HospitalInspections.org

Based on interview and record review, the hospital failed to provide a safe transfer for one of 25 sampled patients (Patient 1).

This failure could have resulted in Patient 1's condition worsening while being transported in a private car.

Findings:

Record review on 1/23/23 at 10:00 a.m. of Patient 1's electronic medical record indicated he had sustained a closed head injury when a 500 lb. pipe fell on his head while he was working on a job site. Patient 1 was brought to the emergency department (ED) of Hospital A on 12/20/22 for medical care.

Record review of ED triage note dated 12/20/22 at 11:53 a.m. indicated: "Patient is here for head injury around 30-45 minutes prior. Patient reports a steel rod approximately 500 lbs fell into his head. +LOC (positive for loss of consciousness). Patient now reports headache denies N/V (nausea, vomiting). Pupils equal and reactive at this time. Patient is awake and alert. No focal weakness." The medical screening exam was initiated by Physician B at 12:00 p.m. and the ED secondary assessment indicated: "Patient had a 500 lb. steel rod fall and hit him on the top of the /right side of his head. Per uncle, patient was "delirious after incident but there was no LOC (loss of consciousness. No medications attempted (-) negative vision changes.""

The secondary assessment indicated: "Neuro Patient status post head injury reports dizziness/ right sided headache that has begun to radiate down his right shoulder. Currently appears drowsy, but arousable via verbal stimuli. Neuro: Responsive follows commands. Lungs: WDL (within defined limits). Speaking in full sentences; no accessory muscle use; no wheezing; good air exchange bilateral."

Further record review of the physician's note dated 12/20/22 indicated Physician B ordered a series of CT scans of Patient 1's head, cervical spine and maxillofacial bones. (A CT scan, computerized tomography, uses a series of x-ray images taken from different angles around the body and uses computer processing to create cross sectional images (slices) of the bones, blood vessels and soft issues.)

During an interview on 1/24/23 at 11:50 a.m., CT technologist C, (Tech C) indicated he was the technologist on duty on 12/20/22 and was tasked to perform the series of CT scans for Patient 1.

Tech C stated he attempted to perform the procedure but was unable to do so successfully as Patient 1's weight of 382 lb. exceeded the 300 lb. Weight limit of the CT scanner. When Tech C attempted the scan, the machine stalled and wouldn't function. Tech C stated he then explained to Physician B he was unable to complete the CT scans.

Further record review of Physician B's medical decision-making note dated 12/20/22 indicated: "Closed head injury, initial encounter. Diagnosis management comments: Patient here after closed head injury with substantial force. He has no/ minimal outward evidence of trauma, but energy of mechanism + photophobia (sensitivity to light) raise concerns for sinister (hidden) injury. Plan was for CT of head, spine, face, but the patient is too large for CT at Hospital A. He weighs 382 lb. CT staff tried to perform the study, but the machine stalled and would not function. He has Hospital D insurance. I called Hospital D's EPRP (Emergency Prospective Review Program) to try and locate a CT that can accommodate his weight within Hospital D's network- Physician F had hoped to call me back after about 5 minutes. I called him back an hour later, and he informed me that Hospital D and Hospital E are both closed to transfers, and he was still working to find an in-network location that could receive patient as proper transfer. Because I feel that further delays increase the likelihood of unnecessary injury, I informed Patient and his uncle to head to Hospital D (CT scan can accommodate 450 lbs. patients) and present as walk-in patient. Dc' d (discharged) with this plan in incompletely evaluated condition."

During an interview on 1/24/23 at 1:45 p.m. Physician B stated Patient 1 came into the ED on 12/20/22 and described his injury when a 500 lb. steel pipe fell off a forklift and dropped from 8 feet in the air and hitting Patient 1's unhelmeted head. Patient 1 complained of light sensitivity and nausea and Physician B stated he ordered CT scans of Patient 1's head, spine and face.
Physician B stated Tech C notified him the scans were attempted but the table wouldn't move as Patient 1's weight exceeded the weight limit of the table.

Physician B described how an injury such as Patient 1 sustained was time sensitive, could worsen and develop bleeding and pressure on brain tissue. Physician B indicated Patient 1 required a CT scan which Hospital A could not provide. Physician B stated Patient 1 needed a hospital which could provide access to CT scanner, neuro surgery consultation and any delay increases the risk of death or disability. Physician B stated Patient 1 received his medical care at Hospital D and he was obligated to contact their EPRP for authorization for transfer.

Physician B stated he did contact the EPRP and waited 30 minutes until he received a return call from Physician F and explained the urgency of the situation. Physician B indicated Physician F was aware of the urgency of Patient 1's injury and would see what other resources were available to accommodate Patient 1 in his network.

During the interview Physician B described transfers by ambulance were backed up over two hours and two critical patients were already awaiting ambulance transfer.

Physician B stated after awaiting 45 minutes for a return call, he placed a call to Physician F for an update.

Physician B stated he was informed the closest in net-work location was 78 miles and 1 hour and a half away.

Physician B stated it was not in Patient 1's best interest to wait any longer and determined Hospital B was the closest to Hospital A, had the CT scanner which would accommodate Patient 1 and had neurosurgeon on call.

Physician B stated he informed Physician F he was sending Patient 1 to Hospital D by private car driven by a family member. Patient 1 was advised to present to Hospital D as an ambulatory patient.

Physician B stated he provided maps, directions and discussed risks and benefits of transport by private car and felt the benefits outweighed the risks for Patient 1.

Physician B stated Patient 1 was then driven to Hospital D.

Physician B stated another approach he could have used would have been to contact Hospital A's administrator on call who could then contact Hospital D to facilitate and authorize the transfer.

Record review on 1/24/23 of the hospital policy: "Compliance with Emergency Medical Treatment and Active Labor Act," dated 1/24/2022, indicated: "The hospital may not transfer any patient with an unstabilized emergency medical condition (includes a pregnant patient having contractions, a patient with severe pain, a psychiatric disturbance or symptoms of substance abuse) unless the patient requests the transfer or a physician certifies that the medical benefits reasonably expected from the provision of treatment at the receiving facility outweigh the risks to the patient from the transfer. The Hospital must provide additional examination and treatment as may be required to stabilize the emergency medical condition."