HospitalInspections.org

Based on interviews and review of records, it was determined that the hospital failed to comply with CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases.

Findings include:

As detailed in Tag 2409, it was determined that the hospital failed to assure that an appropriate transfer was effected for 7 of 9 potentially medically unstable patients who were transferred, and therefore, failed to comply with CFR §489.24.


Reference Tag 2409

Based on interviews and review of records, it was determined that the hospital failed to assure that an appropriate transfer were effected for 7 of 9 potentially medically unstable patients whose medical records were reviewed. The hospital's failure to document that the risks and benefits of transferring potentially unstable patients were explained to the patients and/or the patients' representatives, and/or to document the medical stability of the patients, deprived the patients/representatives of the right to be informed of the potential risks and benefits involved in the transfer, as well as the right to refuse the transfer.

Findings include:

PATIENT #1
1.) Patient #1, who was the patient identified in the complaint, was admitted to the Swedish Medical Center - Issaquah Emergency Department (ED) for respiratory distress.
2.) The patient was transferred from the ED at Swedish - Issaquah to Swedish - 1st Hill.
3.) The Swedish - Issaquah ED physician's documentation stated "...a request was made by our hospitalist [physician name] to transfer this patient to First Hill for continuity of care, as [the patient] had had a recent hospitalization there as well, and obtain an non [sic] contrast abdomen CT prior to transfer...arrangements for BLS [Basic Life Support] transfer were made after discussion and acceptance by Dr. [physician name]...at time of transfer, the patient responded very well to IV hydration...Patient is stable for transfer to Swedish First Hill."
4.) Later documentation from the ED physician, under "Critical Care Note", stated "This patient meets the criteria for critical care due to the high probability of imminent deterioration in the patient's condition. System at risk for life-threatening failure: circulatory and respiratory..."
5.) The transfer form stated that the patient was transferred for "specialized treatment or services at receiving facility. Admit - IV [intravenous] fluids".
6.) Review of the documentation did not confirm that the potential risks and benefits had been explained to the patient/patient representative, or that the patient/patient representative had agreed to the transfer.
7.) The portion of the transfer form for physician certification of the need for transfer of the patient had been signed by a nurse, not the patient/patient representative and the portion of the form which was the physician certification explaining the patient's status was not completed. I.e., whether the patient had been stabilized within reasonable medical probability that no material deterioration was likely to result from the transfer, or the patient was unstable but the medical benefits of transfer outweighed the potential risks associated with the transfer.
8.) The medical record was reviewed on March 31, 2017 with the Chief Nursing Officer (CNO) and the Administrative Director (AD) for Accreditation, Safety and Injury Management. Both confirmed the above findings and confirmed that Swedish Medical Center - Issaquah had a critical care service which could provide IV fluids.

PATIENT #8
1.) Patient #8 was admitted to the Swedish Medical Center - Issaquah ED for evaluation of a head injury after a fall.
2.) The patient was transferred from the ED at Swedish Medical Center - Issaquah to another, non-Swedish Medical system hospital.
3.) The ED physician documentation stated that the patient had "multifocal parenchymal and subarachnoid hemorrhage" [multiple areas of bleeding into the brain] and "right occipital bone fracture" [skull fracture], as well as a subdural hematoma [bruise on the brain]".
4.) The portion of the transfer form for physician certification of the need for transfer of the patient was not completed. I.e., whether the patient had been stabilized within reasonable medical probability that no material deterioration was likely to result from the transfer, or the patient was unstable but the medical benefits of transfer outweighed the potential risks associated with the transfer.
5.) The medical record was reviewed on March 31, 2017 with the CNO and the AD, who confirmed the above findings.

PATIENT #14
1.) Patient #14 was admitted to the Swedish Medical Center - Issaquah ED for complaints of flank pain.
2.) The patient's diagnoses included an epidural abscess and s/he was transferred from the ED at Swedish Medical Center - Issaquah to Swedish Medical Center - Cherry Hill.
3.) Documentation from the ED physician stated "...is transferred to Swedish Cherry Hill due to specialty care provided at the receiving facility. Patient consents to the transfer. Benefit of the transfer outweighs the risk...Pt. is medically stable for transfer."
4.) Review of the medical record revealed that there was not a transfer form with physician certification that the patient was stable/unstable, nor was there a patient signature regarding request and/or acceptance of the transfer.
5.) The medical record was reviewed on March 31, 2017 with the CNO and the AD, who confirmed the above findings. The CNO stated that the hospital's computer system had been non-functioning at the time of the transfer, and no transfer form had been generated.

PATIENT #15
1.) Patient #15 was admitted to the Swedish Medical Center - Issaquah ED for symptoms of a stroke.
2.) The patient was transferred from the ED at Swedish Medical Center - Issaquah to Swedish Medical Center - Cherry Hill.
3.) The physician's documentation included the statement that the patient had presented "...with acute neurologic changes from baseline requiring [the ED physician's] immediate evaluation with high potential for clinical deterioration from CVA [cerebrovascular accident, or "stroke"] requiring multiple exam interpretations, consultations with radiology, inpatient neurology, multiple re-evaluations to ensure no clinical deterioration..."
4.) The physician documentation, under heading "DISPOSITION", stated: "After careful consideration of the patient's presentation, the results of testing done in the ED and the patient's ED course, I believe the patient requires further evaluation and/or treatment which cannot safely be done as an outpatient and the patient requires admission to the hospital. Therefore, [Patient #15] will be admitted to Swedish Cherry Hill neuro critical care unit...Pt. is ready for admission and stable for transfer out of the Emergency Department."
5.) The documentation did not explain why that care could not be provided at Swedish Medical Center - Issaquah.
6.) The portion of the transfer form for physician certification of the need for transfer of the patient had been signed by the patient's daughter, but the physician certification portion, which described the patient's status, had not been completed. I.e., whether the patient had been stabilized within reasonable medical probability that no material deterioration was likely to result from the transfer, or the patient was unstable but the medical benefits of transfer outweighed the potential risks associated with the transfer.
7.) The medical record was reviewed on March 31, 2017 with the CNO and the AD, who confirmed the above findings.

PATIENT #16
1.) Patient #16 was a pediatric patient who was admitted to the Swedish Medical Center - Issaquah for abdominal pain and vomiting.
2.) The patient was transferred to Swedish Medical Center - First Hill.
3.) The physician's documentation stated that the "Plan will be for surgical management of acute appendicitis. [S/he] was transferred to first (sic) Hill without further incident".
4.) The physician documentation did not explain why the patient could not be treated at Swedish Medical Center - Issaquah,or if the patient's parent/guardian had requested the transfer, nor did the documentation explain why it was determined that a pediatric patient with acute appendicitis that required surgery was safe to be transferred by private vehicle.
5.) The transfer form stated that the diagnosis was "appy", and the reason for transfer was checked as "specialized treatment or services at receiving facility". The form was not signed, witnessed or dated under the portion of the form titled "Patient Consent". The second page of the transfer form had a portion titled "Transfer by Private Vehicle", which was blank where the patient's name was to be filled in, and had no witness signature.
6.) On March 31, 2017 during the onsite investigation and in an email on April 10, 2017, the CNO confirmed that the Swedish Medical Center - Issaquah hospital did have the capability to perform outpatient surgery on pediatric patients, and could admit pediatric patients for up to 23 hours.

PATIENT #17
1.) Patient #17 was a pediatric patient who was admitted to the Swedish Medical Center - Issaquah ED for ear pain with drainage. The patient had a history of bilateral cochlear [ear] implants as well as bilateral tympanostomy tubes.
2.) The patient was transferred to a local childrens' hospital for IV antibiotics and further evaluation.
3.) The ED physician documented, under heading "CRITICAL CARE TIME", "...the severity of the patient's illness in the face of [her/his] cochlear implantation and the risk of central nervous system infection because of this as well as the possibility of infecting her implant requiring this to be replaced surgically. It includes discussions with the resident on several occasions as well as with the transfer center at [the receiving hospital]...I do consider the fact that the patient could also have a pneumonia...the patient has a progressive and worsening viral URI with subsequent otitis media."
4.) The medical record did not contain documentation of why the critically ill patient was safe to be transported via a private vehicle, nor did the record contain documentation of an explanation of the potential risks and benefits of treatment at another hospital.
5.) No transfer form was provided for this medical record.
6.) The medical record was reviewed on March 31, 2017 with the CNO and the AD, who confirmed the above findings.

Patient #21
1.) Patient #21 was an obstetrics patient who was admitted to the Swedish Medical Center - Issaquah ED at a gestational age of 23 3/7, with a complaint of vaginal bleeding.
2.) The patient was transferred to Swedish Medical Center - First Hill.
3.) The physician assessment documented that the patient came to the ED "...with vaginal bleeding and discomfort suggestive of abruptio placenta. She has a history of placental cyst and chriogangioma (sic) probably ruled out per US 'placental surface cyst' designation...consider transfer to Swedish First Hill for observation."
4.) Documentation by the Registered Nurse stated "Patient left the unit with EMR [Emergency Medical Response]...in stable condition."
5.) The physician documentation did not state why the patient required transfer to another hospital, or that the patient had requested or agreed to the transfer or that the risks and benefits of the transfer had been explained to the patient.
6.) No transfer form was provided for this medical record.
7.) The medical record was reviewed on March 31, 2017 with the CNO and the AD, who confirmed the above findings.