the facility staff to transmit the patient's electronic protected health information (PHI) as requested by a transport vendor.

These lapses in the facility's ability to secure appropriate transfer for a patient with a unstabilized emergent medical condition, whose family requested transfer to another facility, resulted in the patient/patient family agreeing to "sign out AMA and procure private transportation to the other facility. The family transported the patient themselves, in a car, to the other facility.