HospitalInspections.org

Based on observations, record review, and interview, the hospital failed to ensure a system for controlling infections and communicable diseases of patients and personnel was established during a national pandemic of COVID-19. This deficient practice was evidenced by the hospital's failure to include surveillance/monitoring of PPE use to ensure PPE was utilized correctly to prevent the spread of COVID-19 or other infections.

Findings:

Review of a copy of the Infection Control quality dashboard listing quality indicators, provided by S3IC as current, revealed no surveillance for PPE use for staff and/or patients as indicated.

In an interview 07/17/2020 at 2:00 p.m., S3IC reported that the provider did not conduct and document surveillance/monitoring of staff use of PPE, or patient use of PPE, as a part of their infection prevention program quality assurance. S3IC confirmed the quality/performance improvement dashboard did not include surveillance/monitoring of PPE use to ensure the most current procedures for PPE use were performed correctly by hospital personnel in order to prevent the spread of COVID-19 or other infections.

Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by failing to accept an appropriate patient transfer request for which the hospital had the capacity and specialized capability to provide the required stabilizing treatment. This deficient practice is evidenced by the failure of the hospital to accept a patient transfer (Patient #1) from the transferring hospital Emergency Department's physician who had requested orthopedic services for Patient #1. The hospital had an available on call orthopedic physician to evaluate and treat the patient, and had bed availability on the date the transfer was requested for 1 (#1) of 20 sampled patient records reviewed. (See findings A-2411).

Based on review of policies and procedures, and interviews, the hospital failed to accept an appropriate patient transfer for which the hospital had the capacity and capability to provide the stabilizing treatment required by the patient's condition. This deficient practice was evidenced by failure to accept a patient transfer (Patient #1) from the transferring hospital Emergency Department's physician who had requested orthopedic services for Patient #1. The hospital had an available on call orthopedic physician to evaluate and treat the patient, and had bed availability on the date the transfer was requested for 1 (#1) of 20 sampled patient records reviewed.


Findings:


Review of the hospital's Medical Staff Bylaws revealed the following, in part:

Medical Staff Bylaws Article IV: Medical Staff Qualifications, Responsibilities, and Privileges, (c) Scheduling: The Emergency Department call schedule will consist of physicians' representative of each of the services provided by the Hospital to the general public. The Medical Executive Committee will determine the extent of coverage required by specialty, which shall be based upon the frequency of emergency cases requiring care within such specialty, the likelihood that the patient's recovery would be compromised by the unavailability of such specialist, and the number of Practitioners within such specialty having the obligation to participate in the call schedule. The Medical Executive Committee will establish a method by specialty for meeting such coverage requirements. The determination of the level of need and the manner in which this need is met shall be subject to the review and approval of the Board of Trustees to insure full compliance with EMTALA and all applicable laws pertaining to care of emergency patients.


Review of the ED medical record from Hospital "B" for Patient #1 revealed, the patient presented to the ED of Hospital "B" on 06/30/2020 at 4:42 p.m. with left arm swelling, redness, and drainage that began after injecting heroin into the left antecubital a few days prior,. The condition progressively worsened and expanded to the proximal forearm and distal bicep. A patient evaluation was performed which included an all systems review, vital sign assessments, and laboratory tests.


Review of the attending physician's note, dated 06/30/2020 at 6:50 p.m., revealed the following: I gave the patient options of hospitals in town that could provide him with Orthopedic services as the patient is going to need an incision and drainage. He requested to be sent to Ochsner Medical Center Baton Rouge. Regional Referral Center "A" indicated they had Orthopedics on call and contacted S7Ortho (Orthopedics on call at Ochsner Medical Center Baton Rouge on 06/30/2020). According to the nurse handling the transfer, S7Ortho refused the transfer and would not give a reason. The patient then requested a transfer to another area hospital (Hospital "A") to receive Orthopedic Services and arrangements were made.


Review of the Regional Referral Center "A" secure text chat conversation, provided by S6RegRefCtr (Vice President of Patient Flow for Regional Referral Center "A"), dated 06/30/2020, concerning a request to transfer a patient (Patient #1) from Hospital "B" to receive Orthopedics services at Ochsner Medical Center - Baton Rouge, revealed the following text communications:

ED Nurses Station (from Hospital "B" inquiring if Ochsner Medical Center- Baton Rouge had Orthopedic service availability):

Situation: shot up heroin in left a/c (antecubital) and now has an abscess;

Past Medical History: Drug abuse.

Imaging: X-ray elbow mild to moderate tissue swelling around joint

Service needed: Ortho.

6/30/2020 6:27 p.m. Secure chat sent to S7Ortho (Orthopedics on call for Ochsner Medical Center Baton Rouge) requesting transfer of Patient #1 for Orthopedic services.

6/30/2020 6:28 p.m.: Secure chat response from S7Ortho, Orthopedics on call, MD declines transfer request.

6/30/2020 6:48 p.m.: No medical surgical beds available at Ochsner Medical Center Baton Rouge.

6/30/2020 6:54 p.m.: To ED Nurses Station: Notified nurse requesting transfer that MD declined transfer.

6/30/2020 6:55 p.m. Secure chat from S7Ortho: I am not the emergency department. I will not accept a directed admission from an outside emergency room. Particularly an emergency room connected to a system that has access to a level two trauma center, which again, is HIGHER LEVEL OF CARE. End of discussion. Secure chat received.


Review of the hospital on-call schedule for Ochsner Medical Center Baton Rouge revealed S7Ortho was providing Orthopedics coverage from 06/28/2020 - 07/5/2020 from 7 am-7 am (24 hour call).

A review was made of the hospital's inpatient census dated 06/30/2020 by S9RegPI, and she said there was no lack of available medical surgical beds on that date. S9RegPI confirmed the hospital should have been able to accept a transfer of a patient from another hospital who required a medical surgical bed.


In an interview on 07/17/2020 at 10:15 a.m., with S2CNO, she reported part of the function of Regional Referral Center "A" was to have one source that could let them know availability of specialty MDs quickly without having to use nursing staff to place calls for specialty availability as was the practice in the past. She indicated, she was sure part of the function of Regional Referral Center "A" was to keep track of all encounters/transfer requests, including refusals/reasons for refusals.


In an interview on 07/20/2020 at 8:53 a.m., with S8EDMedDir, he indicated the first step in receiving a transfer is the sending facility contacts Regional Referral Center "A" and the center finds out what the patient's needs are, and then from there the center contacts the specialist to ensure they have the capability to care for that type of patient. S8EDMedDir indicated the nursing supervisor is contacted to ensure bed availability. S8EDMedDir indicated the ED MDs are not involved until the very end of the acceptance process because they receive the patient in the ED.


In an interview on 07/20/2020 at 9:07 a.m., with S4EDNsgMgr, she reported typically if someone calls to ask to transfer a patient, they should call Regional Referral Center "A" in New Orleans because they are the gate keeper for coordinating transfers. She explained the Regional Referral Center "A" representative talks to the transferring facility, and they get a basic patient report, specialty needs of the patient, bed type, and Regional Referral Center "A" connects them to the specialty physician on call. She further explained if the transfer is approved by the specialty physician on call and beds are available, then the ED MD gets looped in at that point because they must know about the patient. She indicated the House Supervisor would be involved in the bed availability aspect of the transfer. She confirmed lack of capacity and capability are two reasons a transfer may not be accepted. She indicated the specialist informs Regional Referral Center "A" whether or not they can accept the transfer and she confirmed they must give a reason as to why they can't accept the transfer if they decline the transfer.


In an interview on 07/20/2020 at 9:45 a.m., with S7Ortho, he indicated he is part of a contracted call group that supplies physicians for the hospital. He indicated that when he is on call for the hospital his main focus is to treat anyone coming in through the ED in need of Orthopedic services. S7Ortho reported on 06/30/2020, he responded to a secure chat requesting a transfer from another emergency department. He explained that he was not an ED MD, he was a consultant, and he did not accept direct admits from an outside emergency department. He further explained that he does not direct admit to the hospital and his role is that of providing Orthopedic consulting services. He indicated, he consults on any patient who comes to the ED at this hospital in need of Orthopedics and he further indicated, he has never direct admitted patients. He said, transferred patient admissions are handled through the ED and they do not direct them to him to direct admit. He questioned why you would go from a regional hospital (Hospital "B") with 1,000 beds to a small community hospital with no trauma designation. S7Ortho said he should have spoken to Regional Referral Center "A" directly, but he didn't, he just used the secure chat text messaging system. He said, he directed Regional Referral Center "A" to the ED MD to accept or not accept the transfer. He said he didn't even investigate the request any further, his role is that of a consultant, and he never deals with the receiving end.


In an interview on 07/20/2020 at 10:24 a.m., with S10MD, he indicated he was working in the ED on 06/30/2020 for the mid shift from 12:00 p.m. - 9:00 p.m. He explained the transfer process regarding requests to transfer in were as follows: the outside facility calls Regional Referral Center "A", gets details of the case and what services are required, contacts the receiving hospital to confirm they would be capable of handling the case, verify they can handle the case, then they speak with the House Supervisor to confirm bed availability and to verify staffing in order to ensure they can take care of the patient from a nursing standpoint. He reported, after all of this information has been verified they then involve him, as the ED MD regarding the incoming patient because he would assume care of them at that point. S10MD confirmed if the hospital had the capability and capacity to treat a patient then the transfer should be accepted.


In an interview on 07/20/2020 at 11:19 a.m., with S8EDMedDir, he confirmed if you have a request for a transfer for orthopedic services, you have capability regarding availability of specialty on call (orthopedics) to treat the patient, and the bed capacity to accept the patient, then yes, the patient transfer should be accepted.