HospitalInspections.org

The Condition of Participation for Governing Body is not met based on observations, staff interviews, review of hospital policies/procedures and review of hospital records, based upon the Governing Body failure to ensure the medical staff is accountable and knowledgeable of the requirements for a timely transfer of patients to a higher level of care. The failure resulted in 1 (Patient #4) of 10 patients not being transferred to the geographically closest hospital as required by hospital policy and procedures. The hospital was unable to ensure the care and services regarding transfers to a higher level of care, provided by a contracted service, furnished the services required to meet with the applicable conditions of participation and standards for those contracted services.

Please refer to A-0049 for additional information.

Based on observation, staff interviews, medical record reviews and hospital policy and procedure review the facility failed to ensure the medical staff provided quality of care by the hospital to ensure a timely transfer to a higher level of care for 1 (Patient #4) of the 10 patient's sampled. The hospital was unable to ensure the care and services regarding transfers to a higher level of care, provided by a contracted service, furnished the services required to meet with the applicable conditions of participation and standards for those contracted services.
The findings include:
1. A review of the medical record on 10/17/11 revealed Patient # 4 arrived to the Marco Island Urgent Care (MIUC) at 8:19 a.m. on 10/2/11. The patient is an 80 year old male presenting with symptoms documented to include, but not limited to, Dizziness, Bradycardia (low pulse rate), Confusion, Right Sided weakness and Facial Droop.
Patient #4 ' s medical record documented the patient received diagnostics including not limited to lab work, electrocardiogram and physical assessment. The physical assessment revealed patient's condition had deteriorated and required a transfer from the MIUC to a higher level of care facility.
2. The Naples Community Hospital (NCH) policy entitled "Patient Transfers " Original Date: 3-90, Revision Date 3-11 was reviewed.
The Policy includes (not limited to):
"Purpose: To insure the safe and efficient transfer of patients from an NCH facility to another acute hospital setting, including to another NCH facility or to a Baker Act Receiving Facility.Policy: Transfers to other hospitals or facilities will not be made based on the patient's ability to pay or on any other factor that is substantially unrelated to patient care. Transfers may be instituted for one of the following reasons:* Patient requests transfer (Patient/family preference)*Patient requires specialized treatment that is beyond the scope of services provided within the NCH healthcare System (Higher level of Care). Transfers that are required by Florida Law chapter 394 (Baker Act). "
" Transport Restrictions: " Include (not limited to):
" A patient with an emergency medical condition which has not been stabilized or who is in active labor my not be transferred unless: " Include not limited to:* A physician certifies in writing that, in the physician ' s professional opinion, the expected medical benefits outweigh the risk.""It is the responsibility of the attending physician to determine when a patient should be referred or transferred to an institution which provides definitive services (i.e., burn center, mental health facility, veteran ' s administration hospital, alcoholic detoxification center, chronic care facility). Per Florida Statute Chapter 395, all medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless prior arrangements are in place or the geographically closest hospital is at service capability."
3. According to MapQuest NCH is 18.49 miles from the MIUC. Physician Regional Medical Center (PRMC) is 12.49 miles from the MIUC.
On 10/18/11, the surveyor received via fax from the Director of Patient Advocacy and Regulatory Compliance a copy of the Physician ' s Certification Statement - Transport Criteria, dated 10/2/11, timed at 9:25 a.m., documenting on page 1 in Transport To Section "NCH ED (with initials TM circled) Physicians Regional " and on page 2 Section Room # at Receiving Hospital " NCH ED " and section Checklist Transported by Ground Ambulance has a " X " in the check box.
The MIUC transfer document for Patient #4 indicates the physician did request the patient be transferred to Physician Regional Hospital (which would have been the nearest, geographical hospital (closest) with capabilities to treat /diagnose this patient) and was initialed by the physician. Page 2 of the transfer document contains handwritten entries which document the patient ultimately was sent by ground transport to Naples Community Hospital. The transport vehicle was the NCH Class II ambulance, with two NCH paramedics and one Collier County Fire Rescue/Fire Fighter/paramedic.
The MIUC physician Emergency /Urgent Care Note dated 10/2/11, signed 10/10/11, documents: " We asked for NCH transport however it was before 9 o ' clock and not available, therefore we called 911 of Collier County. - NCH transport crew and a Collier County arrived at approximately in the same time. " On 10/18/11 at 1:10 p.m. during a telephone interview with the Risk Manager for NCH the Collier Co. emergency service vehicle that arrived was a hook and ladder truck.
During an interview with the NCH Chief Nursing Officer, on 10/17/11, at approximately 4:15 p.m., she explained that the previous practice on 10/2/11 was for the transport team to arrive at 9:00 a.m. to the MIUC. On 10/2/11 the NCH transport team and a Collier County emergency vehicle arrived at about 9:20 a.m., based on a review of the MIUC Physician ' s Emergency Urgent Care Note. Patient #4 continued to decompensate and was no longer responsive or following orders. Upon the NCH transport team arrival Patient #4 was placed into the ambulance. To protect his airway, Patient #4 was given 5 mg of Versed, however he was not intubated. The transport vehicle left the MIUC at 9:25 a.m., 39 minutes after initial call for emergency transport and arrived at NCH Emergency Department Downtown campus at 10:05 a.m.
The physician was unaware of the hospital policy citing the Florida Statute Chapter 395, which states "all medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless prior arrangements are in place or the geographically closest hospital is at service capability." As reported during interview on 10/19/11, at 10:32 a.m., the physician stated "Yes" when asked if the NCH ambulance only transfers patient to NCH.
4. The course of events did not follow the NCH policy entitled " Patient Transfers and the physician ' s transport orders contributed to the confusion as to the transport entity and where Patient #4 was to be transported.
The facility governing body failed to ensure the medical staff understands the hospital policies impacting the quality of care provided to the patients requiring transfers to higher levels of care.
5. An interview with the transport manager on 10/17/11, at approximately 12:30 p.m., revealed that MIUC has a designated transport team and ambulance during operational hours for non-emergent transport.
On 10/19/11 an onsite visit to the MIUC was conducted at 7: 50 a.m. to verify the ambulance and transport team were on site and available to the MIUC facility staff. The onsite visit revealed the Ambulance was observed parked on the right side of the building. There were no personnel observed near or in the ambulance. At 8:02 a.m. the MIUC building was entered. On entry the CSR supervisor was asked if the ambulance on the side of the building was used for transport. The supervisor stated "Yes". The supervisor stated the Clinical Director would be in shortly and the she could answer the questions. At 8:15 a.m. the Director of the MIUC arrived on site. The Director was asked if there was a driver present on site for the ambulance. The Director explained there are 2 drivers assigned to the ambulance; they arrive when the facility opens at 8:00 a.m. and are there until closing at 7:00 p.m. The MIUC Director explained the Director of the NCH ED would handle the dispatcher and the driver schedules. The MIUC Director was asked where the driver was, the Director went outside to the ambulance to meet the drivers. An observation confirmed there were no drivers inside or near the ambulance. The onsite visit confirmed the transport team was not in the MICU building as required per the CNO interview conducted on 10/17/11, at 4:15 p.m.
On 10/19/11, at 9:53 a.m., during a telephone interview with the Director of Patient Advocacy and Regulatory Compliance, revealed that the process was for the transport staff to check in with the doctors and nurses on site.
Neither the CSR Supervisor nor the Clinical Director were able to verify if the transport team had checked in with the doctor or nurses on site on 10/19/11, between the hours of 8:02 a.m. and 8:15 a.m., to verify availability for non-emergent transport.
A telephone interview with the physician on duty on 10/2/11 was initiated at 10:32 a.m. on 10/19/11. The physician explained Patient #4 arrived and was breathing on his own. The physician was asked to explain the facility transport and transfers for patients requiring a higher level of care. The physician stated "The ambulance is right outside." When asked if the NCH ambulance only transports to the NCH hospital the physician stated "Yes."
The physician was asked how she knew the transport team was onsite and available to the staff today. The physician stated " Honestly, I don ' t know if they are here. "
6. An interview with the NCH Risk Manager/Attorney on 10/18/11, at 1:10 p.m., confirmed a Fire Rescue/Fire Fighter/paramedic accompanied the NCH transport team on the NCH ambulance. She continued to explain the hospital obtained permission from the county EMS system for the Fire Rescue/Fire Fighter/paramedic assist with this patient transport. With this permission, and the NCH hospital policy, the NCH ambulance should have responded to the geographically closest facility- Physician's Regional Medical Center.
An interview on 10/20/11, at 2:25 p.m., with the Nursing Supervisor at Physicians Regional Medical Center revealed their hospital was not on any diversion and could have adequately received this patient.

The Condition of Participation for Emergency Service is not met based on observations, staff interviews, review of hospital policies/procedures and hospital records Naples Community Hospital (NCH) failed to ensure provided emergency services are integrated with other departments and components of the hospital.
This is due to NCH failing to ensure Marco Island Urgent Care (MIUC), an outpatient facility of NCH provided services to 1 (Patient #4) of 10 patients within time frames that protect the health and safety of patients and within acceptable standards of practice, including the length of time it took to transport the emergency patient from the MIUC to another Hospital department where needed interventions or diagnostic services could be rendered.
The failure of NCH to provide integrated Emergency Services for MIUC patients requiring a timely transfer to a higher level of care and services placed those patients at imminent risk for serious injury, harm, impairment, or death. This results in immediate jeopardy. As a consequence of the failure of MIUC staff on 10/19/11 to readily know of transport availability, immediate jeopardy is ongoing.
Please refer to A-1103 for additional information.

Based upon observation, medical record review and staff interviews Naples Community Hospital (NCH) failed to ensure provided emergency services are integrated with other departments and components of the hospital.
This is due to NCH failing to ensure Marco Island Urgent Care (MIUC), an outpatient facility of NCH provided services to 1 (Patient #4) of 10 patients within time frames that protect the health and safety of patients and within acceptable standards of practice, including the length of time it took to transport the emergency patient from the MIUC to another Hospital department where needed interventions or diagnostic services could be rendered.
The failure of NCH to provide integrated Emergency Services for MIUC patients requiring a timely transfer to a higher level of care and services placed those patients at imminent risk for serious injury, harm, impairment, or death. This results in immediate jeopardy. As a consequence of the failure of MIUC staff on 10/19/11 to readily know of transport availability, immediate jeopardy is ongoing.
The findings include:
1. The Naples Community Hospital (NCH) policy entitled " Patient Transfers " Original Date: 3-90, Revision Date 3-11 was reviewed.
The Policy includes (not limited to):
"Purpose: To insure the safe and efficient transfer of patients from an NCH facility to another acute hospital setting, including to another NCH facility ... "
" Per Florida Statute Chapter 395, all medically necessary transfers shall be made to the geographically closest hospital with the service capability, unless prior arrangements are in place or the geographically closest hospital is at service capability."
According to MapQuest NCH is 18.49 miles from the MIUC. Physician Regional Medical Center is 12.49 miles from the MIUC.
2. Timeline:
? 8:19 a.m. on 10/2/11 - Patient # 4 arrived at Marco Island Urgent Care with signs/symptoms of stroke (rule out Cerebral Vascular Accident [CVA], Right Bundle Branch Block [RBBB], Dizziness, bradycardia, confusion, right sided weakness facial droop were present on admission)
? 8:20 a.m. O2 (oxygen) via NC (nasal cannula) at 3L (liters) (non-rebreather in place) sat 96% (on oxygen) - a #18 (angio cath) at L AC (inside arm above elbow joint), monitor (cardiac) in place.
? 8:29 a.m. EKG run and monitor strip at 8:46 a.m. Atrial Fibrillation (A-Fib) with slow ventilation. Response with rates in the low 50 ' s.
? 8:46 a.m. NCH called for transport
? 8:50 a.m. BP 208/118 P 49 finger stick 133 - nausea without vomiting, increased confusion, 911 called.
? 9:00 a.m. BP 210/108 P 49 - 1000 milliliters NS (Normal Saline) KVO (Keep vein open) up, suctioned scant phlegm, teeth clenched, see neuro sheet. (Not available to us)
? 9:15 a.m. BP 210/110 P 62 increased confusion, decreased response to verbal commands, EMS 911 called
? 9:20 a.m. Sat ' s 96% with oxygen in place. Teeth clenched at present time.
? 9:25 a.m. - to NCH
3. On 10/18/11, the surveyor received via fax from the Director of Patient Advocacy and Regulatory Compliance a copy of the Physician ' s Certification Statement - Transport Criteria, dated 10/2/11, timed at 9:25 a.m., documenting on page 1 in Transport To Section "NCH ED (with initials TM circled) Physicians Regional " and on page 2 Section Room # at Receiving Hospital " NCH ED " and section Checklist Transported by Ground Ambulance has a " X " in the check box.
The MIUC transfer document for Patient #4 indicates the physician did request the patient be transferred to Physician Regional Hospital (which would have been the nearest, geographical hospital (closest) with capabilities to treat /diagnose this patient) and was initialed by the physician. Page 2 of the transfer document contains handwritten entries which document the patient ultimately was sent by ground transport to Naples Community Hospital. The transport vehicle was the NCH Class II ambulance, with two NCH paramedics and one Collier County Fire Rescue/Fire Fighter/paramedic.
The MIUC physician Emergency /Urgent Care Note dated 10/2/11, signed 10/10/11, documents: " We asked for NCH transport however it was before 9 o ' clock and not available, therefore we called 911 of Collier County. - NCH transport crew and a Collier County arrived at approximately in the same time. " On 10/18/11 at 1:10 p.m. during a telephone interview with the Risk Manager for NCH the Collier Co. emergency service vehicle that arrived was a hook and ladder truck.
During an interview with the NCH Chief Nursing Officer, on 10/17/11, at approximately 4:15 p.m., she explained that the previous practice on 10/2/11 was for the transport team to arrive at 9:00 a.m. to the MIUC. On 10/2/11 the NCH transport team and a Collier County emergency vehicle arrived at about 9:20 a.m., based on a review of the MIUC Physician ' s Emergency Urgent Care Note. Patient #4 continued to decompensate and was no longer responsive or following orders. Upon the NCH transport team arrival Patient #4 was placed into the ambulance. To protect his airway, Patient #4 was given 5 mg of Versed, however he was not intubated. The transport vehicle left the MIUC at 9:25 a.m., 39 minutes after initial call for emergency transport and arrived at NCH Emergency Department Downtown campus at 10:05 a.m.
The course of events did not follow the NCH policy entitled " Patient Transfers " , the arrival time of the NCH transport team to MIUC and the physician ' s transport orders contributed to the confusion as to the transport entity and where Patient #4 was to be transported.
During an interview with the Nurse Director of the Emergency Department (ED) on 10/17/11, at approximately 2:45 p.m., revealed that Patient #4 arrived at the ED at 10:05 a.m., on 10/2/11. Review of the Emergency Room Note Final Report documented Patent #4 ' s diagnosis as:
1. Acute massive left-sided intracerebral hemorrhage
2. Acute brainstem bleed
3. Acute subfalcine herniation
4. Acute coagulopathy, severe
5. Acute respiratory failure
6. Pending cardiovascular collapse
Patient #4 expired on 10/3/11.
4. On 10/17/2011 at 12:20 p.m. the Director of the MIUC was interviewed regarding patient transfers. The Director stated the hospital has a transport ambulance that is Advanced Life Support (ALS) equipped and staff are available for patient transport during the hours of operation. She confirmed the hours of operation are " 8:00 a.m. - 7:30 p.m. seven days a week, 365 days per year, and the ambulance and crew are available during those hours. " When asked what occurs when the ambulance is not available. The Director stated " The ambulance is always here." She explained if another transfer is needed for a MIUC patient, but the ambulance is already in route transferring a previous patient, the hospital would call Emergency Medical Services using 911.
An interview with the Transport Manager confirmed the transport staff are paramedics. She continued by stating " The ambulance and staff are available during the hours the Urgent Care is open. " She explained this ambulance has a " Class 2" designation by Collier County. A review of the Class 2 designation provided by the manager confirms the ambulance would be designated as a" Class 2 Certification" for non-emergent transfers between inter-facility (Hospital owned facilities.) A Class 1 designation is for EMS provider capable of rendering on the scene pre hospital advanced life support services and emergency transfer to the nearest hospital that can provided appropriate medical interventions, services and care.
5. During an interview with the Chief Nursing Officer on 10/17/11, at 4:15 p.m., she stated "On 10/03/11 (the day after this event) the policy for the transport team changed. " The CNO explained the report to the work time had changed, and the transport team must be on the MIUC site at 8:00 a.m. and remain available during the open hours of the MIUC.
6. An interview with the transport manager on 10/17/11, at approximately 12:30 p.m., revealed that MIUC has a designated transport team and ambulance during operational hours for non-emergent transport.
On 10/19/11 an onsite visit to the MIUC was conducted at 7: 50 a.m. to verify the ambulance and transport team were on site and available to the MIUC facility staff. The onsite visit revealed the Ambulance was observed parked on the right side of the building. There were no personnel observed near or in the ambulance. At 8:02 a.m. the MIUC building was entered. On entry the CSR supervisor was asked if the ambulance on the side of the building was used for transport. The supervisor stated "Yes". The supervisor stated the Clinical Director would be in shortly and the she could answer the questions. At 8:15 a.m. the Director of the MIUC arrived on site. The Director was asked if there was a driver present on site for the ambulance. The Director explained there are 2 drivers assigned to the ambulance; they arrive when the facility opens at 8:00 a.m. and are there until closing at 7:00 p.m. The MIUC Director explained the Director of the NCH ED would handle the dispatcher and the driver schedules. The MIUC Director was asked where the driver was, the Director went outside to the ambulance to meet the drivers. An observation confirmed there were no drivers inside or near the ambulance. The onsite visit confirmed the transport team was not in the MIUC building as required per the CNO interview conducted on 10/17/11, at 4:15 p.m., referencing to #5 above.
On 10/19/11, at 9:53 a.m., during a telephone interview with the Director of Patient Advocacy and Regulatory Compliance, revealed that the process was for the transport staff to check in with the doctors and nurses on site.
Neither the CSR Supervisor nor the Clinical Director were able to verify if the transport team had checked in with the doctor or nurses on site on 10/19/11, between the hours of 8:02 a.m. and 8:15 a.m., to verify availability for non-emergent transport.
A telephone interview with the physician on duty on 10/2/11 was initiated at 10:32 a.m. on 10/19/11. The physician explained Patient #4 arrived and was breathing on his own. The physician was asked to explain the facility transport and transfers for patients requiring a higher level of care. The physician stated "The ambulance is right outside." When asked if the NCH ambulance only transports to the NCH hospital the physician stated "Yes."
The physician was asked how she knew the transport team was onsite and available to the staff today. The physician stated " Honestly, I don ' t know if they are here. "