HospitalInspections.org

Based on interview, record review, and review of the hospital's policies and procedures, the hospital failed to ensure a transfer occurred using qualified personnel and transportation for one of seventeen patients with an unstable emergency medical condition requiring transfer to a higher level of care (Patient 1). This failure had the potential for all unstable patients with emergency medical conditions requiring transfer from the Emergency Department (ED) to experience a deterioration in their condition, including serious complications or even death.


Findings Include:


Review of the facility's policy titled, "External Transfers - Emergency and Non-Emergency," last revised 09/16 showed, "The physician must certify in writing and inform the patient/family that based on the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility outweigh the increased risks, if any, that a transfer poses ...The patient must be accompanied and transferred by an individual(s) whose level of training and skill is appropriate to the patient's needs, and who will be responsible for the patient during transfer."


Review of Patient 1's ED medical record, dated 07/24/20, showed Patient 1 arrived at Hospital A's ED and Staff E, ED Physician diagnosed him with bilateral mandible fractures (broken jaw bones on both sides) and laceration to the inner mouth. Staff E treated Patient 1 with pain medications and then transferred Patient 1 to a higher level of care for anticipated surgical repair of the mandible fractures. Review of the record showed that Patient 1 transferred by private vehicle, attended only by his parents (who had no medical training), to Hospital B, an acute care hospital over two hundred miles away even though he had an unstabilized emergency medical condition that could have deteriorated potentially causing aspiration or swelling and obstruction of his airway. Patient 1 left Hospital A's ED on 07/24/20 at 10:15 PM. On 07/25/20 at 12:30 AM, Patient 1 arrived at Hospital C's ED (a local community hospital), two hours and fifteen minutes after leaving Hospital A, rating his pain at 10, the worst possible pain. The medical record showed, "They stopped here because he is in such pain that (he) cannot handle car ride anymore." The record showed Patient 1 had difficulty swallowing, swelling and tenderness to right side of jaw and was unable to open or close his jaw. He had drool and blood coming out of his mouth and separation between his two bottom front teeth. The neurological assessment showed he was an aspiration risk due to his decreased ability to handle secretions, and difficulty swallowing saliva. Patient 1 was given Dilaudid .05mg IV (a strong narcotic pain medication) and then transferred to Hospital B, via ALS (advanced life support- life-saving protocols and skills that extend beyond basic life support to further support the circulation and provide an open airway and adequate breathing) ambulance for further care. Review of the medical record from Hospital B showed, Patient 1 arrived at 4:00 AM on 07/25/20 and had surgery to repair his jaw fractures later that day. Patient 1 discharged home on 07/26/20.

Based on interview, record review, and hospital policy review, the hospital failed to ensure the Emergency Department (ED) provided a transfer with appropriate personnel for one of seventeen patients experiencing an unstable emergency medical condition (EMC) that required transfer to a higher level of care (Patient 1). This failure had the potential for a deterioration in the patient's condition to go undetected and untreated, potentially causing unnecessary pain, serious complications like aspiration, an obstructed airway, or even death.


Findings Include:


Review of an emDocs article titled, "Mandibular Fractures: Pearls and Pitfalls" dated July 30, 2018 showed, "Evaluation of patients with possible facial fractures begins with airway management. Mandibular fractures often cause distracting deformities, but they can also lead to substantial bleeding and/or swelling that can quickly progress to airway compromise ...Reassess the airway multiple times during a patient's ED visit ...The patient will need to be admitted if they display signs of impeding airway compromise, such as drooling, inability to tolerate oral intake, stridor (high-pitched breath sounds resulting from airflow through an obstructed airway), subjective difficulty breathing, or significant intraoral swelling ...If you cannot account for all missing teeth, obtain a chest x-ray to evaluate for aspiration ...Like any other fracture, mandibular fractures are very painful. If attempts to obtain adequate analgesia fail, the patient will need to be admitted for pain control ...All patients with mandibular fractures will ultimately require evaluation by a maxillofacial specialist."



Review of Patient 1's medical record from Hospital A showed:


1) Patient 1 arrived at the ED at 5:59 PM with "jaw pain, bleeding from a laceration," and pain described as a "9" (using an adult pain scale of 0-10, with 10 indicating the worst pain).


2) Review of Patient 1's Computer Tomography (CT scan) report, completed at Hospital A on 07/24/20 at 6:05 PM showed, "Acute mildly displaced fractures of the right mandibular angle and left parasymphyseal body (fracture that is not midline) and fracture of the right lateral pterygoid plate (a thin plate that the muscle attaches to allowing the jaw to move in a lateral and medial direction)."


3) Review of Staff D, ED Medical Director's note titled, "ER Physician Documentation," dated 07/24/20 at 6:00 PM showed that Patient 1 was diagnosed with, "an open fracture of both the right and left mandible (jaw bones). "This is an unstable fracture. Patient will need to be transferred to a higher level of care ".


4) Review of Patient 1's "Emergency Department Medication" record dated 07/24/20 showed Staff K, RN, administered intravenous (IV) fluids at 6:05 PM, Staff J, RN administered Morphine 4 milligrams (mg) IV (narcotic pain medication) at 7:10 PM, Staff F, RN administered Fentanyl 50 micrograms (mcg) IV (narcotic pain medication) at 8:18 PM, Cefazolin 2 grams IV (antibiotic) at 8:30 PM, and Fentanyl 50 mcg at 9:55 PM.


5) Review of Patient 1's "Nurse Notes," dated 07/24/20 at 8:50 PM showed Staff F, RN documented arrangements were made to transfer Patient 1 to Hospital B (an acute care hospital located over 200 miles away) for direct admission.


6) Review of the "Physician Assessment and Certification," dated 07/24/20 and signed by Staff E, ED Physician at 8:24 PM, showed a check mark for: "The patient has been stabilized such that within reasonable medical probability, no material deterioration of the patient's condition...is likely to result from transfer," the transport method marked was: "Private Vehicle," the transport agency was marked: "Parent," and written in the line "Risks," was the entry: "Transportation".


7) Staff F, Registered Nurse (RN) wrote, a "Departure Note," dated 07/24/20 at 10:15 PM that showed the patient continued to rate his pain as "9" and the departure status showed transfer by privately owned vehicle, there was no note referencing any attempt to secure other transportation or personnel.

8) During an interview on 08/26/20 at 10:11 AM, Patient 1 stated that he was taken to Hospital A from jail because his jaw was broken. He stated that the nurse at Hospital A gave him the option of going by ambulance or car to Hospital B and that he remembered she told him that he would have to make a down payment for the ambulance. He stated that he based his decision to go by car, with his dad, on the fact that he didn't have any money for a down payment for the ambulance. He said that he was not told by Hospital A staff, of any risks to him of going by car. Patient 1 stated that the nurse gave him pain medication just before he left and told him it should last until he got to Hospital B. He said that they stopped at Hospital C because he "started shaking with pain" and that he couldn't swallow, adding that an ambulance took him to Hospital B from there. Patient 1 stated that all he wanted was for the pain to stop.


9) During a telephone interview with Staff F, ED RN on 08/04/20 at 4:00 PM, Staff F reported that local EMS (Emergency Medical Services) companies do ask uninsured patients about payment and some request down payments "up front." Staff F stated that she had received orders for Patient 1 to transfer via POV by the transferring physician, Staff E, and Staff F added that she had been told by Staff E that the POV had also been approved by the receiving physician at Hospital B. Staff F stated that the hospital uses air transportation for all unstable patients requiring transfer to another facility.


10) During an interview with Staff C, ED Nurse Manager on 08/04/20 at 10:10 AM, Staff C stated that ED staff often have trouble finding ground transportation for patients requiring transfer. Staff C reported the hospital does not have written agreements with local EMS ambulance companies, and that most of them require a "down payment" from uninsured patients. Staff C stated that the County Ambulance service only transfers patients within the county.


11) During an interview on 08/05/20 at 7:30 AM, Staff E, ED Physician, stated that the decision to transfer Patient 1 to Hospital B was made due to Patient 1's need for possible facial surgery not provided at Hospital A. Staff E, when asked, defined a stable patient as, "awake and alert, good airway, could communicate, and was hemodynamically stable (blood flow to vital organs is adequate)." Staff E stated that the risks listed on the transfer certification form as "Transportation," was the same risk Staff E defined for all transfer patients and referred to a possible motor vehicle accident. Staff E denied defining any specific risks or instructions to Patient 1 or his parents for transportation by private vehicle on the transfer certification form and denied giving any verbal instructions or warnings to Patient 1 or his parents regarding transport by private vehicle.


12) Staff E, ED Physician failed to include the potential risks of transporting Patient 1 by private vehicle with personnel with no medical training including aspiration, increased pain, and airway obstruction.



Review of Patient 1's medical record from Hospital C (local community hospital approximately 2 hours and 15 minutes from Hospital A), showed:


1) Review of Staff L's "Triage note", dated 07/24/29 at 12:30 AM, showed Patient 1 arrived by private vehicle with a clinical diagnosis of "fracture of right-side mandible" and rating his pain at 10, the worst possible pain.


2) Review of Staff L's "ED Assessment, Adult" note dated 07/25/20 at 12:39 AM, showed Patient 1 had difficulty swallowing, loose teeth, and malocclusion (not aligned) of teeth. The Neurological assessment showed, Aspiration Risk: Decreased ability to handle secretions, and difficulty swallowing saliva.


3) Review of Staff G, Physician Assistant's (PA's) handwritten "Provider ED Note" dated 07/25/20 at 1:05 AM, showed Patient 1 was seen in Hospital A's emergency room where he was evaluated for an open jaw fracture. He was sent by private car because he didn't have insurance and he could not put a down payment for the ambulance ride. The note showed that they (Hospital A) gave him 50 mcg of Fentanyl and put him in a private car. "They stopped here because he is in such pain that cannot handle car ride anymore." Patient can't speak because of broken jaw ...." The "Focused Physical Exam" showed, "swelling and tenderness to right side of jaw. Drool and blood coming out of mouth. Can't open or close jaw at this time. He has separation b/t (between) two bottom front teeth from fracture. The record showed that Patient 1 was given Dilaudid .05mg IV (a strong narcotic pain medication) and then transferred to Hospital B, via ALS (advanced life support - life-saving protocols and skills that extend beyond basic life support to further support the circulation and provide an open airway and adequate breathing) ambulance for further care.


4) During a telephone interview on 08/05/20 at 1:15 PM, Staff G, PA at Hospital C, stated that she was called after midnight on 07/25/20 to attend to Patient 1, who had arrived at the ED by private vehicle, driven only by parents who were non-English-speaking and had no medical training. Staff G recalled arriving to the ED to care for Patient 1 and found that Patient 1 was "profusely drooling blood and saliva onto a towel," that Patient 1 couldn't talk, and that Patient 1 communicated complaints regarding increased pain and being unable to swallow via written notes. Staff G stated that Hospital C, ED nursing staff called Hospital A, ED staff to ask why Patient 1 had not been sent to Hospital B via ambulance and were told, "the patient couldn't pay." Staff G stated that while it was determined Patient 1 was technically stable because his vital signs were stable, it was determined that Patient 1 required transfer to Hospital B via ALS ambulance. Staff G stated concern that, "(Patient 1) received a lot of pain medication at (Hospital A) and (Patient 1) could have fallen asleep and aspirated (breathed secretions into the lungs)," adding that the ALS technician could monitor Patient 1's airway during the transfer.



Review of Patient 1's Emergency Medical Services (EMS) document showed:


Patient 1 transferred from Hospital C to Hospital B for direct admission on 07/25/20. The document showed Patient 1 was diagnosed with a broken mandible at Hospital A, but when he was unable to give a deposit for an ambulance trip he was given pain medication and sent by POV. Patient 1 was having a hard time swallowing and the pain was becoming to intense, so he stopped at Hospital C. Hospital C arranged ambulance transfer. The ambulance departed Hospital C, with Patient 1 at 1:20 AM and arrived at Hospital B at 3:18 AM. During the ambulance trip to Hospital B, Patient 1 was positioned in High Fowlers (a sitting position in which a patient is placed when the head of the bed needs to be elevated as high as possible, 60-90 degrees). He had issues with spit and blood in his mouth and was assisted in suctioning his airway three times. Patient 1 had increased pain and was given Fentanyl 50 mcg IV twice during the transport. On arrival at Hospital C, Patient 1's care was turned over to the RN.



Review of Patient 1's medical record from Hospital B showed:


Patient 1 arrived on 07/25/20 at 4:00 AM by ALS ambulance for evaluation and likely surgical intervention for bilateral mandible fractures. Patient 1 signed the consent for surgery on 07/25/20 at 10:40 AM. The medical record showed he had an "Open Reduction Internal fixation (the action of making something stable) right mandibular fracture, Open reduction, internal fixation of left mandibular symphyseal fracture (Fractures that occur in the center of the mandible) and removal of a tooth. Four mandibular plates and 16 screws were used for fixation of these fractures.