HospitalInspections.org

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) related policy, Medical Staff Bylaws and Rules and Regulations, Hospital # 2 Emergency Department (ED) medical record (MR), and interviews with staff it was determined Southeast Alabama Medical Center (Hospital # 1) was not in compliance with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to provide a Medical Screening Examination (MSE) and appropriate transfer for a patient requiring emergency services located on the hospital campus.

This deficient practice affected Patient Identifier (PI) # 21, 1 of 1 hospital based wound care center records reviewed, and had the potential to negatively affect all patients served by the facility.

Findings include:


Refer to Tag 2406 and 2409

Based on review of the facility policies and procedures, facility diversionary status listing, ambulance patient care report, ED (Emergency Department) Physician Transfer Line Form Medial Record (MR) from hospital based outpatient wound center, and interviews with facility staff it was determined the facility failed to provide a Medical Screening Examination (MSE), related to diversionary status, for a patient requiring emergency services located on the hospital campus.

This deficient practice affected Patient Identifier (PI) # 21, 1 of 1 hospital based wound care center records reviewed, and had the potential to negatively affect all patients served by the facility.

Findings include:

Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) Administrative Policy
Effective Date: 4/1/19

Purpose: To comply with the EMTALA, which requires a Medicare participating hospital with a dedicated emergency department (DED) to provide a MSE to determine the presence of an emergency medical condition (EMC)...

Scope:
...EMTALA also applies to any individual with what a prudent layperson believes to be an EMC, who presents at a hospital - based outpatient department (HOPD)... or anywhere on a hospital campus that has a DED... which must occur within the appropriate Southeast Health (Southeast Alabama Medical Center) DED. Examples include:

1. Individual arrives on hospital property...within 250 yards of hospital...
...4. Individual presents to a HOPD for unscheduled visit presumably needing emergency medical treatment for an apparent life-threatening emergency...

EMTALA Requirements:

...1. Provide an appropriate MSE to any individual who comes to the emergency department (ED)...

Policy: Physicians Wound Care (PWC)
Subject: PWC Scope of Service
Effective Date: 1/12/17

Policy: ...Southeast Wound Care is an Outpatient department of Southeast Alabama Medical Center...

Policy: PWC
Subject: Transporting of Patients
Effective Date: 7/1/18

Policy: To educate staff of proper procedures when transporting patients from out center to the ER (emergency room)...

Purpose: To ensure safe transport of patient from PWC to the hospital.

Procedure:
Conditions which warrant being taken to the hospital:

...2. Patients who need ER services...

...After 911 is called the staff will activate the emergency code 9 for immediately adjacent response area assistance...As soon as the wound care physician evaluates the patient they will call the ER and speak with a physician and report the condition of the patient and that they should expect the patient in the ER...


PI # 21 presented to the wound care center on 8/22/19 for a Diabetic Foot Ulcer wound care follow up visit.

Review of the Wound Care Center Progress Note dated 8/22/19 revealed the following summary of events:

PI # 21 was observed in the wound care center waiting area by a Employee Identifier (EI) # 4, Registered Nurse (RN) Wound Care Center, who then told the RN Team Leader that the patient looked like "he/she is ready to fall out." PI # 21 was wheeled into the wound care center hallway and vital signs including, pulse of 49, blood pressure of 125/58, and respiration rate of 16 were performed. While in the hallway, EI # 7, Medical Doctor, "came out to observe patient and noticed that he/she was ill appearing cachexic (condition that causes extreme weight loss and muscle wasting), nauseated and dry heaving in a clear plastic bag. He/She appeared severely dehydrated, eyes sunken and termporal (temporal) waisting (wasting)..." EI # 7 recommended the patient be evaluated in the ER (Emergency Room). PI # 21 refused to go to the ED for evaluation and then requested to go to the restroom. While in the restroom, PI # 21 had a bowel movement (BM) which EI # 7 documented "had a strong odor not unlike melena (dark sticky feces containing partly digested blood)." EI # 7 attempted to speak with PI # 21 following the BM and documented "his/her mental status was waxing and waning in and out of consciousness." EI # 7 instructed EI # 4 to call 911. PI # 21 was then taken to wound care exam room with the EI # 4 who waited with PI # 21 until Emergency Medical Services (EMS) arrived. When EMS arrived EI # 7 went into the exam room with PI # 21 and was notified by EMS that Southeast Alabama Medical Center was on diversion. EI # 7's documented response to EMS on the diversionary status was "he/she for sure needs emergent care and should not be discharged to his/her home without being evaluated in (the) ER." EMS placed PI # 21 on a stretcher and left the wound center.

Review of the Ambulance Patient Care Report dated 8/22/19 revealed documentation the ambulance was dispatched at 9:02 AM to Southeast Alabama Medical Center Wound Care and arrived at 9:08 AM. Emergency Medical Services (EMS) documented PI # 21's vitals signs as pulse 46, blood pressure 92/54, and respiration rate of 18.

Further review of the Ambulance Patient Care Report dated 8/22/19 revealed PI # 21 was transported to hospital # 2 at 9:26 AM.

Review of the ED Physician Transfer Line Form dated 8/22/19 revealed no documentation of a call from the Southeast Alabama Medical Center Wound Care.

Review of the Southeast Alabama Medical Center diversionary status listing revealed the facility was on a Med (Medical) Surg (Surgical) diversion from 8/21/19 at 11:30 PM until 8/22/19 at 2:50 PM.

The facility failed to provide a MSE for PI # 21 who required emergency services and was located on the hospital campus.

Interviews:

1. An interview was conducted on 10/2/19 at 8:20 AM with EI # 2, Director of Emergency Services, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 2 was asked the process for transferring patient's from an outpatient department of the hospital, such as the wound care center, to the ED. EI # 2 stated "anything that's in the main hospital there is a code 9. A team from the ED would go there or the department would bring the patient to the ED. Outside of the actual building would be a 911 call or if we are notified we would still respond to those areas." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 2 stated, "if someone is on our immediate campus the patient should be brought to us regardless of a diversionary status."

EI # 2 was asked if the wound care center was on the hospital campus. EI # 2 stated, "it meets the 250 yard rule."

2. An interview was conducted on 10/2/19 at 8:43 AM with EI # 3, Director of Quality Management, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 3 was asked what the process was for the outpatient departments/clinics to transfer a patient to the ED for evaluation. EI # 3 stated, "they call 911 and they are supposed to notify the ED..." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 3 stated, "If they are on campus it should not affect the patient. If EMS is called, they should bring the patient here..."

EI # 3 confirmed the wound care center was within 250 yards of the hospital campus.

3. An interview was conducted on 10/2/19 at 9:18 AM with EI # 5, RN, Inpatient Wound, Ostomy, and Continence Nurse, who was the first person to observe PI # 21's condition. EI # 5 stated, "I was taking wound vac's to the wound center. As a car left the building I saw a man/woman holding onto the handrail. His/Her color was awful. I got a wheelchair and took him/her in the lobby. I told (employee identified) at the window they need to get him/her help. He/She really looked like he/she might die."

4. An interview was conducted on 10/2/19 at 9:25 AM with EI # 4, RN, Wound Care Center Team Leader, to describe what he/she knew about the care of PI # 21. I was told "you have a patient out there that doesn't look good. Do you want me to bring him/her back?" I told him/her yes. I started to get his/her vitals. Medical Doctor (MD) came down. MD said he/she needed to go to the ER. The patient refused and went to the bathroom. MD talked with him/her again and then told me to call 911 because he/she was in and out of consciousness. I called 911, took him/her to a room, and sat with him/her until 911 got there. The EMS said, 'you know southeast health is on diversion.' MD said well he/she can't go home. The EMS asked if he/she (referring to EI # 7) wanted him/her to go to (hospital # 2 identified). MD said he/she can't go home, take him/her to Hospital # 2 then.

EI # 4 was asked what the process was to transfer a patient to the ED for an evaluation from the wound care center. EI # 4 stated, "We call 911. We call a code 9 and give report to the ER."

During a follow up interview with EI # 4 on 10/2/19 at 2:32 PM, EI # 4 confirmed there was no documentation a code 9 was initiated or a report was given to the ER for PI # 21.

Based on review of the facility policies and procedures, facility diversionary status listing, ambulance patient care report, ED (Emergency Department) Physician Transfer Line Form Medial Record (MR) from hospital based outpatient wound center, and interviews with facility staff it was determined the staff inappropriately permitted EMS (Emergency Medical Services) to transfer the patient to a different hospital related to ED diversionary status.

This deficient practice affected Patient Identifier (PI) # 21, 1 of 1 hospital based wound care center records reviewed, and had the potential to negatively affect all patients served by the facility.

Findings include:

PI # 21 presented to the wound care center on 8/22/19 for a Diabetic Foot Ulcer wound care follow up visit.

Review of the Wound Care Center Progress Note dated 8/22/19 revealed the following summary of events:

PI # 21 was observed in the wound care center waiting area by a Employee Identifier (EI) # 4, Registered Nurse (RN) Wound Care Center, who then told the RN Team Leader that the patient looked like "he/she is ready to fall out." PI # 21 was wheeled into the wound care center hallway and vital signs including, pulse of 49, blood pressure of 125/58, and respiration rate of 16 were performed. While in the hallway, EI # 7, Medical Doctor, "came out to observe patient and noticed that he/she was ill appearing cachexic (condition that causes extreme weight loss and muscle wasting), nauseated and dry heaving in a clear plastic bag. He/She appeared severely dehydrated, eyes sunken and termporal (temporal) waisting (wasting)..." EI # 7 recommended the patient be evaluated in the ER (Emergency Room). PI # 21 refused to go to the ED for evaluation and then requested to go to the restroom. While in the restroom, PI # 21 had a bowel movement (BM) which EI # 7 documented "had a strong odor not unlike melena (dark sticky feces containing partly digested blood)." EI # 7 attempted to speak with PI # 21 following the BM and documented "his/her mental status was waxing and waning in and out of consciousness." EI # 7 instructed EI # 4 to call 911. PI # 21 was then taken to wound care exam room with the EI # 4 who waited with PI # 21 until EMS arrived. When EMS arrived EI # 7 went into the exam room with PI # 21 and was notified by EMS that Southeast Alabama Medical Center was on diversion. EI # 7's documented response to EMS on the diversionary status was "he/she for sure needs emergent care and should not be discharged to his/her home without being evaluated in (the) ER." EMS placed PI # 21 on a stretcher and left the wound center.

Review of the Ambulance Patient Care Report dated 8/22/19 revealed documentation the ambulance was dispatched at 9:02 AM to Southeast Alabama Medical Center Wound Care and arrived at 9:08 AM. Emergency Medical Services (EMS) documented PI # 21's vitals signs as pulse 46, blood pressure 92/54, and respiration rate of 18.

Further review of the Ambulance Patient Care Report dated 8/22/19 revealed PI # 21 was transported to hospital # 2 at 9:26 AM.

Review of the ED Physician Transfer Line Form dated 8/22/19 revealed no documentation of a call from the Southeast Alabama Medical Center Wound Care.

Review of the Southeast Alabama Medical Center diversionary status listing revealed the facility was on a Med (Medical) Surg (Surgical) diversion from 8/21/19 at 11:30 PM until 8/22/19 at 2:50 PM.

The facility failed to provide documentation the patient was transferred to the ED for stabilizing treatment, a physician signed certification that contained a summary of the risks and benefits to the patient required for transfer, the receiving hospital had been contacted and accepted the patient, and the receiving hospital was provided the patient's medical records.

Interviews:

1. An interview was conducted on 10/2/19 at 8:20 AM with EI # 2, Director of Emergency Services, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 2 was asked the process for transferring patient's from an outpatient department of the hospital, such as the wound care center, to the ED. EI # 2 stated "anything that's in the main hospital there is a code 9. A team from the ED would go there or the department would bring the patient to the ED. Outside of the actual building would be a 911 call or if we are notified we would still respond to those areas." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 2 stated, "if someone is on our immediate campus the patient should be brought to us regardless of a diversionary status."

EI # 2 was asked if the wound care center was on the hospital campus. EI # 2 stated, "it meets the 250 yard rule."

2. An interview was conducted on 10/2/19 at 8:43 AM with EI # 3, Director of Quality Management, to determine the facility's transfer practices related to outpatient departments and ED diversionary status. EI # 3 was asked what the process was for the outpatient departments/clinics to transfer a patient to the ED for evaluation. EI # 3 stated, "they call 911 and they are supposed to notify the ED..." When asked if a med/surg diversion should affect a patient that required ED services within an outpatient department/clinics of the hospital campus. EI # 3 stated, "If they are on campus it should not affect the patient. If EMS is called, they should bring the patient here..."

EI # 3 confirmed the wound care center was within 250 yards of the hospital campus.

3. An interview was conducted on 10/2/19 at 9:18 AM with EI # 5, RN, Inpatient Wound, Ostomy, and Continence Nurse, who was the first person to observe PI # 21's condition. EI # 5 stated, "I was taking wound vac's to the wound center. As a car left the building I saw a man/woman holding onto the handrail. His/Her color was awful. I got a wheelchair and took him/her in the lobby. I told (employee identified) at the window they need to get him/her help. He/She really looked like he/she might die."

4. An interview was conducted on 10/2/19 at 9:25 AM with EI # 4, RN, Wound Care Center Team Leader, to describe what he/she knew about the care of PI # 21. I was told "you have a patient out there that doesn't look good. Do you want me to bring him/her back?" I told him/her yes. I started to get his/her vitals. Medical Doctor (MD) came down. MD said he/she needed to go to the ER. The patient refused and went to the bathroom. MD talked with him/her again and then told me to call 911 because he/she was in and out of consciousness. I called 911, took him/her to a room, and sat with him/her until 911 got there. The EMS said, 'you know southeast health is on diversion.' MD said well he/she can't go home. The EMS asked if he/she (referring to EI # 7) wanted him/her to go to (hospital # 2 identified). MD said he/she can't go home, take him/her to Hospital # 2 then.

EI # 4 was asked what the process was to transfer a patient to the ED for an evaluation from the wound care center. EI # 4 stated, "We call 911. We call a code 9 and give report to the ER."

During a follow up interview with EI # 4 on 10/2/19 at 2:32 PM, EI # 4 confirmed there was no documentation a code 9 was initiated or a report was given to the ER for PI # 21.