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Based on observation, staff interview, medical record and administrative document review, the hospital failed to comply with CFR 489.20 and 489.24 for one of one patients (Patient 1) when the hospital failed to provide an appropriate transfer for Patient 1 within its capability that minimized the risks to the individuals health; when the hospital failed to have an on-call list of physicians that provided adequate specialty on-call coverage consistent with the services provided at the hospital; when the hospital failed to have written policies and procedures in place to respond to situations in which particular specialties (neurologists and neurosurgeons) were not available; and when after the medical screen was done and the hospital had determined that an emergency medical condition existed the hospital failed to provide stabilizing treatment within its capability.

These failures resulted in potential for harm when the hospital had the capability and capacity to care for Patient 1 but transferred him to another hospital two and a quarter hours away.

Based on staff interview, clinical record and administrative document review, the hospital failed to provide an appropriate transfer for 1 of 20 patients (Patient 1) when the hospital failed to provide medical treatment within its capability and capacity that included treatment and minimized the risks to Patient 1's health. This failure resulted in exposing Patient 1 to unnecessary risks during the two hour and sixteen minute transfer to the receiving hospital.

Findings:

Patient 1's clinical record indicated he was found in his room on 1/22/13 (at a skilled nursing facility) on his hands and knees after having possibly fallen down. Patient 1 was wearing a hard plastic helmet to protect his head due to previous falls. The skilled nursing facility transferred him to Hospital 1 (the transferring hospital).


Patient 1's clinical record indicated he was admitted to the ED on 1/22/13 at 5:07 p.m., he was triaged at 5:33 p.m.

Patient 1's Emergency Room Report, dated 1/22/13 at 5:23 p.m., indicated a medical screening exam had been done and found there were no obvious focal neurological deficits. A focal neurological deficit is a problem with nerve, spinal cord, or brain function. It affects a specific location, such as the left side of the face, right arm, or even a small area such as the tongue (definition found at: neurologic deficit )


MD 1 initiated a transfer request at 9:50 p.m. The receiving physician was contacted at 1:25 a.m., and Patient 1 was transferred at 3:46 a.m., and arrived at the receiving hospital on 1/23/13 at 6:02 a.m.


Patient 1's CT scan of the brain, dated 1/22/13 at 8:05 p.m. indicated it was compared to a previous study done on 11/5/12. The findings indicated "1-2 mm (millimeters - unit of measure) of left-to-right midline shift again seen. No hydrocephalus, Periventricular white matter likely chronic small vessel ischemic disease. Very mild paranasal sinus mucosal thickening."


Patient 1's final Diagnostic Imaging Report dated 1/22/13 at 8:05 p.m., indicated it was compared to previous studies dated 11/5/12 and 12/15/12. The findings indicated "Again noted are bilateral subdural hematomas, smaller as compared to the previous study. There is no evidence of acute re-hemorrhage since the previous study of 12/15/12. Conclusion: 1. Slow improvement in bilateral subdural hematomas. No evidence of acute re-injury and no mass effect. ... "


On 2/11/13 at 4:00 p.m., during an interview, the Manager of Regulatory Compliance (MRC) stated, "We do not have neurologists on call 24 hours. We have telemedicine neurologists that use robots, but they are only for stroke patients. We have no on-call neurology schedule. We have three neurologists who are active members of our medical staff. If a primary doctor needs a consult they call these doctors to see if they are available.


On 2/12/13 at 1:40 p.m., during a concurrent interview and observation in the Emergency Department (ED) of transferring hospital, the ED Director stated the transfer process consisted of a Medical Doctor (MD) giving a directive to transfer a patient. The MD would then notify the ED charge nurse and the ward clerk responsible to coordinate transfers. The Ward Clerks (WC's) usually called hospitals from a "frequently called list". They then coordinated admission to the receiving hospital. The MD would then call the receiving hospital MD to see if they could accept the patient. The MD would then call the administrator of the transferring hospital to obtain acceptance. The WC stated, "Both [the receiving MD and the receiving administrator] have to say yes to transfer the patient."


A review of the transferring hospital's frequently called list indicated there are 16 hospitals on the list. The list indicated there were 6 hospitals that were Trauma facilities or had neurosurgery specialties and 3 were within 1 hour of the transferring hospital. The receiving hospital was not on this listing.


On 2/15/13 at 3:00 p.m., during an interview, Ward Clerk (WC) 1 stated she worked in the ED on the night shift (7 p.m. to 7 a.m.). She stated that the process for transfers was that the doctor requested a transfer and the ward clerk made the calls - we usually use a standard list of hospitals and their telephone numbers. She stated that she called hospitals in Modesto first then Fresno. Then they asked the doctor who else he wanted to call. Generally, if the call is local we used a transfer center. If it is not local usually it is a doctor to doctor. She stated there was another ward clerk on the night shift working with her on 1/23/13. He had trouble finding a hospital that would accept Patient 1. When asked if a record of the hospitals that were called was available WC stated a record of the hospitals called was not available.


On 2/12/13 at 2:00 p.m., during an interview, Registered Nurse/Charge Nurse (RN/CN) stated the determination of which hospital to call depended on several factors. For example, the factors could be diagnosis, which level of care was required such as Intensive care or Medical Surgical. The Ward Clerk of the transferring hospital would continue calling hospitals until they received an acceptance of the patient by the receiving hospital. The MD was then notified of the acceptance by the receiving hospital. Then the MD of the transferring hospital would call the receiving MD to give report on the patient. RN/CN stated, "For head bleeds some neurology surgeons require Intensive Care Beds (ICU) and others do not."


On 2/13/13 at 1:30 p.m., the MRC stated, "Each unit of the hospital [transferring hospital] has 34 beds except ICU and ER. ICU has 20 and ER has 24. In a later communication she confirmed the census on 1/23/13 of the ICU was 12.


On 2/14/13 at 11:25 a.m., MD 1 was interviewed, and stated he could not identify the hospital administrator of Hospital 2 who accepted Patient 1's transfer on 1/23/13. MD 2 from the receiving hospital initially accepted the case. MD 1 stated, "The patient had a repeat fall and was positive for a bleed. The patient had a CT and the medical group that read it indicated there was an acute and chronic bleed." MD 1 called MD 3 and told him Patient 1 possibly needed surgery and the hospital had no neurosurgeon back up. MD 1 attempted to contact some neurosurgeons but was unable to get a hold of anyone. When asked which Neurosurgeons he contacted MD 1 stated he could not remember. MD 1 stated he did not contact the hospital's Hospitalist on call because, "They do not take care of cranial bleeds." MD 1 stated he was told by MD 3 "You just want to get rid of the patient. I said, no, you have an Intensive Care Bed (ICU) and you can take this patient." MD 3 stated,"You can take the patient to the emergency room. I am not accepting the patient." MD 3 stated, "He (Patient 1) is a Do Not Resuscitate (DNR) and a No intubation (NI)." (Patients undergoing surgery with general anesthesia require intubation. General anesthesia places the patient under deep sedation) MD 1 acknowledged Patient 1 was DNR and NI.


She remembered Patient 1 because that was the only time recently that they sent a patient to hospital 2 (receiving hospital). WC 1 stated there was an argument between our doctor and the doctor from hospital 2. She stated the transferring Hospitalist was not called.


The Physician Certification to "Transfer and Consent to Transfer" indicated the reason for transfer was decompensation of patient, traffic delays, accident or death and the condition indicated stable and the form was dated 1/22/13 at 9:04 p.m.

Patient 1's clinical record indicated he was coded "priority 3 urgent yellow" The transferring hospital's classification system indicated there were 4 levels; One was immediate treatment care required; Two was emergent, care needs to be provided quickly; Three was urgent, prolonged delay may result in deterioration of condition; Four minimal intervention required delayed care would not result in deterioration.

On 2/11/13 at 3:20 p.m., during an interview, Hospital 2's (receiving hospital) Director of Nursing (DON) stated their trauma surgeon and neurosurgeon did not recommend transfer of Patient 1 on 1/22/13. She stated the transferring hospitals CT scan report, dated 1/22/13, were reviewed. The DON stated it was the consensus of the hospitals (receiving) physicians there was no indication Patient 1 needed a higher level of care. She also stated during Patient 1's stay he had a neurological evaluation but no surgery. The DON stated Physicians at the hospital had been trained not to say no when doctors called them for transfer if there were appropriate beds available.

The receiving hospital's policy and procedure titled "EMERGENCY SERVICES DEPARTMENT CONSULTATION 7 REFERRALS, EMTALA" dated 7/12, indicated "IV. GUIDELINE: A. When the Emergency department physician determines that a consultation or specialized treatment beyond the capability of the Emergency department Licensed Independent Practitioner (LIP) is needed to provide necessary stabilizing treatment to a patient with an emergency condition, the Emergency medical condition, the emergency LIP shall arrange for the service of a member of the Medical staff to come to the Hospital...