HospitalInspections.org

Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 482.24.

Findings include:

1. The Hospital failed to ensure that a emergency medical condition was stabilized prior to discharging a patient. A-2407.

2. The Hospital failed to ensure that an appropriate transfer was conducted for a patient with an emergency medical condition. A-2409.

Based on document review and interview, it was determined that for 1 of 20 patient (Pt. #1) records reviewed for stabilization, the Hospital failed to stabilize a patient prior to discharge.

Findings include:

1. On 2/8/2022, the Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)" dated 6/1/2021, was reviewed. The policy required, " ...Definitions ...11. To Stabilize: a. Non-labor related EMC [Emergency Medical Condition] to provide medical treatment of the condition as may be necessary to ensure, with reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during transfer or upon discharge...Policy ...3. Individuals with an EMC receive treatment within the facility's capabilities and capacity until the condition is stabilized or an appropriate transfer to another facility is made ..."

2. On 2/8/2022, Pt. #1's clinical record from Hospital A was reviewed. Pt. #1 presented to the Emergency Department on 12/28/2021 at 6:59 PM, with a chief complaint of leg pain and a history of left calf deep vein thrombosis.

-The ultrasound of the left lower extremity dated 12/28/2021 at 8:50 PM, included, " ...Impression: 1. Nearly occlusive thrombosis (blood clot) identified of the visualized left external iliac vein ..."

-The Physician orders included an order dated 12/29/2021 at 3:30 AM, for heparin (anticoagulant/blood thinner) 25,00 units in 0.45% sodium chloride 500 ml (milliliters) continuous infusion at 29 ml/hr.

-The History and Physical authored by the ED Physician (MD #1) dated 12/29/2021 at 5:13 AM, included, "Patient [Pt. #1] complains of 2 days of left lower extremity pain, specifically in the lateral calf, that she says feels similar to previous DVT [deep vein thrombosis] ...Patient [Pt. #1] says the pain has gradually worsened over the last 24-48 hours, and in the last 6 hours, has become even more severe, and is now accompanied with paresthesias [tingling sensation] to the left lower extremity, from the knee down, particularly in the lateral calf and foot, as well as all of her toes ...Physical Exam - Musculoskeletal ...left lower leg swollen compared to right, specifically from the knee down ..."

-The ED course notes dated 12/29/2021 at 5:12 AM, included the following:
At 0445 [4:45 AM] " ...Patient continues to have a foot that is cool to touch, without palpable or dopplerable dorsalis pedis or posterior tibial pulse to the left ...I spent extensive time discussing the situation with the patient [Pt. #1], and expressed my concern that she could be suffering from an acute ischemic limb, and the longer we waited to have her evaluated by a vascular surgeon, the more we were increasing risk that she could lose her foot or leg. I explained that I have called as many hospitals as I can think of in the city of Chicago, and even outside the city, and no one is accepting transfers, as there are no available beds. Patient [Pt. #1] subsequently spoke to her husband, who says he will come and pick her [Pt. #1] up from our emergency department, and physically take her to another ER, so she can be evaluated at a hospital that has vascular surgery available. I did call and speak to one of the [receiving hospital] ER residents, who took the patient's [Pt. #1] name and date of birth, and said that the charge nurse was aware, and that they would watch for the patient to check in to their emergency department, so as to attempt to expedite her evaluation at their facility. I apologize emphatically to the patient [Pt. #1], that we were unable to provide her with the potentially definitive care that she would need today, and given the current pandemic we are in and hospitals being at capacity, that I am not able to facilitate transfer for her via ambulance. Will dc [discontinue] heparin [anticoagulant] and IV [intravenous] and dc [discharge] patient [Pt. #1] so she can go to a facility where vascular surgery is available...Disposition: Discharge after treatment."

-The discharge instructions included, "Please leave our emergency department and go immediately to [receiving hospital/Hospital B] ER so you can be evaluated by a vascular surgeon, as you may have an arterial occlusive process that could result in the loss of your limb if not appropriately treated. Regardless of the vascular surgeon assessment, you will need to be started on anticoagulation therapy (blood thinner) for your DVT. Please be sure to discuss this will [with] the ER provider that you see at the other hospital."

3. On 2/8/2022, Pt. #1's clinical record from the receiving hospital dated 12/29/2021, was reviewed.
-The ED Physician note dated 12/29/2021 at 9:46 AM, included, " ...presents to ED with c/o [complain of] 2 days of LLE [left lower extremity] swelling and pain ...She initially went to [treatment hospital/Hospital A] ED where she had US [ultrasound] showing LLE and DVT and CTA [computed tomography angiography/visualize arteries] that was inconclusive but ED MD was concerned about acute limb ischemia based on exam so patient [Pt. #1] was started on heparin and [treatment hospital] attempted to arrange transfer to hospital with vascular surgery. No hospitals were accepting transfers so patient [Pt. #1] was discharged and came by private vehicle to [receiving hospital/Hospital B] ED ... Medical decision: vascular surgery emergently consulted ...will restart heparin. Plan to admit after workup complete."

-The ultrasound of the left extremity dated 12/29/2021 at 8:46 AM, included, " ...findings suggestive of recurrent left lower extremity DVT ..."

-The ED course notes dated 12/29/2021 at 1433 (2:33 PM) included, the following:
At 1010, Pt. [Pt. #1] was evaluated by vascular surgery, they do not have concern with acute limb ischemia at this time. They recommend IR [interventional radiology] consult for possible thrombolysis and CT venogram [x-ray with contrast to used visualize veins and diagnosis DVT's] to evaluate extent of clot. They also agree with continuing heparin.

4. On 2/9/2022 at 10:20 AM, an interview was conducted with the ED Director (E #6). E #6 stated that the administrative team is currently searching for a vascular surgery team. E #6 stated that the Interventional Radiologist (IR) has a cardiologist and are more involved with vascular cases. E #6 stated the best practice would have been to transfer Pt. #1 instead of discharging her, but it was the Physician's decision. E #6 stated that Pt. #1 could have been admitted but it was MD #1's decision to discharge Pt. #1 and send her to [Hospital B] ED due to the concern of Pt. #1 potentially losing a limb. E #6 stated that she has not seen a heparin drip discontinued and the patient immediately discharged to self. E #6 stated that MD #1 used her best judgement and thought it was safe since Pt. #1's husband would be driving Pt. #1 directly to [Hospital B] ED. E #6 stated that under normal circumstances a Physician does not document that after discharge from the ED the patient should go directly to another ED.

Based on document review and interview, it was determined that for 1 of 8 patients (Pt. #1) reviewed for transfer from the Emergency Department, the Hospital failed to ensure that an appropriate transfer to higher level of care for a patient with an emergency medical condition.

Findings include:

1. On 2/8/2022, the Hospital's policy titled, "Emergency Medical Treatment and Labor Act (EMTALA)" dated 6/1/2021, was reviewed. The policy required, " ...Policy ...3. Individuals with an EMC receive treatment within the facility's capabilities and capacity until the condition is stabilized or an appropriate transfer to another facility is made ...Patient transfer 1. A decision regarding patient transfer may be made either by request or physician certification ...i. Inform individual of the risk, alternatives (if any) and obligation to provide further examination and treatment sufficient to stabilize the EMC [emergency medical condition] ...e. The transfer is completed through appropriately trained professionals ...2. b. The receiving facility ...i. Has available space and qualified personnel available to treat the individual ...has agreed to accept transfer of the individual and to provide appropriate medical treatment ...during the transfer as determined by the transferring physician ..."

2. On 2/8/2022, Pt. #1's clinical record from Hospital A was reviewed. Pt. #1 presented to the Emergency Department on 12/28/2021 at 6:59 PM, with a chief complaint of leg pain and a history of left calf deep vein thrombosis.
-The ultrasound of the left lower extremity veins dated 12/28/2021 at 8:50 PM, included, " ...Impression: 1. Nearly occlusive thrombosis identified of the visualized left external iliac vein ..."
-The ED notes authored by a Unit Secretary (E #4) dated 12/29/2021 at 3:22 AM, included, "Per [proper name] no bed at any [receiving Hospital's network/Hospital B] hospitals.
-The History and Physical authored by the ED Physician (MD #1) dated 12/29/2021 at 5:13 AM, included, "Patient [Pt. #1] complains of 2 days of left lower extremity pain, specifically in the lateral calf, that she says feels similar to previous DVT [deep vein thrombosis] ...Patient [Pt. #1] says the pain has gradually worsened over the last 24-48 hours, and in the last 6 hours, has become even more severe, and is now accompanied with paresthesias [tingling sensation] to the left lower extremity, from the knee down, particularly in the lateral calf and foot, as well as all of her toes ...Physical Exam - Musculoskeletal ...left lower leg swollen compared to right, specifically from the knee down ..."
-The ED course notes dated 12/29/2021 at 5:12 AM, included the following:
At 0317 (3:17 AM), "Patient [Pt. #1] continuing with worsening pain, lateral and posterior calf and foot are still cool to the touch, still cannot palpate or doppler pulse in left foot ...Will start reaching out to other hospitals for vascular surgery intervention"
At 0343 (3:43 AM), "...All [receiving hospital network hospitals/Hospital B]...say they will not even page their on call vascular surgery team to discuss this patient, as they are not accepting transfers right now..."
At 0445 (4:45 AM) " ...Patient continues to have a foot that is cool to touch, without palpable or dopplerable dorsalis pedis or posterior tibial pulse to the left ...I spent extensive time discussing the situation with the patient [Pt. #1], and expressed my concern that she could be suffering from an acute ischemic limb, and the longer we waited to have her evaluated by a vascular surgeon, the more we were increasing risk that she could lose her foot or leg. I explained that I have called as many hospitals as I can think of in the city of Chicago, and even outside the city, and no one is accepting transfers, as there are no available beds. Patient [Pt. #1] subsequently spoke to her husband, who says he will come and pick her [Pt. #1] up from our emergency department, and physically take her to another ER, so she can be evaluated at a hospital that has vascular surgery available. I did call and speak to one of the [receiving hospital/Hospital B] ER residents, who took the patient's [Pt. #1] name and date of birth, and said that the charge nurse was aware, and that they would watch for the patient to check in to their emergency department, so as to attempt to expedite her evaluation at their facility. I apologize emphatically to the patient [Pt. #1], that we were unable to provide her with the potentially definitive care that she would need today, and given the current pandemic we are in and hospitals being at capacity, that I am not able to facilitate transfer for her via ambulance. Will dc [discontinue] heparin [anti-coagulant] and IV [intravenous] and dc [discharge] patient [Pt. #1] so she can go to a facility where vascular surgery is available...Disposition: Discharge after treatment."
-The discharge instructions included, "Please leave our emergency department and go immediately to [receiving hospital/Hospital B] ER so you can be evaluated by a vascular surgeon, as you may have an arterial occlusive process, that could result in the loss of your limb if not appropriately treated. Regardless of the vascular surgeon assessment, you will need to be started on anticoagulation therapy (blood thinner) for your DVT. Please be sure to discuss this will [with] the ER provider that you see at the other hospital."
-Pt. #1's clinical record lacked the documentation of a transfer order and physician certification statement (PCS) by the ED Physician (MD #1) from the initial Hospital A.

3. On 2/8/2022, Pt. #1's clinical record from the receiving hospital dated 12/29/2021, was reviewed.
-The ED Physician note dated 12/29/2021 at 9:46 AM, included, " ...presents to ED with c/o [complain of] 2 days of LLE [left lower extremity] swelling and pain ...She initially went to [treatment hospital/Hospital A] ED where she had US [ultrasound] showing LLE and DVT and CT that was inconclusive but ED MD was concerned about acute limb ischemia based on exam so patient [Pt. #1] was started on heparin and [treatment hospital/Hospital A] attempted to arrange transfer to hospital with vascular surgery. No hospitals were accepting transfers so patient [Pt. #1] was discharged and came by private vehicle to [receiving hospital/Hospital B] ED ..."

4. On 2/8/2022 at 1:30 PM, an interview was conducted with an Emergency Department Physician (MD #1). MD#1 stated that she took care of Pt. #1 on 12/28/2021. MD #1 stated that Pt. #1's ultrasound showed Pt. #1 had a DVT, but clinically Pt. #1 had signs of an arterial occlusion. MD #1 stated that she was concerned that Pt. #1 had an ischemic limb (little or no blood supply reaches extremity). MD #1 stated that when she (MD #1) explained to Pt. #1 the difficulty of getting her (Pt. #1) transferred to a Hospital with a vascular surgeon, Pt. #1 asked if she could leave and go to another hospital. MD #1 stated that she explained to Pt. #1 that she (MD #1) could not make her (Pt. #1) stay at the hospital and then she (MD #1) provided Pt. #1 with a list of hospital with vascular surgery. MD #1 stated that she discharged Pt. #1 and Pt. #1's husband took her (Pt. #1) by personal vehicle to [receiving hospital/Hospital B]. MD #1 stated that she did what she felt was in the best interest of Pt. #1 in order to prevent Pt. #1 from losing her leg. MD #1 stated that she (MD #1) called [receiving hospital's/Hospital B] ED Physician, as a courtesy, to provide them with Pt. #1's name and date of birth and to alert them of Pt. #1's condition.

5. On 2/8/2022 at 2:21 PM, an interview was conducted with the Emergency Department Medical Director (MD #3). MD #3 stated that Pt. #1 was truly in an emergency medication condition. MD #3 stated that MD #1 did the right thing by discharging the patient and advising to go to the other (Hospital B) ED, because beds were not available.