HospitalInspections.org

Based on review of Medical Records (MR), facility policies and procedures and interviews with staff it was determined the facility failed to:

1. Encourage a patient presenting with psychotic symptoms from leaving the Emergency Department (ED) prior to the completion of the Medical Screening Exam (MSE) for Patient Identifier (PI) # 3. Additionally, the facility failed to inform a patient who refused to consent to stay for completion of the MSE of the risks and benefits of the examination and stabilizing treatment. Refer to findings in Tag A-2407.

2. Provide a non-delayed acceptance of a transfer from Hospital B, Transferring Hospital, to inquire about the individual's method of payment or insurance status which caused a delay in the transfer and continuation of the MSE for PI # 22. Refer to findings in Tag A-2408.

3. Accept an appropriate transfer from Hospital B, of PI # 22, who was experiencing a Ruptured Globe of Right Eye, and required the facility's specialized capabilities when the facility had the capability and capacity to treat PI # 22. Refer to findings in Tag A-2411.

Based on review of facility policy and procedure, medical records (MR), and interview with staff, it was determined the facility failed to inform a patient who refused to consent to stay for completion of the Medical Screening Exam (MSE) of the risks and benefits of the examination and stabilizing treatment.

The deficient practice affected 1 of 1 patients reviewed who eloped from the facility ED with psychotic symptoms, including Patient Identifier (PI) # 3 and had the potential to affect all patients served by the facility Emergency Department (ED).

Findings Include:

Facility Policy: Refusal of Care by Patients AMA (Against Medical Advice)
Review/Revision Date: 7/2/21

Policy: Management of the patient in the ED who refuses care.

Procedure: In the event a patient refuses care prescribed by the ED physician...documentation of the event in the EMR (electronic MR) should be performed to include, but not limited to, the following:

...5. Verification that the patient understands the possible complications and risks associated with not following medical advice.

1. PI # 3 presented to the ED on 11/29/21 at 12:29 AM. Review of the MR revealed:

An ED Triage note at 12:32 AM, which documented the patient stated the chief complaint as "...I need to bleed so I can get air." Further review revealed nursing documentation of "...Answers most questions appropriately but does seem to have some flight of ideas. Blood noted to hand, states it came from aortic artery in (his/her) hand. Denies Suicidal/homicidal ideations..."

An ED Physician Note at 12:47 AM revealed documentation of the patient had a history of Schizophrenia and presented psychotic features appearing paranoid and tangential with a self inflicted cut to left hand. The physician documented the patient had cut a hole in the palm of his/her left hand because "...I need more oxygen in my blood..." The patient denied any auditory or visual hallucinations and suicidal or homicidal ideations. The physician documented the "Location/Symptoms: Acute Psychosis, Paranoia, Self Mutilation Timing/Onset: this evening Duration: constant...Severity: moderate to severe..." The physician documented the patient was pending work up and psych evaluation and "...staff informs me that pt has eloped from the ER (emergency room); police notified...Impression: psychotic, self mutilation...Disposition: eloped..."

A Nursing Note at 3:16 AM revealed documentation of the patient walked out of the ED and the nurse approached the patient about removing the intravenous (IV) line to which the patient responded he/she had removed the IV themselves, was tired and wanted to go home. The nurse documented the police department was notified and would go to the home to check on the patient.

Review of the ED Discharge Information revealed PI # 3 departed the ED at 3:15 AM with a discharge disposition of "elope after provider".

Review of the MR revealed no documentation the patient was provided the risks and benefits of the staying for the completion of the MSE and stabilizing treatment with verification the patient understood.

An interview was conducted on 4/8/22 at 1:45 PM with Employee Identifier # 1, Chief Quality Officer, who confirmed there was no documentation the patient was provided the risks and benefits of the staying for the MSE and stabilizing treatment with verification the patient understood.

Based on review of medical records (MR), facility policy and Hospital B, Transferring Hospital, transfer center audio calls, it was determined Hospital A (Flowers Hospital) delayed acceptance of a transfer from Hospital B to inquire about the individual's method of payment or insurance status which caused a delay in the transfer and continuation of the Medical Screening Examination (MSE).

This did affect Patient Identifier (PI) # 22 and had the potential to affect all patients with a request for transfer to Flowers Hospital.

Findings include:

Facility Policy: Emergency Medical Treatment and Active Labor Act (EMTALA)
Version: 4
Review Date: 2/5/21

...II. Medical Screening Exam

...3. Inquiry Regarding Insurance Status

An MSE, stabilizing treatment, or appropriate transfer may not be delayed in order to obtain patient financial information...

1. PI # 22 presented to Hospital B, Transferring Hospital on 3/29/22 at 3:19 AM via ambulance with a chief complaint of Motor Vehicle Crash (MVC) and Trauma.

Review of the ED (Emergency Department) Provider Note dated 3/29/22 at 3:19 AM revealed PI # 22 complained of right eye swelling and pain. Physical Exam findings included a "massive right proptosis (upper eyelid droops. https://www.aao.org) and chemosis (occurs when inner lining of the eyelids swell. https://www.health.com) with the complete hyphema (blood collects inside front of the eye. https://www.aao.org) obscuring vision and even light sensitivity. Ocular pressure on the right was 4, left was 7. There is a jagged laceration lateral to the lateral canthus, 4-5 cm (centimeter) total. Pupil on the right is not reactive... Severe tenderness with palpation or manipulation of the right eye... Intoxicated."

Review of the ED Provider Note dated 3/29/22 at 4:59 AM revealed an "open globe noted on CT (Computerized Tomography) scan, attempted to contact (Employee Identifier # 3, Flowers Hospital on-call Ophthalmologist identified)...awaiting call back..."

Review of the ED Provider Note dated 3/29/22 at 7:00 AM revealed PI # 22 was diagnosed with a Ruptured Globe of Right Eye.

Review of the ED Provider Note dated 3/29/22 at 7:48 AM revealed PI # 22 had a suspected right globe rupture with significant intraocular hemorrhage (bleeding inside the eye), medial and inferior orbital wall fracture with no obvious muscle entrapment and "...extensive discussions..." with Employee Identifier (EI) # 3.

Review of Hospital B's Transfer Center Audio Calls dated 3/29/22, no time documented, revealed Hospital B's ED Physician, spoke with EI # 3 and explained PI #22 was in a MVC with a ruptured globe and inferior orbital fracture. After a discussion about the patient's condition, including sobriety level with an alcohol level of 200 (alcohol level: normal 0-50 mg/dl. https://ebmconsultat.com), and the patient going to the surgery center versus Hospital A, EI # 3 asked if the patient had insurance. While the ED physician attempted to locate insurance information for PI # 22, the discussion continued about PI # 22's medical status and test results. At the end of the phone call, the ED physician revealed to EI # 3 the patient did not have insurance. EI # 3 then verbalized to send PI # 22's CT results and EI # 3 would "...let you know what to do..."

The facility failed to ensure that the policy and procedure was followed as evidenced by EI # 3 delayed acceptance of PI # 22 from Hospital B to inquire about the method of payment or insurance status which caused a delay in the transfer.

Based on review of the facility policies, medical record (MR) reviews, facility Transfer Center Call Summary, Hospital A and Hospital B Audio File Transcripts, facility On Call Calendar, facility bed census review, Ambulance Run Report, and staff interviews, it was determined Flowers Hospital (FH), Hospital A, refused to accept from Hospital B an appropriate transfer within the boundaries of the United States, Patient Identifier (PI) # 22, who was experiencing a Ruptured Globe of Right Eye, and required Hospital A's specialized capabilities. Hospital A had the capability and capacity to treat PI # 22, when contacted by Hospital B which did not have the capability of treating PI # 22. PI # 22 was ultimately transferred to Hospital C.

This deficient practice affected 1 of 1 emergency transfer requests reviewed, who were appropriate for transfer to the facility and, which FH had the capability and capacity to treat and had the potential to affect all patients with a request for transfer to FH.

Findings include:

Facility Policy: EMTALA (Emergency Medical Treatment and Active Labor Act) Medical Screening Stabilization Policy
Revision Date: 3/26/19

...Medical Screening Examination Requirements

...10. A Hospital that is not in diversionary status may not refuse or fail to accept a telephone or radio request for transfer or admission...

Facility Policy: EMTALA
Version: 4
Review Date: 2/5/21

...IV. Transfer of Individuals.

...G. No refusal of transfer from other facilities

A hospital that is not in diversionary status may not refuse or fail to accept a request for appropriate transfer or admission of an individual with an EMC (Emergency Medical Condition) if the individual requires a specialized service...if the hospital has the capacity to treat the individual, and the transferring facility does not have the specialized services needed. The hospital must accept the determination by the transferring facility, hospital or QMP (Qualified Medical Provider) that the patient has an EMC. Any failure or refusal could represent a violation of the Hospital's obligations under EMTALA...

1. PI # 22 presented to Hospital B, Transferring Hospital on 3/29/22 at 3:19 AM via ambulance with a chief complaint of Motor Vehicle Crash (MVC) and Trauma.

Review of the ED (Emergency Department) Provider Note dated 3/29/22 at 3:19 AM revealed PI # 22 complained of right eye swelling and pain. Physical Exam findings included a "massive right proptosis and chemosis with the complete hyphema obscuring vision and even light sensitivity. Ocular pressure on the right was 4, left was 7. There is a jagged laceration lateral to the lateral canthus, 4-5 cm (centimeter) total. Pupil on the right is not reactive... Severe tenderness with palpation or manipulation of the right eye... Intoxicated."

Further review of the ED Provider Note dated 3/29/22 at 4:59 AM revealed an "open globe noted on CT (Computerized Tomography) scan, attempted to contact (Employee Identifier # 3, Flowers Hospital on-call Ophthalmologist identified)...awaiting call back..."

Review of the ED Provider Note dated 3/29/22 at 7:00 AM revealed PI # 22 was diagnosed with a Ruptured Globe of Right Eye.

Review of the ED Provider Note dated 3/29/22 at 7:48 AM revealed PI # 22 had a suspected right globe rupture with significant intraocular hemorrhage, medial and inferior orbital wall fracture with no obvious muscle entrapment. Employee Identifier (EI) # 3 (Hospital A) was contacted for transfer of PI # 22 to FH who recommended transfer to the ED at FH for further evaluation of the eye due to possibility of it not being a globe rupture but a small posterior rupture. The ED provider contacted EI # 5, FH ED Physician, who accepted PI # 22 for transfer initially but called back about "...5-10 minutes later..." and refused to accept PI # 22 for transfer due to EI # 3 not accepting the patient. The ED Provider documented EI # 3 had informed him/her of the inability to accept PI # 22 since the patient was a trauma and was intoxicated, which was the reason for the ED-to-ED transfer and the FH physicians were talking behind the scenes. The ED Provider documented "I am also reaching out to (Hospital C, Receiving Hospital identified) as I am now 2-1/2 (two and a half) hours in to attempting to find an appropriate specialist to evaluate this patient's potential ruptured globe."

Further review of the ED Provider dated 3/29/22 at 7:48 AM revealed PI # 22 was accepted at Hospital C even though there were concerns about how the patient would return home to which the Provider documented "...this patient requires emergent ophthalmologic evaluation... I do not at this point have a closer alternative..."

Flowers Hospital (FH), Hospital A, Transfer Center Call Summary, audio file transcripts and Hospital B, Transferring Hospital audio file transcripts:

Review of the Transfer Center Call Summary dated 3/29/22 at 5:10 AM, Hospital B, Transferring Hospital, requested a transfer for PI # 22 due to a right eye injury and MVC.

Review of the 3/29/22 FH Audio File Transcript, no time documented, revealed the initial transfer request call from Hospital B and the on-call physician (Hospital A) would return the call to Hospital B.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 5:25 AM, the reason for transfer was updated to Right Hyphema, Ruptured Right Globe.

Review of 3/29/22 Hospital B Audio File Transcript, no time documented, revealed the initial contact between Hospital B's ED Physician and a staff member of EI # 3, FH on-call Ophthalmologist. The ED Physician provided EI # 3's staff with the following information, PI # 22 was a patient involved in a MVC, was intoxicated and ran his/her car off side of the road and CT results revealed the only injury to the patient was a ruptured right globe with complete vision loss and a hemorrhage kind of feeling in entire ocular space. The ED Physician then verbalized since PI # 22 was intoxicated he/she presumed surgery would need to happen at a hospital opposed to the eye center. EI # 3's staff verbalized EI # 3 would return the call to the ED Physician.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 5:32 AM, the call center was notified contact with Hospital B had been made and EI # 3 would be speaking with Hospital B's ED Physician.

Review of 3/29/22 Hospital B's Audio File Transcript, no time documented, revealed Hospital B's ED Physician informed EI # 3 of the patient's condition, including PI # 22 was in motor vehicle accident with a 200-alcohol level, the CT showed a right orbital floor and medical orbital wall displace fractures with no Extraocular muscle entrapment, ruptured right globe and intraocular hematoma. At the end of the conversation EI # 3 asked to be sent the CT report to review and notified the ED Physician he/she would call them back.

Review of 3/29/22 Hospital B's Audio File Transcript, no time documented, revealed Hospital B's ED Physician spoke with FH ED Physician about PI # 22's condition and a conversation with EI # 3, who felt the globe might not be ruptured and would like to examine PI # 22 in the ED. At the end of the conversation FH's ED Physician accepted the patient for an ED-to-ED transfer.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 6:57 AM, revealed PI # 22 was accepted for an ED-to-ED transfer with EI # 3 to evaluate in FH ED.

Review of 3/29/22 Hospital B Audio File Transcript, no time documented, revealed FH ED Physician notified Hospital B's ED Physician, FH was denying the transfer request due to EI # 3 not accepting the patient. FH ED Physician continues with he/she has just taken ATLS (Advanced Trauma Life Support), and a ruptured globe should be transferred to a place who can provide definitive care and FH does not repair ruptured globes. Hospital B's ED Physician verbalized he/she has spoken with EI # 3 since 4 AM trying to get PI # 22 evaluated by an Ophthalmologist. EI # 3 requested the patient to be transferred for evaluation, and this is delaying the patients care since there was not another Ophthalmologist within 150 miles.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 6:59 AM, revealed PI # 22's transfer request was changed to "cancel" with explanation of "sending (hospital) found placement elsewhere."

Review of the FH Transfer Center Call Summary dated 3/29/22 at 7:00 AM, revealed the call center staff was notified by FH ED charge nurse, PI # 22's injury was out of the scope of EI # 3 practice and PI # 22 was declined for transfer.

Review of the 3/29/22 FH Audio File Transcript, no time documented, revealed the call center staff was notified by the FH ED charge nurse, PI # 22 was not accepted for transfer due to EI # 3 does not handle the type of eye injury the patient has and would not accept PI # 22. The ED charge nurse verbalized Hospital B would need to be called back and told PI # 22 was not accepted for transfer.

Review of the 3/29/22 FH Audio File Transcript, no time documented, revealed the call center staff notified Hospital B's, ED Physician, PI # 22's injury was out of the scope of practice for EI # 3, and the transfer request was denied. Hospital B, ED Physician requested EI # 3 to call personally to confirm it was out of EI # 3 scope of practice.

Review of the 3/29/22 FH Audio File Transcript and Hospital B's Audio File Transcript, no time documented, revealed EI # 3 spoke with Hospital B's, ED Physician. In the call Hospital B's ED Physician verbalized he/she told FH's ED Physician he/she had spoken with EI # 3, and the patient needed to be transferred ED to ED for EI # 3 to consult on the patient, to look at the anterior chamber, since it was unclear if the globe was ruptured. The FH ED Physician initially accepted PI # 22 for transfer then not 5 minutes later called back and verbalized he/she (FH ED Physician) had recently taken ATLS, and a globe rupture was high energy and should be transferred to another facility. Hospital B's ED Physician expressed his/her frustration due to trying to get PI # 22 transferred for continued care since 4:45 AM and FH was the only facility with Ophthalmology on-call for 150 miles. EI # 3 responded that he/she told the FH ED Physician, EI # 3 was not accepting the patient, because "I don't accept anybody" but would consult in the ED on the patient. EI # 3 verbalized the FH ED Physician said since EI # 3 would not accept the patient, the patient would not be accepted for transfer. EI # 3 verbalized the FH ED Physician was told EI # 3 would look at the eye and would decide if he/she could repair the injury or if PI # 22 would need to be transferred to another facility. EI # 3 further verbalized he/she felt PI # 22 deserved an evaluation and there was a reasonable chance it was not ruptured due to the AC (Anterior Chamber). Following the physician's conversation, the call center staff asked Hospital B's ED Physician about the plan for PI # 22. Hospital B's ED Physician verbalized PI # 22 would be transferred to another facility where they could get the needed care and he/she felt the declined request represented an EMTALA violation. The call center staff notified Hospital B's ED Physician, FH administration was notified of all declined transfers. The ED Physician then stated, "...to be clear, I was requesting transfer to a hospital that has capability, capacity with a specialist on call that could at least look and evaluate this patient and we don't know if it's too complex for the consultant or not. That's why I contacted (FH ED Physician identified) to accept (the patient) in transfer. He/She (FH ED Physician) refused. I am going to send...elsewhere." The call center staff verbalized understanding and the call was ended.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 7:26 AM, revealed FH administration on call, EI # 2, Assistant Chief Nursing Officer, was notified of declined transfer request.

Review of the 3/29/22 FH Audio File Transcript, no time documented, revealed the call center staff notified EI # 2 of the declined transfer request for PI # 22, who EI # 3 agreed to consult on since there was uncertainty as to whether the globe was ruptured. EI # 2 requested to speak with EI # 3. The call center staff attempted to reach EI # 3 unsuccessfully and EI # 2 was told a message was left asking EI # 3 to call EI # 2.

There was no documentation or audio file for the call between EI # 3 and EI # 2.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 8:23 AM and 3/29/22 FH Audio File Transcript, no time documented, revealed EI # 2 notified the call center staff an ED nurse at Hospital B was notified FH would accept PI # 22 for a ED to ED transfer but to be aware there was a "...high degree of likelihood that we did not have the equipment to take care of the patient ..." EI # 2 then asked the call center staff to follow up with Hospital B to see if PI # 22 was to be transferred to FH ED.

Review of the FH Transfer Center Call Summary dated 3/29/22 at 8:30 AM and 3/29/22 Hospital B Audio File Transcript, no time documented, revealed the call center spoke with Hospital B, ED Nurse and was advised placement for PI # 22 was found at another facility.

Review of the FH Bed Census Review dated 3/29/22 revealed FH ED had 13 available ED beds from 5:00 AM until 7:00 AM, 12 available ED beds from 7:00 AM until 8:00 AM, and 11 available ED beds from 8:00 AM until 9:00 AM.

Further review of the FH Census Review dated 3/29/22 revealed FH four north had 4 available beds, fifth floor had five available beds and sixth floor had seven available beds.

Review of the FH On-call Physician Calendar dated 3/29/22 revealed EI # 3 was the on-call Ophthalmologist for FH.

Review of the Ambulance Run Report dated 3/29/22 revealed PI # 22 was transferred at 11:55 AM from Hospital B, Transferring Hospital, and arrived at Hospital C, Receiving Hospital at 3:24 PM.

Review of Hospital C, Receiving Hospital, MR revealed PI # 22 was transferred to Hospital C on 3/29/22 where the patient underwent an Open Globe Exploration and Repair to the Right Eye and Left Eye Exam under Anesthesia then discharged home on 3/29/22.

An interview was conducted on 4/7/22 at 4:05 AM with EI # 2 who confirmed if a hospital calls for a transfer and we (FH) have the capacity and the capability we are required to accept the transfer. EI # 2 also verbalized he/she remembered the transfer request on PI # 22. EI # 2 verbalized he/she received a call from the transfer center staff who explained the issue and we may not have capability along with the conflict between the providers. EI # 2 verbalized he/she spoke with EI # 3 who confirmed he/she was willing to see the patient. Then EI # 2 spoke with FH's ED Physician to clarify EI # 3's role and obtained the acceptance for PI # 22. Following the acceptance, EI # 2 contacted Hospital B about 8:00 AM to convey acceptance of PI # 22. EI # 2 verbalized if PI # 22 would have been transferred and required FH admission, PI # 22 would have been placed on four north, fifth floor or sixth floor.

The facility failed to ensure that their policies and procedures were followed as evidenced by failing to accept an appropriate transfer of PI # 22 on 3/29/22, who required the hospital's specialized ophthalmic capabilities and services.