HospitalInspections.org

Based on interview and record review, the hospital failed to comply with the regulatory requirements for EMTALA for one of 30 sampled patients (Patient 1) when Hospital 1 requested to transfer Patient (Pt) 1 to Hospital 2 and Hospital 2 did not approve the transfer. Pt 1 was diagnosed with acute appendicitis (a serious medical condition in which the appendix [a tube-shaped sac attached to and opening into the lower end of the large intestine] becomes inflamed and painful) and required surgical services that Hospital 1 did not have the capability to provide. Hospital 2 claimed to be at capacity but had surgeons and operating room availability on 2/28/23, the day of the request to transfer. Hospital 2 did not follow its policy and procedure related to establishing whether the hospital had the capability to provide the services requested by Hospital 1.

These failures resulted in the delay of providing the surgical services needed to address Pt 1's appendicitis which had the potential to result in a worsening condition. Pt 1 was transported nearly 6 hours to Hospital 4 which was located out of the area. Hospital 1 was located less than 1 hour from hospital 2. (Refer to A 2411)

The cumulative effect of this systemic failure resulted in the hospital's inability to ensure the provision of quality healthcare in a safe and responsible manner.

Based on interview and record review Hospital 2 failed to comply with Recipient Hospital Responsibilities for one of seven sampled patients (Patient 1) when Hospital 1 requested to transfer Patient (Pt) 1 to Hospital 2 and Hospital 2 did not approve the transfer. Pt 1 was diagnosed with acute appendicitis (a serious medical condition in which the appendix [a tube-shaped sac attached to and opening into the lower end of the large intestine] becomes inflamed and painful) and required surgical services Hospital 1 did not have the capability to provide. Hospital 2 claimed to be at capacity but had surgeons and OR availability on 2/28/23, the day of the request to transfer. Hospital 2 did not follow its policy and procedure related to establishing whether the hospital had the capability to provide the services requested by Hospital 1.

These failures resulted in the delay of providing the surgical services needed to address Pt 1's appendicitis which could have resulted to a worsening condition. Pt 1 was transported nearly 6 hours to Hospital 4 which was located out of the area. Hospital 1 was located less than 1 hour from hospital 2.

Findings:

During an interview on 5/1/23, at 8:33 a.m., with the Director of Surgical Education (DSE) for Hospital 3, the DSE stated, on 2/28/23 Hospital 3 accepted Pt 1 for transfer for appendicitis that would require surgery and he was the surgeon on call and performed the surgery. The DSE stated, Pt 1 arrived the next morning to Hospital 3 by ambulance which was a 200-mile one-way trip which he was informed took six hours due to the stormy weather. The DSE stated, based on Hospital 1's records Pt 1 was denied transfer by seven different closer hospitals which had surgical services. DSE stated, the next day, Hospital 3 had difficulty discharging the patient since she lived 200 miles away, had no vehicle and no family who could drive to pick her up. The DSE stated, on 3/2/23 Pt 1 went home by taxi. The DSE stated, "This should never have happened, they [Hospital 3] are over 200 miles away and this hospital [Hospital 2] is only 60 plus miles and was more convenient for this patient."

During a review of Pt 1's Face Sheet (from Hospital 3), the face sheet indicated, Pt 1's encounter date was 3/1/23 with an Admitting Diagnosis of Acute appendicitis.

During a review Pt 1's document titled, "Transfer Call List", dated 2/28/23, the Transfer Call List indicated, Hospital 1 called Hospital 2 on 2/28/23 at 9:07 p.m. and was informed that Hospital 2 could not take the patient due to them having no capacity to do so.

During a review of Hospital 2's document titled, "Census," dated 5/1/23, the "Census" indicated, the total hospital census on 5/1/23 was 585 patients.

During a review of Hospital 2's document titled, "License," on 5/1/23, the "License" indicated, the hospital had a capacity of 685 General Acute Care licensed beds: 84 Intensive Care Newborn Nursery; 78 Intensive Care; 49 Perinatal; 32 Rehabilitation; 10 Burn; 8 Pediatric; 424 Unspecified General Acute Care.

During an interview on 5/2/23, at 1:45 p.m., with the Director of Emergency Department (DED), the DED stated, "We [the hospital ED - Emergency Department] don't have a set capacity. We flex (bend) to capacity if a patient comes, we see them." The DED stated, the ED is licensed for 74 beds and as of this morning ED Census was over 100 with more than half of those admitted and waiting on beds. The DED stated, "We report our volume to the house supervisor, and we never say we cannot take patients."

During an interview on 5/2/23, at 1:58 p.m., with the Director of Patient Flow Command Center (DPFCC) and the Manager of Patient Flow Command Center (MPFCC), the DPFCC stated, when another facility requested a transfer to the hospital the Transfer Nurse who answered the call would ask what service they were requesting and determined if a higher level of care was needed, whether it was emergent and then the Transfer nurse would look at house capacity and ED capacity if they were an ED to ED transfer. The DPFCC stated if the Transfer Nurse determined the hospital did not have capacity to take the transfer, then the transfer was declined but if there was capacity, they would then contact the Service line i.e., Surgery, Trauma, Burn, Cardiac and if they agreed to take the patient then the transfer would be accepted. The DPFCC stated, the transfer center would look at the census at the time of the call and determined capacity based on what it actually looked like. The DPFCC stated, "So for example if the flex beds (authorized additional beds by CMS) in the ED are almost full, and they have a census over a hundred the transfer center will not accept a transfer. The Transfer nurse will deny the transfer due to capacity and document the ED census, Admit holds, East Hallway beds census, and the Capacity Index (this is a complex number done by the computer and takes into account numbers of patients, beds, and staff in the hospital. Anything over 1.09 the hospital follows its disaster plan.)." The DPFCC stated, the surgery schedule for the day would have no impact on why (the hospital) would take a patient. The DPFCC stated, if the hospital determined they were at capacity they will not accept a transfer unless it was a Trauma, Stroke (a medical emergency where blood flow to the brain is blocked), Burn, STEMI (most severe type of heart attack). The DPFCC stated, "... because we are a Trauma 1 Care Facility (facility that provides the highest level of trauma care to critically ill or injured patients), we make sure we have Trauma beds available." The DPFCC stated, "We have to eliminate the lower acuity so we can take the higher acuity [patient], we limit because we have to be available for Trauma, Burn, STEMI, and stroke patients." The MPFCC stated, "We check in every shift with the departments and sometimes hour by hour before we decide we are at capacity, the Manager, DPFCC and the Chief Medical Office (CMO) discuss the census and make the decision to limit transfers."

During a concurrent interview and record review, on 5/2/23, at 2:17 p.m., with the Bed Control Registered Nurse (Transfer Nurse- BCRN), the list of transfer requests on 2/28/23 from 6 p.m. to 6 a.m. on 3/1/23 were reviewed. The BCRN stated there were seven requests made during the time period. The BCRN stated as a transfer nurse she looked at the hospital census, ED census, and admit holds, she looked to see how many Intensive Care Unit (ICU) beds were holding the capacity. The BCRN stated she looked at each department and could see if there were any open beds in each unit. The BCRN stated she communicated with bed control and management to determine what the plan was for the day i.e., number of discharges, or if there were no bed they had to adhere to a more restrictive criteria. The BCRN stated Pt 1's transfer request came in on 2/28/23 at 9:07 p.m., it indicated "Requesting ER to ER transfer for surgical services, for a 40-year-old female with appendicitis. Requested that she fax a patient packet to [phone number provided]. Aware that unfortunately we will have to deny this request at this time, as we are on restrictive capacity and only accepting trauma, burns, and life/limb saving procedures within 6-12 hours. Please continue to reach out to other facilities, and feel free to re-contact us in 12-24 hours if unsuccessful to see if capacity has changed. ED census: 199 Admit holds: 93 EH [East Hallway in ED]: 28 Capacity index: 1.11."

During an interview on 5/3/23, at 2 p.m., with the DPFCC, the DPFCC stated, on 2/28/23 during the time the transfer was requested for Pt 1, the hospital was at a Capacity Index of 1.11, anything over 1.09 the hospital followed its "Disaster Capacity" plan at that point in time the hospital had no capacity. The DPFCC stated, the hospital had been in disaster emergency operations plan since March of 2020 and they continued to operate in this plan. The DPFCC stated, the Governing Body (GB)approved the capacity policy, so they do not reach out to them (GB) every time they had to go into disaster plan. The DPFCC stated the decision to change from acceptance to not accepting was made by himself, his manager and the CMO. The DPFCC stated, "... today our Capacity Index is 1.19." The DPFCC stated, the first step to determine if the hospital can take a transfer was to see if there was an available room in the ED or if it would be safer for the transfer to come to an overcrowded ED. The DPFCC stated, "If there is ED capacity then we reach out to the physician service for availability, if they accept then we accept the transfer." The DPFCC stated, there were times lower acuity patients (referring to Pt 1) were stuck for days in the ED while higher acuity patients were being seen so it was safer to deny the transfer and have them try to get them into another facility.

During a concurrent interview and document review, on 5/4/23, at 8:57 a.m., with the Surgery Operations Manager (SOM) and the Surgery Manager (SM), the Surgery Schedule titled "[Name of hospital] Temporary Report," dated 2/28/23 and 3/1/23 were reviewed. The SM stated, the Surgery Schedule for 2/28/23 indicated the last surgery scheduled that day was at 4:15 p.m. The SM stated, the Surgery Schedule for 3/1/23 indicated the first surgery was scheduled at 7:15 a.m. The SM stated, there were no surgeries scheduled on the evening of 2/28/23. The SM stated, the hospital had three teams on call ready to do cases in the middle of the night for general surgery, they have two Neuro teams on call, and one cardiac team on call if needed and could run up to six operating rooms at night. The SM stated, during the day the hospital could run 22 to 23 operating rooms. A review of "Who's On" list dated 2/28/23 indicated, there was one Trauma Faculty Surgeon on from 5 p.m. to 8 a.m. with one back up on call if needed, also one General surgery Consult Resident on and one Trauma-Acute Care Surgery Consult Resident on that night from 6:30 p.m. to 6:30 a.m. The SM stated, once ED has determined they had a patient that needed surgery, the ED would call the Operating Rooms (ORs) front charge desk and provide all the information on the patient and when the physician would be available to do the surgery. The SM stated a patient who needed an appendectomy (referring to Pt 1) was considered emergent and would go first before any non-emergent cases. The SM stated, based on documents reviewed there was a surgeon and OR staff available on the night of 2/28/23 to 3/1/23 to perform surgery for Pt 1.

During a concurrent interview and policy review, on 5/4/23, at 11:40 a.m., with the DPFCC, the hospital policy titled, "Transfer of Patients - In Bound," dated 2/9/23, was reviewed. The Transfer of Patients - In Bound policy indicated on page 2 of 5, "... System-wide communications are on-going to assure that no patient is denied due to capacity before exhausting every appropriate resource ..." The DFCC stated after reviewing the list of transfer request on 2/28/23 wherein Pt 1 was denied transfer because it was a general surgery request and not a trauma. The DFCC stated the facility exhausted all their efforts but could not pass the first step in the policy which was capacity. The DFCC stated Pt 1's diagnosis of appendicitis did not meet a high acuity patient and because they were a trauma 1 level care center, they needed to preserve their specialty beds for those patients.

During an interview on 5/4/23, at 1:45 p.m., with the DED, the DED stated, trauma beds were always available in the ED. The DED stated, "... once we stabilize a patient, we move them so the trauma bed can be open for the next trauma." The DED stated on 2/28/23 the ED had its flex areas open allowing for more patient space if needed. The DED stated the facility had capacity calls that occurred twice daily and at that time they find out the house census and they informed them their numbers of patients waiting to be seen, admitted waiting for beds, and possible discharges. The DED stated the ED was not involved in the decision to accept a transfer from another hospital. The DED stated the ED was in the business of seeing people and did not turn anyone away. The DED stated, "We have a system in place and the transfer center determines who is transferred into our facility and they inform the ED when a transfer has been accepted."

During a review of the facility policy and procedure titled, "Transfer of Patients - In Bound," dated 2/9/23, the policy indicated, "... I. PURPOSE A. To provide a system to ensure continuity of care and the coordination of safe and timely transfer of patients to [name of hospital]. B. the ensure transfer procedures are compliant with the Emergency Medical Treatment and Active Labor Act (EMTALA), the Consolidated Omnibus Budget Reconciliation Act of 1986 (COBRA), California legislation Senate Bill 12 and Assembly Bill 214 and California Consent Law and Title 22, Centers of Medicare & Medicaid Services (CMS) Conditions of Participation and the Joint Commission (TJC) Standards, and other federal, state and local regulations. C. To describe the defined process for acceptance or denial of transfer requests for patients from a facility to a [name of hospital] emergency Department (ED) or to an inpatient bed. II. DEFINITIONS ... B. Capacity and capability: The ability to provide medical treatment in which the receiving facility has available space, qualified personnel, equipment and supplies for treatment of the individual and the lack of these resources creates a potentially unsafe environment for both patient and staff ... C. Emergency medical condition: 1. A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in : ... b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part ... III. POLICY ... D. [name of organization] accepts all appropriate transfers of patients who have emergency medical conditions and who need [abbreviations for organization] specialized capabilities and facilities, as long as [abbreviation for organization] has the capacity and capability to do so. System-wide communications are on-going to assure that no patient is denied due to capacity before exhausting every appropriate resource ..."