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Based on review of hospital policies, closed medical records, and variance/occurrence reports, staff interviews, and review of hospital documents, the hospital failed to analyze the cause of an adverse patient event for 1 of 2 adverse patient events reviewed (Patient #2).

The findings include:

Review of the hospital's policy, "Management of Sentinel Events", revised 10/30/2006, revealed, "Purpose: To provide a method for identification, reporting, intensive analysis and prevention of sentinel events, and adverse outcomes in patient care. Policy: Administrative Staff, Medical staff, Risk Management Staff and Quality Services Staff will work collaboratively to review sentinel events and adverse outcomes in patient care. Root causes will be identified and appropriate action taken to prevent reoccurrence and to correct system weakness and failures. Definition: A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. ...The phrase 'or the risk thereof' includes any process variation for which a reoccurrence would carry a significant chance of a serious adverse outcome....Procedure: 1. Report sentinel event to Risk Manager at (phone number) immediately. 2. The Risk Manager, in conjunction with the Quality Services Director, will conduct the initial investigation of the event. Investigation will begin immediately upon notification. 3. The Risk Manager/Quality Services Director will evaluate the reported event. If the event meets criteria for intensive analysis, the Risk Manager/Quality Services Director will notify the administrator, legal counsel, President of the Medical Staff, and the Chief of the appropriate service. Following intensive analysis, a determination will be made to decide if a sentinel event has occurred and/or if conducting a root cause analysis is appropriate. ...Points to Remember: 1. An employee or medical staff member who witnesses or becomes aware of a patient care event which may be a sentinel event should immediately report the event to Risk Management. If Risk Management is not immediately available, notify the nursing supervisor who will contact the Risk Manager and/or the Quality Services Director. In their absence, notify the administrator on call. 2. The Risk Manager will contact legal counsel to proceed with the investigation...."

Closed record review for Patient #2 revealed a 75 year-old male that presented via EMS (Emergency Medical Services) to Hospital A's emergency department on 12/04/2010 at 0938 after he sustained a fall at home. Record review revealed the patient was not accompanied by any family members. Review of Registered Nurse (RN - day shift nurse) #4's nursing notes at 0938 revealed, "Pt (patient) to ed (emergency department) bed 4 per ems (emergency medical services) stretcher r/t (related to) fall this am. Pt states that he keeps falling because his 'legs keep giving out.' Pt has hx (history) of falls and restless leg syndrome." Record review revealed a triage assessment completed by RN #4 at 0951. Review of the triage assessment revealed the patient's vital signs were as follows: Temperature (T) - 98.3 degrees Fahrenheit, Pulse (P) - 103, Respirations - 24, Blood Pressure (BP) - 147/94, and Oxygen Saturation (Pulse Ox) - 97%. Review of the triage pain assessment revealed the patient rated his pain to be a 7-8 (on a scale of 0 - 10, with 10 being the most severe pain). Review of the triage assessment revealed, "Chief Complaint - Falling....Past Medical Histor(y) - COPD (chronic obstructive pulmonary disease), CAD (coronary arterial disease), CHF (congestive heart failure), HTN (hypertension), Renal....Additional: Hyercholesterolemia, Afib? (atrial fibrillation), prostate cancer; Foley Indwelling (urinary catheter)...." Review of the triage assessment revealed documentation the patient's home medications included Coumadin (blood thinner) 5 milligrams (mg) 1 tablet 5 times per week and 1/2 tablet 2 days per week. Further review of the triage assessment revealed documentation the patient was alert and oriented, his pupils were equal and reactive, and a Glasgow Coma Scale (GCS - neurological assessment) assessment was 15 (opened eyes spontaneously, oriented, and obeyed commands). Record review revealed Physician #3 (ED physician) examined the patient at 0948. Review of Physician #3's history and physical note revealed, "...presents with Pain Head for 1 Hour(s). The Onset is Acute....Additional Symptoms or Pertinent History also involve None. Furthermore, the Patient/Family Denies no loc (loss of consciousness). Patient states exacerbating Factors that occur are coumadin....pt 'restless leg syndrome - but they never gave out on me like this'...." Further review of Physician #3's note revealed documentation the physician's review of all systems (including the neurological system) was negative (no abnormal findings). Review of Physician #3's documented examination revealed the patient was alert and oriented x 3, pupils were equal and reactive to light, and the GCS was 15. Record review revealed documentation at 1036 the laboratory notified RN #4 the patient's PT was 100.4 seconds (high - reference range = 9.3-11.5 seconds) and INR (international normalized ratio) was 10.92 (critical high - reference range for patients on oral anticoagulant therapy [Coumadin] = 2.0-3.0). Record review revealed RN #4 notified Physician #3 of the PT and INR results at 1038. Record review revealed at 1044 Physician #3 ordered a Type and Screen, transfusion of 2 units of FFP (fresh frozen plasma) and administration of Vitamin K (blood coagulation modifier) 10mg subcutaneously (order for route changed to intravenously at 1057). Review of Physician #3's notes at 1048 revealed, "dispo(sition):: trauma, excess anticoagulation, transfer to trauma center, call to (Hospital C)." Review of the CT results revealed, "IMPRESSION: RIGHT-SIDED PARA FALCINE SUBDURAL HEMATOMA WITH ASSOCIATED EFFACEMENT OF SULCI, ASSOCIATED SUBARACHNOID HEMORRHAGE AND EXTENSION ALONG THE TENT." Review of Physician #3's orders revealed, "(at 1057) cobra transfer to (Hospital C)....(at 1107) C-Spine (neck) X-Ray." Review of Physician #3's notes at 1059 revealed, "critical care:: pt at risk of death from intracranial bleed without immediate intervention." Review of Physician #3's notes at 1106 revealed, "dispo:: accepted by (Hospital C) 12/4/2010 neurosurgery (Physician #4 - Hospital C)." Review of RN #4's notes revealed, "12:57...Pt noted to have AMS (altered mental status) at this time. Charge nurse (RN #6) and (Physician #3) aware. Pt monitored closely....12:59...(Hospital C) contacted at this time. they have no icu beds at this time and will call back." Review of RN #6's notes at 1339 revealed, "Pt with decreased LOC, HR 159 bpm (beats per minute), (Physician #3) notified. Pt moved to ER bed 9 with plans to intubate." Review of Physician #3's notes at 1339 revealed, "await transfer:: pt less responsive, rhythm 150 wide complex, rsi (rapid sequence intubation)." Review of RN #6's notes at 1341 revealed, "(Hospital C) notified per (Emergency Services Coordinator - ESC #1) that pt's condition has deteriorated. No transport available from (Hospital C) at this time. Pt has bed assignment, unable to transport at this time. (Physician #3) aware." Review of Physician #3's notes at 1356 revealed, "1345 rapid sequence intubation:: pt less responsive." Review of RN #6's notes revealed, "13:50...(Hospital E's transport service) declines transport, none available. 13:52...(Hospital F's transport service) declines transport, none available." Review of RN #7's notes at 1352 revealed, "(RN #6) continues to attempt to establish critical care transport. Denied by (Hospital B's transport service)." Review of RN #6's notes revealed, "13:55...(Hospital B's transport service) declines transport, none available. 13:57...(Hospital G's transport service) declines ground transport, none available. Will verify air transport. Return call with more info(rmation)." Review of RN #7's note at 1404 revealed, "Per (ESC #1), transport denied per (Hospital G). (ESC #1) to try (Hospital G's) air crew." Review of RN #6's notes at 1405 revealed, "No air transport available per (Hospital G)." Review of RN #7's notes revealed, "...14:06...(ESC #1) to try (Hospital D's transport service) critical transport...". Review of Physician #3's notes at 1404 revealed, "(Hospital C) notified of deterioration." Review of RN #6's notes revealed, "14:12...(Hospital D's transport service) has no available Critical Care Transports available x approx(imately) 5-6 hrs". Review of RN #6's notes at 1516 revealed, "Per (Hospital C's) Transfer Center, (Hospital C) to arrange ground transport once available, at least 3 hours when they are available to leave." Review of RN #5's notes at 1533 revealed, "(Name) with (Hospital C's) Air Care states 'There will be no transport for approx 5-6 hours and then whether (weather) permitting after that time. I will put you on our list to be called back as soon as I know anything.'" Record review revealed at 1537 RN #4 notified Physician #3 the patient was "severely diaphoretic and jerking". Review of RN #6's notes at 1328 revealed, "Per (Hospital C), truck not available until after change of shift at 6 PM. Informed per (Hospital A's) staff that was acceptable d/t (due to) lack of transport for pt at this time." Review of RN #4's notes revealed, "1655...(Hospital C's) Air care called this rn and stated no traffic at this time. TO call back when truck is available. 17:07...(Hospital D's transport service), (Hospital F's transport service), (Hospital B's transport service), (Hospital E's transport service), (Hospital G's transport service) all contacted at this time per this am (RN) about transportation for pt. All trucks tied up on (and) the only one that we have a time for is for (Hospital D's transport service) with an ETA (estimated time of arrival) around 1800. Charge nurse and (Physician #3) made aware." Review of Physician #3's notes at 1711 revealed, "heroic efforts made to obtain prompt transport - all sources tied up." Review of RN #6's notes at 1737 revealed, "Report called to (Hospital C's) ER charge RN, notified that (Hospital D's transport service) would be available for transport after 1900. Informed of recent changes in HR, meds given." Review of RN #4's notes at 1850 revealed, "(Hospital D's transport service) called and said they should be here within the hour and will call when they are on the way." Review of RN #2's (night shift charge nurse) note at 1942 revealed, "PER (name), (Hospital D's transport service) CREW CHIEF. STATES TRUCK IS GROUNDED, UNABLE TO TRANSPORT PT. I RE-INITIATED ATTEMPTS TO FIND TRANSPORT. CALLED (Hospital B's transport service), PLACED ON WAIT LIST, ALSO NOTIFIED (Hospital C's) TRANSFER CENTER AND THEY WILL ALSO ATTEMPT TO FIND TRANSPORT." Review of RN #8's notes revealed, "19:57...REPORT GIVEN TO (name) WITH (Hospital C's) AIR CARE..... 22:13...Hospital C's) AIR CARE GROUND CREW HERE TO TRANSPORT. ... REPORT GIVEN TO (nurse's name) WITH (Hospital C). (Hospital C) CREW AT BEDSIDE AND IS TAKING OVER CARE... 22:48...REPORT CALLED TO (initials of staff) AT (Hospital C's) NEURO ICU." Record review revealed Hospital C's Critical Care Transport team arrived at Hospital A to transport the patient at 2213 (11 hours and 7 minutes after Hospital C's physician accepted the patient and 8 hours and 34 minutes after the patient's condition deteriorated). Record review revealed no documentation Hospital A's staff or physicians sought a bed assignment for the patient at another hospital when there was a delay in obtaining transport of the patient to Hospital C.

Review of variance/occurrence report #1 dated 12/04/2010 revealed an ER (emergency room) patient in ER 8 (room number in ER) had an event on 12/04/2010 (not timed) . Review of the report revealed a check mark beside "Transfer Concern". Review of the handwritten documentation signed by RN #2 revealed, "Other pertinent facts: I took over at 1900. Lifelink (Hospital D's Transport Service)called and enroute w/in (within) 1 hr (hour). 1942- phc (phone call) from (name of Lifelink staff) stated they would be unable to transported- they were 'grounded'. I then began calling again to re-establish transport. (Hospital B) put us on a waiting list. I then called (Hospital C) transfer center to inform them of same and they stated that the initial request had been cancelled but he would re-initiate request for transport. (Hospital C) Air Care called for report @ (at) 1957. ? (questioned) why pt had been here all day, etc. Stated they were on the way @ 1600 and were contacted to cancel. She repeated same when she arrived here....told her we are only aware of what's in notes and what has occurred since 7 pm." Review revealed documentation the report was reviewed and signed by the Vice President of Nursing and the Chief Operations Officer (COO - who was also the hospital's Risk Manager) on 12/07/2010 (3 days after the occurrence was reported. Review revealed documentation the report was reviewed and signed by the Quality Services Director on 12/16/2010 (12 days after the occurrence was reported). Review of the report revealed a typed attachment dated 12/10/2010 authored (but not signed) by RN #3, a house supervisor. Review of the attachment revealed, "On Friday, December 10, 2010, I was notified by (name), Director of Health Information that the son of (Patient #2) would be contacting me in relation to the notification of his father's expiring at our hospital on 12/04/2010 in our Emergency Department. The son wanted an explanation as to why the family had not been contacted when his father was admitted to our emergency department. In anticipation of his call I reviewed the Medical Record with (name of HIM Director). (Patient #2's son) did call me later that day and wanted to know why no one tried to notify the family of his father's admission to the E.R. I related that on the patient's demographic sheet there were two numbers of relatives to contact...I expressed my sincere concern for their not having received information about their father's admission to the E.R. and corrected their statement that he had expired in our E.R. I told him his father was transferred to (Hospital C) Neurology Unit and was alive at transport. I gave him the number to (Hospital C) (phone number) and he said he had already talked with them and they had his father in their morgue....I also shared this information with (Name), Emergency Room Director."

Review of variance/occurrence report #2 revealed a check mark beside ER Patient, Location of Variance - ED, occurrence date 12/04/2010 (not timed), recognized date 12/16/2010 (12 days after the occurrence), and signed as reviewed by the Quality Services Director on 12/20/2010 (16 days after the occurrence). Review of the report revealed handwritten notes by the Quality Services Director, dated 12/21/2010. Review of the notes revealed, "Talked c(with) (Physician's name), pt's PCP (primary care physician). He states son (name) had called him about concerns (and) he had sent him a copy of the ED record he had. Stated he was not aware pt had sons in (Name of State) until this occurred. States pt was a 'loner' but usually kept himself. States his wife was younger than he (and) died some time ago after a stroke....States son was told by son that deputy went to house at someone's request and numbers were on table...." Review of the report revealed an attachment with an e-mail from the CEO to the ED Director, Risk Manager/COO, Quality Services Director and Vice President of Nursing, dated 12/17/2010 at 1714. Review of the e-mail revealed., "We should look into this further, but it is curious to me that two hospitals were not able to reach the family. Anything we can learn for the next family will be helpful. Perhaps we should have a protocol, if the family is not able to be reached by phone. Could we have alerted law enforcement to visit the address of next of kin? An unfortunate situation for all." Further review of the attachment revealed an e-mail from the Risk Manager/COO to the CEO, ED Director, Quality Services Director and the Vice President of Nursing, dated 12/19/2010 at 1015. Review of the e-mail revealed, "...I now have the complaint that you sent on Friday. We can meet Monday afternoon. Please get with (name of Quality Services Director) to schedule a time."

Review of variance/occurrence report #3 revealed a check mark beside ER Patient, Location of Variance - ER, and occurrence date 12/16/2010 (not timed). Review of the report revealed a typed attachment dated 12/16/2010, authored by the ED Director (but not signed). Review of the attachment revealed, "Received message from (name of ED charge nurse) to call (Patient #2's son) regarding a complaint that his family was never notified that his father was a patient in the ED....He told me that he wanted to file a formal grievance and he would make sure that this never happened to anyone else....12/17/2010 (Patient #2's son) called me back this morning and inquired as to where we were in his formal grievance process. I informed him that I had documented his concerns and I would share with the appropriate staff in the facility that could assist him in investigating this situation and determining where any follow-up was necessary....12/28/2010 (Patient #2's son) called again today and said he had reviewed his father's medical record. He stated that it was 'criminal' that his father did not receive timely transport to (Hospital C) and it was 'criminal' that no additional efforts were made to contact the family....He also said that the chart noted 'heroic efforts' to transport patient. He stated that he wanted a face-to-face meeting so that 'heroic' could be defined because it was obvious that his definition was 'quite different' and that he was sure that nothing 'heroic' was done for this father...."

Interview on 03/08/2011 at 0930 with the Chief Operations Officer (COO), as the surveyors were walking down the hall for entrance conference revealed, "I wonder if you're here for the same complaint that we've just responded to The Joint Commission about....We've sent them our response and closed the case."

Telephone interview on 03/09/2011 at 1030 with RN #4 revealed the nurse was Patient #2's primary nurse during the dayshift (0700-1900) on 12/04/2010. Interview revealed, "He was alert and oriented. He wanted to sit on the side of the bed, but we wouldn't move him until after the CT scan." Interview revealed the CT scan showed the patient had "2 bleeds" in his head. Interview revealed, "After we found the bleeds, the physician wanted him transferred out because we don't have resources (for a patient with a head bleed)....I don't recall if any calls were made to other hospitals to request they take the patient there (other than Hospital C)....". Further interview revealed, "Before I left at 7 (PM), I made attempts to call back to all of the places we had called earlier in the day (for transport to Hospital C)....I called (Hospital E), (Hospital F), (Hospital C), (Hospital D), (Hospital B), and (Hospital G)....I asked if they had the ability and a truck to take the patient to (Hospital C). They all said 'none available' except for (Hospital D), who said maybe after 7 (PM)....Air Care (at Hospital C) and (Hospital B's) Air were both grounded....(Hospital D) called me back at about ten til seven and aid they would have a truck available within the hour, they thought, and they would call back when they were on the way here....The roads when I left at 7 (PM) were fine. I live about 20 minutes away (from the hospital). It had rained on and off throughout the day." Interview revealed the next day the nurse found out that the patient was transferred to Hospital C between 2200 and 2300 on 12/04/2010. Further interview revealed, "We were called in to administration for a meeting with the lawyer, not that long go (1-2 months ago). I met with (Director of the ED), (Chief Nursing Officer), and someone else (not sure who). They asked questions about trying to contact his family and about trying to get him transferred out....I don't recall any suggestions for improvement."

Interview on 03/08/2011 at 1645 with RN #6 revealed the nurse was the Charge Nurse in the DED from 0700 - 1900 on 12/04/2010. Interview revealed, "I spent a lot of time trying to call for transport for him....(Physician #3) called (Hospital C) first and got an accepting physician....(Hospital C's) physician accepted the patient, but didn't have a bed." Interview revealed after the patient's condition declined ("altered mental status and intubation") "we called back to (Hospital C) to see if they had a bed". Interview revealed the nurse reviewed the medical record with the surveyor. Interview revealed, "At 1341 I had (ESC #1) call (Hospital C) and tell them the patient's condition had deteriorated. (They said) we have a bed but no transport available....We don't have access to ALS transport at this hospital. (The local county EMS) is ALS, but they do EMS runs (from the field). (They) don't do hospital transports out of county....I called (Hospital E) at 1350 and (Hospital F) at 1352 from the code room. They had no transport available. I called (Hospital B) and they had no transport available....I called (Hospital G) and they declined ground transport. They said no trucks were available, but they would check air transport. I took a call from (Hospital G) at 1405 (and they said) no air transport was available....I called (Hospital D) at 1412 (and they said) no transport was available for 5 to 6 hours, they had trucks out. I told them we will take that, we couldn't find anything else....All of these calls were requests for transport of the patient from (Hospital A) to (Hospital C)....About this time I asked (Physician #3) about the possibility of calling another hospital for a bed. He felt he had a bed and there was no guarantee we could get anything better, so we should stay the course." Further interview revealed Hospital C called back at 1533 and said they would not have transport available for another 5-6 hours, but they would put them on a call list. Interview revealed Hospital C called back at 1628 and said they wouldn't have transport available until after the change of shift at 6 PM. Interview revealed, "I think (ESC #1) relayed the message to me and I told her to tell them 'That's fine, come on.'" Interview revealed Hospital C called back at 1655 and told (RN #4) there was no air transport available and they would call back when a truck was available. Interview revealed at that point RN #4 again contacted Hospitals D, F, B, E, and G and requested transport for the patient to Hospital C. Interview revealed all trucks were tied up except for Hospital D, who gave them an estimated time of arrival of 1800. Interview revealed, "At 1737 I called the charge nurse at (Hospital C). I told him the patient was critical and I was concerned he would die before we could ever get him there. I updated him on (the patient's) condition." Further interview revealed, "I don't recall any efforts to get another bed. I left at 7 (PM)....The next day I asked what time he left and they told me almost 11 PM. I couldn't believe it. (They) said (Hospital C) told them we had cancelled the transport request. I almost had a stroke....We (the ED staff involved) met with administration and gave information and interviews....We did a Root Cause Analysis (RCA) this morning (03/08/2011 - 3 months after the incident)....It had been scheduled on February 22nd, but was rescheduled."

Interview on 03/08/2011 at 1400 with the Director of Emergency Services revealed, "(On 12/04/2010) the snow was minimal here but more north of here, where our tertiary care centers are, except for (Hospital G) and (Hospital E), and they had no transport (to Hospital C) available....We met with all of the nurses to discuss the incident and try to figure out what happened. (The incident) happened on a weekend and the first thing (the following) Monday morning my staff met me at the door and said they wanted to change our T-RAC (Trauma Regional Advisory Committee) destination....(They said) we had this man that needed transport...we tried all day long...nobody would come get him...we felt so helpless." Interview revealed staff did not call the local county EMS, because "our EMS has never transported a patient from our hospital to another hospital". Interview revealed the Director and administrative staff reviewed the patient's medical record. Interview revealed, "We picked the chart apart to see if we did everything in our power to arrange transport....It looked like we did everything we could....We met with (Physician #3) and (Physician #2). The two of them have had discussions regarding EMTALA and the transfer. I was present with (the Chief Operating Officer) and (the Director of Quality). (Physician #2 - the Medical Director) was saying it might would have been helpful if he tried to obtain a bed in another facility also, even if transport wasn't available, so you could show you'd done everything possible. (Physician #3) said if we would have had 5 beds across the state we still had nobody to get him to a bed....(Physician #5) wasn't involved in these discussions....(Physician #2) is going to post an algorithm for transports, a quick reference....It should be done in a couple of weeks."

Interview on 03/09/2011 at 0930 with the Vice President of Nursing revealed, "We started our root cause analysis related to (Patient #2) yesterday (03/08/2011- 3 months, 4 days after the incident). The meeting scheduled before that was cancelled because (ED Medical Director - Physician #2) was not available. On February 16, 23 realized we had an opportunity for doing a root cause. This was prompted by an inquiry from The Joint Commission." Interview further revealed the hospital attorney had met with all of the involved staff to go through the event (date unknown). Interview revealed, "The physicians were not involved in these meetings. This information is considered attorney-client privilege." Interview further revealed, "Would it be helpful for us to put together a timeline of events?...The only actions we've done prior to yesterday's meeting was to develop a policy regarding contacting family members....After the RCA (Physician #2) developed a list of EMTALA Action Points."

Interview on 03/09/2011 at 1300 with the Quality Services Director revealed an "Investigation Timeline for (Patient #2)" had been developed immediately prior to the interview. Interview further revealed, "A variance report was written by (RN #2) on 12/04/2010. The variance report was routed to the nursing supervisor, then to (the COO) and the (VP of Nursing) and then to me....I doubt (that I investigated it). It was just a transfer delay. I don't investigate (transfer delays) unless its a complaint or something....I may have reviewed the chart, I don't recall." Interview further revealed, "After we met with the patient's son on January 12th (2011), we identified the issue of notification of kin. We didn't have a policy for notification of kin. We called several hospitals and (name of hospital alliance) and asked to put the topic on a list serve. I googled it and found an advisory group with recommendations. Our new policy for notification of kin was approved by the PI (performance improvement) counsel on February 9th. It was approved by the Med-Exec yesterday (03/08/2011) and will go to the full medical staff on March 15th for approval." Interview further revealed, "We had already done an intensive anlysis with our attorney, so we thought we had done what we needed to do....When we got the complaint from The Joint Commission (TJC) we thought we may need some additional information to send to them (TJC) and to see if there was anything else we could have done....(Physician #2) had already reviewed the case and did not identify any problems from a medical care stand point....Our response was sent to The Joint Commission on February 24th....We did the first RCA yesterday (03/08/2011)." Interview further revealed, "We identified two issues in our root cause meeting yesterday. The first was notification of kin, which we have fixed with our new policy. The second was the delay in transfer. This is really what the RCA focused on." Interview revealed the action items recommended from the RCA meeting included development of a transfer quick reference guide, re-education of providers and staff to EMTALA, re-education of providers and staff to transfer documentation, and reminding staff to follow the chain of command. Interview further revealed, "no EMTALA concerns were identified. We didn't' identify a problem with chain of command being followed either although I wish nursing would have called the nursing supervisor about the delay in transport". Interview revealed, "It (the Chain of Command) was followed, but we always re-enforce it. In hind sight, we wish they would have called someone else, the Nursing Supervisor. She could have then called the Administrator on call....I don't think we would have done the RCA without The Joint Commission complaint. We thought we had corrected this....The only other thing we could have done was we should have called another hospital to find another bed..."

Review of the "Investigation Timeline for (Patient #2)" (signed by the Quality Services Director) that was presented to the surveyor on 03/09/2011 at 1300 revealed:
? 12/04/2010: Variance report was written by (RN #2) about transfer delay concern and sent to Administration;
? 12/10/2010: ...received a call from (Patient #2's) son requesting to know why family was not contacted when patient was in (Hospital A) ED....a variance report was completed and sent to Administration by the Nursing Supervisor;
? 12/16/2010: ...received a message...to call (Patient #2's son) regarding a complaint that his family was never notified; 12/17/2010: ...(Patient #2's son) called...requested where we were in investigating his complaint;
? 12/28/2010: (Patient #2's) son called (ED Nurse Director) to let her know he had reviewed his father's record from primary physician and was upset that father did not receive timely transport to (Hospital C) and family was not contacted. Requested to meet with administration on 01/12/2011;
? 01/12/2011: (Patient #2's) two sons and his granddaughter came to (Hospital A) and met with (Risk Manager/COO, CNO and ED Nurse Director)....(CEO) was verbally made aware of the meeting;
? 01/13/2011: (COO and Quality Services Director) contacted (Name), the liability carrier claims representative, to report the situation. Work has begun on developing a formal Notification of Kin policy;
? 01/1320/11: The ED Medical Director peer reviewed (Patient #2's) record and was made aware of the family's concern; 01/28/2011: The hospital attorney met with all hospital staff involved in patient's care....an intensive analysis of the situation was done. The attorney reviewed a draft of the Notification of Kin policy and made suggestions;
? 02/07/2011: Communication was received from The Joint Commission that a complaint was received about a delay in transfer of (Patient #2) and requesting a response by 03/09/2011; The ED Nurse Director, Quality Services Director, CNO and COO began working on the response to The Joint Commission utilizing investigation information already completed;
? 02/16/2011: A root cause analysis session was scheduled for February 22, 2011 at 10AM;
? 02/21/2011: The root cause analysis session was cancelled for February 22, 2011 due to an unforeseen ED Physician scheduling emergency and high ED and inpatient census;
? 02/23/2011: The root cause analysis session was scheduled for March 8, 2011 at 10 AM. The Board of Trustee Executive Committee was made aware of the complaint;
? 02/24/2011: A response was submitted to the Joint Commission including analysis, conclusions and follow-up actions;
? 03/04/2011: A communication was received from the Joint Commission that the response had been reviewed, the Joint Commission would take no further action at this time, and the case had been closed;
? 03/08/2011: The scheduled root cause analysis was conducted to determine any further opportunities for improvement. The Joint Commissi

Based on review of hospital policy, closed medical record review, and staff and physician interviews the nursing staff failed to supervise and evaluate patient care by failing to follow the hospital's chain of command policy for 1 of 1 sampled delayed patient transfers to a tertiary care hospital for specialized care (Patient #2).

The findings include:

Review of the hospital's policy, "Chain of Command for Resolving Conflict/Clinical and/or Ethical Issues", revised 10/2009, revealed, "...Purpose: To provide patients, designated representatives, physicians and hospital employees an opportunity to participate in the consideration of conflict/clinical and/or ethical issues. Policy: Conflict/clinical and/or ethical issues may be identified by patients/designated representatives, employees and/or physicians. (Hospital A) recognizes and respects that: ...3. The hospital has a responsibility to involve the patient/designated representative in the mechanism determined to consider conflict/clinical and/or ethical issues. ...The process for addressing conflict/clinical and/or ethical issues will proceed as outlined in the Conflict/Clinical and/or Ethical Issues flowchart. ...The flowchart will enable the involved persons to work through a process that is geared toward obtaining background information on the situation, selecting all possible options and consequences of those options, and applying conflict/clinical and/or ethical principles to those options. Conflict/clinical and/or ethical issues will be addressed and responded to in a timely manner. All issues and action taken should be documented...." Review of the flowchart attached to the policy revealed, "Procedure: 1. Discuss conflict/clinical and/or ethical concern with the attending physician. 2. Notify department/nurse manager (in their absence, notify the Nursing Supervisor). 3. Notify the Risk Manager. 4. If unresolved, contact administrative advisor of the involved department. 5. Administration assesses concern and discusses with involved parties. 6. If unresolved, Administration/designee may call the Chief of Service...."

Closed record review for Patient #2 revealed a 75 year-old male that presented via EMS (Emergency Medical Services) to Hospital A's emergency department on Saturday 12/04/2010 at 0938 after he sustained a fall at home. Record review revealed the patient was not accompanied by any family members. Review of Registered Nurse (RN - day shift nurse) #4's nursing notes at 0938 revealed, "Pt (patient) to ed (emergency department) bed 4 per ems (emergency medical services) stretcher r/t (related to) fall this am. Pt states that he keeps falling because his 'legs keep giving out.' Pt has hx (history) of falls and restless leg syndrome." Record review revealed a triage assessment completed by RN #4 at 0951. Review of the triage assessment revealed the patient's vital signs were as follows: Temperature (T) - 98.3 degrees Fahrenheit, Pulse (P) - 103, Respirations - 24, Blood Pressure (BP) - 147/94, and Oxygen Saturation (Pulse Ox) - 97%. Review of the triage pain assessment revealed the patient rated his pain to be a 7-8 (on a scale of 0 - 10, with 10 being the most severe pain). Review of the triage assessment revealed, "Chief Complaint - Falling....Past Medical Histor(y) - COPD (chronic obstructive pulmonary disease), CAD (coronary arterial disease), CHF (congestive heart failure), HTN (hypertension), Renal..." Review of the triage assessment revealed documentation the patient's home medications included Coumadin (blood thinner) 5 milligrams (mg) 1 tablet 5 times per week and 1/2 tablet 2 days per week. Further review of the triage assessment revealed documentation the patient was alert and oriented, his pupils were equal and reactive, and a Glasgow Coma Scale (GCS - neurological assessment) assessment was 15 (opened eyes spontaneously, oriented, and obeyed commands). Record review revealed Physician #3 (ED physician) examined the patient at 0948. Review of Physician #3's history and physical note revealed, "...presents with Pain Head for 1 Hour(s). The Onset is Acute....Additional Symptoms or Pertinent History also involve None. Furthermore, the Patient/Family Denies no loc (loss of consciousness). Patient states exacerbating Factors that occur are coumadin....pt 'restless leg syndrome - but they never gave out on me like this'...." Further review of Physician #3's note revealed documentation the physician's review of all systems (including the neurological system) was negative (no abnormal findings). Review of Physician #3's documented examination revealed the patient was alert and oriented x 3, pupils were equal and reactive to light, and the GCS was 15. Record review revealed documentation at 1036 the laboratory notified RN #4 the patient's PT was 100.4 seconds (high - reference range = 9.3-11.5 seconds) and INR (international normalized ratio) was 10.92 (critical high - reference range for patients on oral anticoagulant therapy [Coumadin] = 2.0-3.0). Record review revealed at 1044 Physician #3 ordered a Type and Screen, transfusion of 2 units of FFP (fresh frozen plasma) and administration of Vitamin K (blood coagulation modifier) 10mg subcutaneously (order for route changed to intravenously at 1057). Review of Physician #3's notes at 1048 revealed, "dispo(sition):: trauma, excess anticoagulation, transfer to trauma center, call to (Hospital C)." Review of the CT results revealed, "IMPRESSION: RIGHT-SIDED PARA FALCINE SUBDURAL HEMATOMA WITH ASSOCIATED EFFACEMENT OF SULCI, ASSOCIATED SUBARACHNOID HEMORRHAGE AND EXTENSION ALONG THE TENT." Review of Physician #3's orders revealed, "(at 1057) cobra transfer to (Hospital C)....(at 1107) C-Spine (neck) X-Ray." Review of Physician #3's notes at 1059 revealed, "critical care:: pt at risk of death from intracranial bleed without immediate intervention." Review of Physician #3's notes at 1106 revealed, "dispo:: accepted by (Hospital C) 12/4/2010 neurosurgery (Physician #4 - Hospital C)." Review of RN #4's notes revealed, "12:57...Pt noted to have AMS (altered mental status) at this time...12:59...(Hospital C) contacted at this time. they have no icu beds at this time and will call back." Review of RN #6's (charge nurse's) notes at 1339 revealed, "Pt with decreased LOC, HR 159 bpm (beats per minute), (Physician #3) notified. Pt moved to ER bed 9 with plans to intubate." Review of Physician #3's notes at 1339 revealed, "await transfer:: pt less responsive, rhythm 150 wide complex, rsi (rapid sequence intubation)." Review of RN #6's notes at 1341 revealed, "(Hospital C) notified per (Emergency Services Coordinator - ESC #1) that pt's condition has deteriorated. No transport available from (Hospital C) at this time. Pt has bed assignment, unable to transport at this time. (Physician #3) aware." Review of Physician #3's notes at 1356 revealed, "1345 rapid sequence intubation:: pt less responsive..." Review of RN #6's notes revealed, "13:50...(Hospital E's transport service) declines transport, none available. 13:52...(Hospital F's transport service) declines transport, none available." Review of RN #7's notes at 1352 revealed, "(RN #6) continues to attempt to establish critical care transport. Denied by (Hospital B's transport service)." Review of RN #6's notes revealed, "13:55...(Hospital B's transport service) declines transport, none available. 13:57...(Hospital G's transport service) declines ground transport, none available. Will verify air transport. Return call with more info(rmation)." Review of RN #7's note at 1404 revealed, "Per (ESC #1), transport denied per (Hospital G). (ESC #1) to try (Hospital G's) air crew." Review of RN #6's notes at 1405 revealed, "No air transport available per (Hospital G)." Review of RN #7's notes revealed, "...14:06...(ESC #1) to try (Hospital D's transport service) critical transport...". Review of Physician #3's notes at 1404 revealed, "(Hospital C) notified of deterioration." Review of RN #6's notes revealed, "14:12...(Hospital D's transport service) has no available Critical Care Transports available x approx(imately) 5-6 hrs". Review of RN #6's notes at 1516 revealed, "Per (Hospital C's) Transfer Center, (Hospital C) to arrange ground transport once available, at least 3 hours when they are available to leave." Review of RN #5's notes at 1533 revealed, "(Name) with (Hospital C's) Air Care states 'There will be no transport for approx 5-6 hours and then whether (weather) permitting after that time. I will put you on our list to be called back as soon as I know anything.'" Record review revealed at 1537 RN #4 notified Physician #3 the patient was "severely diaphoretic and jerking". Review of RN #6's notes at 1328 revealed, "Per (Hospital C), truck not available until after change of shift at 6 PM. Informed per (Hospital A's) staff that was acceptable d/t (due to) lack of transport for pt at this time." Review of RN #4's notes revealed, "1655...(Hospital C's) Air care called this rn and stated no traffic at this time. TO call back when truck is available. 17:07...(Hospital D's transport service), (Hospital F's transport service), (Hospital B's transport service), (Hospital E's transport service), (Hospital G's transport service) all contacted at this time per this am (RN) about transportation for pt. All trucks tied up on (and) the only one that we have a time for is for (Hospital D's transport service) with an ETA (estimated time of arrival) around 1800. Charge nurse and (Physician #3) made aware." Review of Physician #3's notes at 1711 revealed, "heroic efforts made to obtain prompt transport - all sources tied up." Review of RN #6's notes at 1737 revealed, "Report called to (Hospital C's) ER charge RN, notified that (Hospital D's transport service) would be available for transport after 1900. Informed of recent changes in HR, meds given." Review of RN #4's notes at 1850 revealed, "(Hospital D's transport service) called and said they should be here within the hour and will call when they are on the way." Review of RN #2's (night shift charge nurse) note at 1942 revealed, "PER (name), (Hospital D's transport service) CREW CHIEF. STATES TRUCK IS GROUNDED, UNABLE TO TRANSPORT PT. I RE-INITIATED ATTEMPTS TO FIND TRANSPORT. CALLED (Hospital B's transport service), PLACED ON WAIT LIST, ALSO NOTIFIED (Hospital C's) TRANSFER CENTER AND THEY WILL ALSO ATTEMPT TO FIND TRANSPORT." Review of RN #8's notes revealed, "19:57...REPORT GIVEN TO (name) WITH (Hospital C's) AIR CARE..... 22:13...Hospital C's) AIR CARE GROUND CREW HERE TO TRANSPORT. ... REPORT GIVEN TO (nurse's name) WITH (Hospital C). (Hospital C) CREW AT BEDSIDE AND IS TAKING OVER CARE... 22:48...REPORT CALLED TO (initials of staff) AT (Hospital C's) NEURO ICU." Record review revealed Hospital C's Critical Care Transport team arrived at Hospital A to transport the patient at 2213 (11 hours and 7 minutes after Hospital C's physician accepted the patient and 8 hours and 34 minutes after the patient's condition deteriorated). Record review revealed no documentation Hospital A's staff or physicians sought a bed assignment for the patient at another hospital when there was a delay in obtaining transport of the patient to Hospital C. Record review revealed no documentation the ED staff notified the nursing supervisor or the administrator on call of the delay in the transfer of Patient #2.

Telephone interview on 03/09/2011 at 1030 with RN #4 revealed the nurse was Patient #2's primary nurse during the dayshift (0700-1900) on 12/04/2010. Interview revealed EMS brought the patient to the ED on the morning of 12/04/2010 after the patient fell at home. Interview revealed, "He was alert and oriented. He wanted to sit on the side of the bed, but we wouldn't move him until after the CT scan." Interview revealed the CT scan showed the patient had "2 bleeds" in his head. Interview revealed, "After we found the bleeds, the physician wanted him transferred out because we don't have resources (for a patient with a head bleed)....I don't recall if any calls were made to other hospitals to request they take the patient there (other than Hospital C)....I was in his room most of the time." Interview revealed after the CT scan was completed, the patient began to ask repetitive questions and had a change in his mental status. Interview revealed the lab results showed the patient's INR was high, for which the physician ordered FPS transfusions. Interview revealed, "After the first unit (of FPS), his mental status changed more. He wasn't responding as much as he was (before). (His) vital signs changed and he became diaphoretic....We moved him from Bed 4 to Bed 9 due to his severe change in condition. (He was) not even talking to us anymore....Any patient we suspect might need incubation or defibrillation we move to Room 9....(I) gave the second unit (of FPS). Everything just went down hill....Calls were made to find transport after we got to Room 9...(Physician #3) was with the patient the majority of the day, especially after we moved him to Room 9." Further interview revealed, "Before I left at 7 (PM), I made attempts to call back to all of the places we had called earlier in the day (for transport to Hospital C)....I called (Hospital E), (Hospital F), (Hospital C), (Hospital D), (Hospital B), and (Hospital G)....I asked if they had the ability and a truck to take the patient to (Hospital C). They all said 'none available' except for (Hospital D), who said maybe after 7 (PM)....Air Care (at Hospital C) and (Hospital B's) Air were both grounded....(Hospital D) called me back at about ten til seven and aid they would have a truck available within the hour, they thought, and they would call back when they were on the way here....The roads when I left at 7 (PM) were fine. I live about 20 minutes away (from the hospital). It had rained on and off throughout the day." Interview revealed the next day the nurse found out that the patient was transferred to Hospital C between 2200 and 2300 on 12/04/2010.

Interview on 03/08/2011 at 1645 with RN #6 revealed the nurse was the Charge Nurse in the DED from 0700 - 1900 on 12/04/2010. Interview revealed, "I spent a lot of time trying to call for transport for him....(Physician #3) called (Hospital C) first and got an accepting physician....(Hospital C's) physician accepted the patient, but didn't have a bed." Interview revealed after the patient's condition declined ("altered mental status and intubation") "we called back to (Hospital C) to see if they had a bed". Interview revealed the nurse reviewed the medical record with the surveyor. Interview revealed, "At 1341 I had (ESC #1) call (Hospital C) and tell them the patient's condition had deteriorated. (They said) we have a bed but no transport available....We don't have access to ALS transport at this hospital. (The local county EMS) is ALS, but they do EMS runs (from the field). (They) don't do hospital transports out of county....I called (Hospital E) at 1350 and (Hospital F) at 1352 from the code room. They had no transport available. I called (Hospital B) and they had no transport available....I called (Hospital G) and they declined ground transport. They said no trucks were available, but they would check air transport. I took a call from (Hospital G) at 1405 (and they said) no air transport was available....I called (Hospital D) at 1412 (and they said) no transport was available for 5 to 6 hours, they had trucks out. I told them we will take that, we couldn't find anything else....All of these calls were requests for transport of the patient from (Hospital A) to (Hospital C)....About this time I asked (Physician #3) about the possibility of calling another hospital for a bed. He felt he had a bed and there was no guarantee we could get anything better, so we should stay the course." Further interview revealed Hospital C called back at 1533 and said they would not have transport available for another 5-6 hours, but they would put them on a call list. Interview revealed Hospital C called back at 1628 and said they wouldn't have transport available until after the change of shift at 6 PM. Interview revealed, "I think (ESC #1) relayed the message to me and I told her to tell them 'That's fine, come on.'" Interview revealed Hospital C called back at 1655 and told (RN #4) there was no air transport available and they would call back when a truck was available. Interview revealed at that point RN #4 again contacted Hospitals D, F, B, E, and G and requested transport for the patient to Hospital C. Interview revealed all trucks were tied up except for Hospital D, who gave them an estimated time of arrival of 1800. Interview revealed, "At 1737 I called the charge nurse at (Hospital C). I told him the patient was critical and I was concerned he would die before we could ever get him there. I updated him on (the patient's) condition." Further interview revealed, "I don't recall any efforts to get another bed. I left at 7 (PM)....The next day I asked what time he left and they told me almost 11 PM. I couldn't believe it. (They) said (Hospital C) told them we had cancelled the transport request. I almost had a stroke...."

Telephone interview on 03/09/2011 at 0930 with RN #8 revealed the nurse was Patient #2's primary nurse in the DED from 1900 on 12/04/2010 until the patient was transferred. Interview revealed, "(When I came on at 1900 the patient was) in the code room, intubated,...waiting for transfer. Days had called for transfer....(Hospital D) had told days they were coming soon after 7 (PM)....(RN #7) called (Hospital C) at about 8 (PM) and they said they could come get him. They thought transportation had already been found. (Hospital C) got a truck there at about 10:30 (PM)....I don't think anyone called another hospital to get a bed for him. That wasn't the issue. He had a bed, it was just getting him there. Our main goal was to get him out of our ED to (Hospital C)."

Interview on 03/09/2011 at 0945 with RN #2 revealed the nurse was the ED Charge Nurse on the night shift (1900-0700) of 12/04/2011. Interview revealed, "When I got there they told me they had contacted several facilities for transport. Ground (transport) was backed up from all facilities. Air (transport) was grounded. The plan at that time was (Hospital D) was supposed to arrive at about 8 (PM). The roads here were fine. (Name of staff from Hospital D's transport service) called and said they couldn't do the transport because the trucks were grounded due to the weather....I called (Hospital B)...they had nothing available. I think I called (Hospital F), but I'm not sure. Then I called (Hospital C)....They said they still had us on (the) list and could be there within the next couple of hours. I think they got there around 10 (PM) or so....(Hospital B) had to come to get a patient for their hospital, I think it was after (Patient #2) left. They facilitate transfers to their hospital before they do third party transfers....We did not call another hospital to see if they could accept him as a transfer because he had a bed at (Hospital C) and when I spoke to them they said they would be here in a couple of hours."

Interview on 03/08/2011 at 1400 with the Director of Emergency Services revealed, "(On 12/04/2010) the snow was minimal here but more north of here, where our tertiary care centers are, except for (Hospital G) and (Hospital E), and they had no transport (to Hospital C) available....We met with all of the nurses to discuss the incident and try to figure out what happened. (The incident) happened on a weekend and the first thing (the following) Monday morning my staff met me at the door and said they wanted to change our T-RAC (Trauma Regional Advisory Committee) destination....(They said) we had this man that needed transport...we tried all day long...nobody would come get him...we felt so helpless." Interview confirmed there was no documentation Hospital A's staff or physicians sought a bed assignment for the patient at another hospital when there was a delay in obtaining transport of the patient to Hospital C. Further interview with the Director of the ED on 03/09/2011 at 1115 revealed T-RAC was "a State program that designates trauma centers for our use". Interview revealed, "Our T-RAC hospital is (Hospital C), which means we are on an auto-accept policy (with them). They will always accept our patients....They have all specialty services....That doesn't mean we can't call the other hospitals (to request patient transfer)....We usually start with (Hospital C) since we are in their RAC." Further interview revealed, "Staff did not call me (on 12/04/2010) and report concerns with (Patient #2). (RN #9) was the house (nursing) supervisor (on 12/04/2010). I don't know if they called her or not."

Interview on 03/09/2011 at 1230 with RN #9 revealed the nurse was the House Supervisor during the dayshift of 12/04/2010. Interview revealed, "The ED is a self-sufficient department. The only time we get called is if they have a code or if they have a TNKase (Tenecteplase- thrombolytic -dissolves clots)...That's the only time we get involved. I make rounds in the ED in the morning and afternoon....No concerns from the ED were brought to my attention (on 12/04/2010)....I think that was the day we had snow or ice, but I don't remember....On afternoon rounds I noted (Patient #2) was waiting for transfer....I don't have any part of assisting with transfers from the ED."

Interview on 03/09/2011 at 1500 with the hospital's Chief Executive Officer (CEO) revealed the CEO was the administrator on call on 12/04/2010. Interview revealed, "I was not called about the delay for (Patient #2's transfer). I could see where they could have called the Administrator on Call in this situation. Our chain of command policy was not followed."

NC00071035

Based on review of hospital policies, closed medical records, and variance/occurrence reports, staff interviews, and review of hospital documents, the hospital failed to analyze the cause of an adverse patient event for 1 of 2 adverse patient events reviewed (Patient #2).

The findings include:

Review of the hospital's policy, "Management of Sentinel Events", revised 10/30/2006, revealed, "Purpose: To provide a method for identification, reporting, intensive analysis and prevention of sentinel events, and adverse outcomes in patient care. Policy: Administrative Staff, Medical staff, Risk Management Staff and Quality Services Staff will work collaboratively to review sentinel events and adverse outcomes in patient care. Root causes will be identified and appropriate action taken to prevent reoccurrence and to correct system weakness and failures. Definition: A sentinel event is defined as an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. ...The phrase 'or the risk thereof' includes any process variation for which a reoccurrence would carry a significant chance of a serious adverse outcome....Procedure: 1. Report sentinel event to Risk Manager at (phone number) immediately. 2. The Risk Manager, in conjunction with the Quality Services Director, will conduct the initial investigation of the event. Investigation will begin immediately upon notification. 3. The Risk Manager/Quality Services Director will evaluate the reported event. If the event meets criteria for intensive analysis, the Risk Manager/Quality Services Director will notify the administrator, legal counsel, President of the Medical Staff, and the Chief of the appropriate service. Following intensive analysis, a determination will be made to decide if a sentinel event has occurred and/or if conducting a root cause analysis is appropriate. ...Points to Remember: 1. An employee or medical staff member who witnesses or becomes aware of a patient care event which may be a sentinel event should immediately report the event to Risk Management. If Risk Management is not immediately available, notify the nursing supervisor who will contact the Risk Manager and/or the Quality Services Director. In their absence, notify the administrator on call. 2. The Risk Manager will contact legal counsel to proceed with the investigation...."

Closed record review for Patient #2 revealed a 75 year-old male that presented via EMS (Emergency Medical Services) to Hospital A's emergency department on 12/04/2010 at 0938 after he sustained a fall at home. Record review revealed the patient was not accompanied by any family members. Review of Registered Nurse (RN - day shift nurse) #4's nursing notes at 0938 revealed, "Pt (patient) to ed (emergency department) bed 4 per ems (emergency medical services) stretcher r/t (related to) fall this am. Pt states that he keeps falling because his 'legs keep giving out.' Pt has hx (history) of falls and restless leg syndrome." Record review revealed a triage assessment completed by RN #4 at 0951. Review of the triage assessment revealed the patient's vital signs were as follows: Temperature (T) - 98.3 degrees Fahrenheit, Pulse (P) - 103, Respirations - 24, Blood Pressure (BP) - 147/94, and Oxygen Saturation (Pulse Ox) - 97%. Review of the triage pain assessment revealed the patient rated his pain to be a 7-8 (on a scale of 0 - 10, with 10 being the most severe pain). Review of the triage assessment revealed, "Chief Complaint - Falling....Past Medical Histor(y) - COPD (chronic obstructive pulmonary disease), CAD (coronary arterial disease), CHF (congestive heart failure), HTN (hypertension), Renal....Additional: Hyercholesterolemia, Afib? (atrial fibrillation), prostate cancer; Foley Indwelling (urinary catheter)...." Review of the triage assessment revealed documentation the patient's home medications included Coumadin (blood thinner) 5 milligrams (mg) 1 tablet 5 times per week and 1/2 tablet 2 days per week. Further review of the triage assessment revealed documentation the patient was alert and oriented, his pupils were equal and reactive, and a Glasgow Coma Scale (GCS - neurological assessment) assessment was 15 (opened eyes spontaneously, oriented, and obeyed commands). Record review revealed Physician #3 (ED physician) examined the patient at 0948. Review of Physician #3's history and physical note revealed, "...presents with Pain Head for 1 Hour(s). The Onset is Acute....Additional Symptoms or Pertinent History also involve None. Furthermore, the Patient/Family Denies no loc (loss of consciousness). Patient states exacerbating Factors that occur are coumadin....pt 'restless leg syndrome - but they never gave out on me like this'...." Further review of Physician #3's note revealed documentation the physician's review of all systems (including the neurological system) was negative (no abnormal findings). Review of Physician #3's documented examination revealed the patient was alert and oriented x 3, pupils were equal and reactive to light, and the GCS was 15. Record review revealed documentation at 1036 the laboratory notified RN #4 the patient's PT was 100.4 seconds (high - reference range = 9.3-11.5 seconds) and INR (international normalized ratio) was 10.92 (critical high - reference range for patients on oral anticoagulant therapy [Coumadin] = 2.0-3.0). Record review revealed RN #4 notified Physician #3 of the PT and INR results at 1038. Record review revealed at 1044 Physician #3 ordered a Type and Screen, transfusion of 2 units of FFP (fresh frozen plasma) and administration of Vitamin K (blood coagulation modifier) 10mg subcutaneously (order for route changed to intravenously at 1057). Review of Physician #3's notes at 1048 revealed, "dispo(sition):: trauma, excess anticoagulation, transfer to trauma center, call to (Hospital C)." Review of the CT results revealed, "IMPRESSION: RIGHT-SIDED PARA FALCINE SUBDURAL HEMATOMA WITH ASSOCIATED EFFACEMENT OF SULCI, ASSOCIATED SUBARACHNOID HEMORRHAGE AND EXTENSION ALONG THE TENT." Review of Physician #3's orders revealed, "(at 1057) cobra transfer to (Hospital C)....(at 1107) C-Spine (neck) X-Ray." Review of Physician #3's notes at 1059 revealed, "critical care:: pt at risk of death from intracranial bleed without immediate intervention." Review of Physician #3's notes at 1106 revealed, "dispo:: accepted by (Hospital C) 12/4/2010 neurosurgery (Physician #4 - Hospital C)." Review of RN #4's notes revealed, "12:57...Pt noted to have AMS (altered mental status) at this time. Charge nurse (RN #6) and (Physician #3) aware. Pt monitored closely....12:59...(Hospital C) contacted at this time. they have no icu beds at this time and will call back." Review of RN #6's notes at 1339 revealed, "Pt with decreased LOC, HR 159 bpm (beats per minute), (Physician #3) notified. Pt moved to ER bed 9 with plans to intubate." Review of Physician #3's notes at 1339 revealed, "await transfer:: pt less responsive, rhythm 150 wide complex, rsi (rapid sequence intubation)." Review of RN #6's notes at 1341 revealed, "(Hospital C) notified per (Emergency Services Coordinator - ESC #1) that pt's condition has deteriorated. No transport available from (Hospital C) at this time. Pt has bed assignment, unable to transport at this time. (Physician #3) aware." Review of Physician #3's notes at 1356 revealed, "1345 rapid sequence intubation:: pt less responsive." Review of RN #6's notes revealed, "13:50...(Hospital E's transport service) declines transport, none available. 13:52...(Hospital F's transport service) declines transport, none available." Review of RN #7's notes at 1352 revealed, "(RN #6) continues to attempt to establish critical care transport. Denied by (Hospital B's transport service)." Review of RN #6's notes revealed, "13:55...(Hospital B's transport service) declines transport, none available. 13:57...(Hospital G's transport service) declines ground transport, none available. Will verify air transport. Return call with more info(rmation)." Review of RN #7's note at 1404 revealed, "Per (ESC #1), transport

Based on review of hospital policy, closed medical record review, and staff and physician interviews the nursing staff failed to supervise and evaluate patient care by failing to follow the hospital's chain of command policy for 1 of 1 sampled delayed patient transfers to a tertiary care hospital for specialized care (Patient #2).

The findings include:

Review of the hospital's policy, "Chain of Command for Resolving Conflict/Clinical and/or Ethical Issues", revised 10/2009, revealed, "...Purpose: To provide patients, designated representatives, physicians and hospital employees an opportunity to participate in the consideration of conflict/clinical and/or ethical issues. Policy: Conflict/clinical and/or ethical issues may be identified by patients/designated representatives, employees and/or physicians. (Hospital A) recognizes and respects that: ...3. The hospital has a responsibility to involve the patient/designated representative in the mechanism determined to consider conflict/clinical and/or ethical issues. ...The process for addressing conflict/clinical and/or ethical issues will proceed as outlined in the Conflict/Clinical and/or Ethical Issues flowchart. ...The flowchart will enable the involved persons to work through a process that is geared toward obtaining background information on the situation, selecting all possible options and consequences of those options, and applying conflict/clinical and/or ethical principles to those options. Conflict/clinical and/or ethical issues will be addressed and responded to in a timely manner. All issues and action taken should be documented...." Review of the flowchart attached to the policy revealed, "Procedure: 1. Discuss conflict/clinical and/or ethical concern with the attending physician. 2. Notify department/nurse manager (in their absence, notify the Nursing Supervisor). 3. Notify the Risk Manager. 4. If unresolved, contact administrative advisor of the involved department. 5. Administration assesses concern and discusses with involved parties. 6. If unresolved, Administration/designee may call the Chief of Service...."

Closed record review for Patient #2 revealed a 75 year-old male that presented via EMS (Emergency Medical Services) to Hospital A's emergency department on Saturday 12/04/2010 at 0938 after he sustained a fall at home. Record review revealed the patient was not accompanied by any family members. Review of Registered Nurse (RN - day shift nurse) #4's nursing notes at 0938 revealed, "Pt (patient) to ed (emergency department) bed 4 per ems (emergency medical services) stretcher r/t (related to) fall this am. Pt states that he keeps falling because his 'legs keep giving out.' Pt has hx (history) of falls and restless leg syndrome." Record review revealed a triage assessment completed by RN #4 at 0951. Review of the triage assessment revealed the patient's vital signs were as follows: Temperature (T) - 98.3 degrees Fahrenheit, Pulse (P) - 103, Respirations - 24, Blood Pressure (BP) - 147/94, and Oxygen Saturation (Pulse Ox) - 97%. Review of the triage pain assessment revealed the patient rated his pain to be a 7-8 (on a scale of 0 - 10, with 10 being the most severe pain). Review of the triage assessment revealed, "Chief Complaint - Falling....Past Medical Histor(y) - COPD (chronic obstructive pulmonary disease), CAD (coronary arterial disease), CHF (congestive heart failure), HTN (hypertension), Renal..." Review of the triage assessment revealed documentation the patient's home medications included Coumadin (blood thinner) 5 milligrams (mg) 1 tablet 5 times per week and 1/2 tablet 2 days per week. Further review of the triage assessment revealed documentation the patient was alert and oriented, his pupils were equal and reactive, and a Glasgow Coma Scale (GCS - neurological assessment) assessment was 15 (opened eyes spontaneously, oriented, and obeyed commands). Record review revealed Physician #3 (ED physician) examined the patient at 0948. Review of Physician #3's history and physical note revealed, "...presents with Pain Head for 1 Hour(s). The Onset is Acute....Additional Symptoms or Pertinent History also involve None. Furthermore, the Patient/Family Denies no loc (loss of consciousness). Patient states exacerbating Factors that occur are coumadin....pt 'restless leg syndrome - but they never gave out on me like this'...." Further review of Physician #3's note revealed documentation the physician's review of all systems (including the neurological system) was negative (no abnormal findings). Review of Physician #3's documented examination revealed the patient was alert and oriented x 3, pupils were equal and reactive to light, and the GCS was 15. Record review revealed documentation at 1036 the laboratory notified RN #4 the patient's PT was 100.4 seconds (high - reference range = 9.3-11.5 seconds) and INR (international normalized ratio) was 10.92 (critical high - reference range for patients on oral anticoagulant therapy [Coumadin] = 2.0-3.0). Record review revealed at 1044 Physician #3 ordered a Type and Screen, transfusion of 2 units of FFP (fresh frozen plasma) and administration of Vitamin K (blood coagulation modifier) 10mg subcutaneously (order for route changed to intravenously at 1057). Review of Physician #3's notes at 1048 revealed, "dispo(sition):: trauma, excess anticoagulation, transfer to trauma center, call to (Hospital C)." Review of the CT results revealed, "IMPRESSION: RIGHT-SIDED PARA FALCINE SUBDURAL HEMATOMA WITH ASSOCIATED EFFACEMENT OF SULCI, ASSOCIATED SUBARACHNOID HEMORRHAGE AND EXTENSION ALONG THE TENT." Review of Physician #3's orders revealed, "(at 1057) cobra transfer to (Hospital C)....(at 1107) C-Spine (neck) X-Ray." Review of Physician #3's notes at 1059 revealed, "critical care:: pt at risk of death from intracranial bleed without immediate intervention." Review of Physician #3's notes at 1106 revealed, "dispo:: accepted by (Hospital C) 12/4/2010 neurosurgery (Physician #4 - Hospital C)." Review of RN #4's notes revealed, "12:57...Pt noted to have AMS (altered mental status) at this time...12:59...(Hospital C) contacted at this time. they have no icu beds at this time and will call back." Review of RN #6's (charge nurse's) notes at 1339 revealed, "Pt with decreased LOC, HR 159 bpm (beats per minute), (Physician #3) notified. Pt moved to ER bed 9 with plans to intubate." Review of Physician #3's notes at 1339 revealed, "await transfer:: pt less responsive, rhythm 150 wide complex, rsi (rapid sequence intubation)." Review of RN #6's notes at 1341 revealed, "(Hospital C) notified per (Emergency Services Coordinator - ESC #1) that pt's condition has deteriorated. No transport available from (Hospital C) at this time. Pt has bed assignment, unable to transport at this time. (Physician #3) aware." Review of Physician #3's notes at 1356 revealed, "1345 rapid sequence intubation:: pt less responsive..." Review of RN #6's notes revealed, "13:50...(Hospital E's transport service) declines transport, none available. 13:52...(Hospital F's transport service) declines transport, none available." Review of RN #7's notes at 1352 revealed, "(RN #6) continues to attempt to establish critical care transport. Denied by (Hospital B's transport service)." Review of RN #6's notes revealed, "13:55...(Hospital B's transport service) declines transport, none available. 13:57...(Hospital G's transport service) declines ground transport, none available. Will verify air transport. Return call with more info(rmation)." Review of RN #7's note at 1404 revealed, "Per (ESC #1), transport denied per (Hospital G). (ESC #1) to try (Hospital G's) air crew." Review of RN #6's notes at 1405 revealed, "No air transport available per (Hospital G)." Review of RN #7's notes revealed, "...14:06...(ESC #1) to try (Hospital D's transport service) critical transport...". Review of Physician #3's notes at 1404 revealed, "(Hospital C) notified of deterioration." Review of RN #6's notes revealed, "14:12...(Hospital D's transport service) has no available Critical Care Transports available x appr