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Based on staff interview and review of medical records, hospital policies, and ER logs, it was determined the hospital failed to ensure emergency services were provided in compliance with 42 CFR Part 489.24. This resulted in a lack of treatment for a patient (#19) and the failure of the hospital to accept an appropriate transfer for a patient (#21). Findings include:

1. Refer to A2407 as it relates to the failure of the hospital to provide stabilizing treatment to a patient with an emergency medical condition.

2. Refer to A2411 as it relates to the failure of the hospital to accept a patient for transfer.

Based on staff interview and review of medical records, it was determined the hospital failed to ensure 1 of 7 patients (#19) with emergency medical conditions, whose records were reviewed, received treatment required to stabilize her condition. This failure to stabilize placed the patient and her family in danger of injury. Findings include:

Patient #19's medical record documented a 13 year old female who presented to the hospital on 8/31/11 at 11:37 AM. She was brought to the hospital by her mother over rural mountain roads from a town approximately 55 miles away. The triage note by the RN at 11:45 AM on 8/31/11, stated "MOM DROVE UP FROM [name of town] WITH DAUGHTER. PT AGGRESSIVE TOWARD MOM, HITTING, PULLING HAIR. MOM UPSET. PT IN CAR, WENT OUT TO CAR TO TALK TO [], SHE OPENED THE CAR DOOR. AGREED TO COME IN AND TALK TO ME, TOLD PT WE WOULD GO TO RM 12 AND MOM WOULD BE WAITING FOR US. WALKED INTO RM, PT TURNED AROUND GRABBING MOM'S HAIR, PULLED HAIR AND STARTED PINCHING. MOM STATES THAT BEHAVIOR HAS BEEN CONSISTENT X 1 YR. PT ALERT TO NAME. RESPONDS YES, NO TO SIMPLE QUESTIONS."

A Case Manager, who was a social worker, evaluated Patient #19. His note, dated 8/31/11 at 1:01 PM, stated "HER BEHAVIORS ARE GETTING MORE AGGRESSIVE, SHE HAS BEEN AGGRESSIVE WITH FAMILY AND DESTRUCTIVE WITH HER ROOM. WHATEVER SHE CAN GET HER HANDS ON SHE WILL THROW. ALSO HITTING ANIMALS, (FAMILY HAS TWO DOGS AND A CAT.) TODAY MOM WAS TAKING HER TO SEE [a physician] AND MOM INDICATES THAT THE WHOLE WAY HERE [Patient #19] WAS PULLING MOM'S HAIR HITTING MOM, TRYING TO PULL THE KEYS OUT OF THE IGNITION. ANYTIME [Patient #19] DOES NOT WANT TO GO SOMEWHERE THIS BEHAVIOR HAPPENS. ALL SHE WANTS TO DO IS STAY HOME. A MONTH AGO SHE STABBED HER DAD WITH A FORK. MOM HAS HAD TO PUT AWAY ALL THE UTENSILS AND PT EATS WITH A PLASTIC FORK." The Case Manager continued "PATIENT DOES MEET CRITERIA FOR HOSPITALIZATION, HOWEVER [the hospital] DOES NOT HAVE BED AVAILABILITY TODAY. THIS CM CHECKED WITH [another hospital] AND SPOKE WITH ADMISSION PERSON...AND THEY ARE UNABLE TO TAKE HER. MOM DOES NOT FEEL SHE CAN TRANSPORT [Patient #19] TO SEATTLE OR BOISE."

The untitled physician dictation, dated 8/31/11 at 5:03 PM, stated Patient #19 had "...a history of autism and developmental delay who was brought in with behavioral problems including violent behavior. The mother states that the child has a history of violent behavior. She has been hitting and yelling recently, and it is much worse than usual. Ten days ago, they attempted to bring her to [an amusement park], and she became agitated. She started hitting people that were at [the amusement park] and then started hitting her mother and took off her clothes. It took some time before she would calm down, and eventually they went home. Five days ago, they were attempting to go her brother's football game, but she became agitated in the van and started hitting her 10 year old brother. She then started tearing the van apart, and eventually they were not able to go to the game. Four days ago, the mother and father were out for dinner and the patient was being watched by the 10 year old when she started hitting the 10 year old. The mother feels she can no longer control the patient's behavior and brings her in for further evaluation."

The physician dictation for Patient #19 stated his impression was "1. Violent agitated behavior. 2. Autism. 3. Developmental delay." The physician dictation stated a bed was not available on the psychiatric unit and "Eventually, we had to discharge the patient home with plans to bring her back when a bed was available." The physician dictation did not state Patient #19 was stable or that she was not a danger to herself or others. Patient #19's medical record documented an examination but did not document any treatment of the patient.

The ER physician who examined Patient #19 was interviewed on 10/05/11 beginning at 3:10 PM. He stated Patient #19 would have been admitted if a bed had been available. He said although the child was violent with her brother and her mother, "She wasn't going to kill or hurt anyone." He stated he could not admit Patient #19 to a medical floor until a psychiatric bed was available because the hospitalists were not comfortable caring for psychiatric patients and patients did not get watched closely. Patient #19 was sent home with her mother. When asked about the possibility of Patient #19 causing a motor vehicle accident on the drive home, the ER physician stated "I see your point about safety, but there weren't any beds."

The Case Manager for the Behavioral Health Unit, who assessed Patient #19, was interviewed beginning at 3:30 PM on 10/05/11. He stated Patient #19's mother had brought her to the ER by herself. He said it was a "battle" for the mother to transport the child and the mother had "lots of trouble getting her here." He stated Patient #19 was violent and autistic. He said no behavioral health beds were available. He said the mother did not want to have the child admitted to Seattle or Boise hospitals. He stated he developed a safety plan for Patient #19's mother. He said if Patient #19 became violent or aggressive, the plan was to call the police or take her to an emergency room. He stated he could not remember if he talked with the mother about concerns transporting Patient #19 home.

The RN, who was the ER nurse who cared for Patient #19, was interviewed on 10/5/11 beginning at 4:00 PM. She stated Patient #19's mother had come to the front desk and stated the child had punched, kicked, and hit her all the way to the hospital. The RN stated she went to the van and brought Patient #19 into the hospital. She stated, when they arrived in the examination room, Patient #19 jumped on her mother, hit her, had her hand deep in her mother's hair, pinched her, and kicked her. She stated Patient #19 was big for her age, weighed 220 pounds, and was very fast. The RN stated Patient #19's mother stated Patient #19 behaved that way during the trip to the hospital. The RN stated Patient #19's mother stated she was also concerned Patient #19 would hurt her sibling. The RN stated she was upset Patient #19 was discharged from the hospital. She stated she told the Case Manager about the attack in the ER but he said the mother was "OK."

The hospital did not provide stabilizing treatment to Patient #19.

Based on staff interview and review of medical records, hospital policies, and ER Logs, it was determined the hospital failed to ensure 1 of 1 patient (#21), who requested transfer and whose record was reviewed, was accepted for transfer. In addition, the hospital failed to develop a system to process requests for transfers from other hospitals. This resulted in the inability of the hospital to recognize transfer requests and process those requests, resulting in delayed treatment. Findings include:

1. Patient #21's medical record, from an Idaho CAH, documented a 28 year old male who presented to the CAH on 9/11/11 at 8:02 PM. The "Emergency Department Charting Form" stated he arrived at the CAH by ambulance following a motor vehicle accident. The form stated he complained of head, neck, chest, and thoracic pain. Ambulance personnel had started an intravenous line. His documented vital signs at 8:11 PM were as follows: blood pressure 128/97, pulse 77, respirations 20. His oxygen saturation level was 100% while receiving an unknown quantity of oxygen. His blood pressure decreased to 120/80 at 9:15 PM. His oxygen saturation levels remained above 90%. A CT scan of Patient #21's brain was negative for bleeding. CT scans showed fractures at C7 without dislocation, a fracture at T5 and a tiny right pneumothorax (punctured lung). He also had 4 rib fractures which were not displaced. His EKG was normal. The CAH did not have a neurosurgeon on staff to evaluate the cervical and thoracic fractures. The "EMERGENCY PHYSICIAN RECORD," dated 9/11/11, stated the CAH physician contacted the neurosurgeon from KMC. The time of the call was not documented. The note stated "Discussed [with neurosurgeon] who prefers pt to be transferred to [an out of state hospital] due to multiple traumas." The CAH then contacted the out of state hospital and Patient #21 was transferred there at 12:06 AM on 9/12/11.

The ER physician at the CAH was interviewed on 10/7/11 beginning at 9:15 AM. He stated Patient #21 was involved in a high speed single car rollover accident. He said Patient #21 had fractures at C7, T5, and four ribs. He stated Patient #21 also had a tiny pneumothorax. He said neither the fractured ribs nor the pneumothorax required special treatment. He stated he called the ER at KMC to arrange for transfer. He stated in order to transfer a patient, permission from the neurosurgeon was normally required. He stated ER personnel gave him the number for the neurosurgeon on call. He said he then called the neurosurgeon. He stated the neurosurgeon told him that, because of Patient #21's other injuries, the patient would be better served by sending him to an out of state hospital. He stated he then transferred Patient #21 to the out of state hospital.

The KMC neurosurgeon on call on the night of 9/11/11 was interviewed on 10/11/11 beginning at 10:13 AM. He stated the CAH's ER physician called him directly. He stated he was not aware the CAH physician had called the KMC ER before calling him. He stated he was not aware the CAH physician was requesting transfer for Patient #21. He said he recommended Patient #21 be treated at an out of state hospital.

The CAH failed to recognize and accept a request to transfer a patient.

2. The policy "Guidelines for Diverting Patients from KMC to other Area Hospitals," Revised 7/05, stated its purpose was "To provide guidelines for determining when an appropriate placement or service(s) cannot be provided at KMC." The policy stated "The decision to divert patients must be made by the Vice President for Patient Care or designee." The policy contained a procedure for staff to follow to when diverting patients to another hospital for treatment. The policy did not specify a procedure for staff to follow when another hospital called KMC seeking approval to transfer patients to KMC's care. The policy did not provide direction to staff as to how to handle calls from rural hospitals seeking to speak with specialty physicians in order to determine whether they were seeking to transfer a patient to KMC.

The Manager of Emergency Services was interviewed on 10/05/11 beginning at 8:30 AM. She stated calls from other hospitals involving transfers to KMC came to the ER physician. She stated specialty physicians could reject a patient but this was not the hospital's process. She stated the ER Charge Nurse would call the House Supervisor to check if beds were available on a particular unit. She stated the KMC ER physician should determine whether a patient needed to be diverted to another hospital for lack of capability to treat. She said patients who were diverted to another hospital from KMC would be documented on the "LOG OF INBOUND TRANSFER REQUESTS." She stated she was not aware of a policy which outlined this process. She later provided the policy for the diversion of patients, stating it had been archived.

No inquiries for transfer were documented on 9/11/11 on the "LOG OF INBOUND TRANSFER REQUESTS." The Manager of Emergency Services, interviewed on 10/05/11 beginning at 8:30 AM, confirmed the "LOG OF INBOUND TRANSFER REQUESTS" did not document the attempt by the CAH to transfer Patient #21 to KMC.

The House Supervisor for the night of 9/11/11 was interviewed on 10/05/11 beginning at 10:35 AM. She stated she did not receive an inquiry on 9/11/11 asking if the hospital could accept any emergency patients.

The ER Charge Nurse for the night of 9/11/11 was interviewed on 10/05/11 beginning at 11:50 AM. She stated she was not aware of an inquiry on 9/11/11 asking if the hospital could accept any emergency patients. She stated the only reason the hospital would have diverted a patient was if the neurosurgeon did not accept the patient. She stated the CAH's ER physician had to contact an ER physician at KMC to get the neurosurgeon's telephone number.

The hospital had not developed a procedure to recognize and accept patient transfers.