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Based on the nature of the standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.54, Outpatient Services, was out of compliance. The hospital failed to ensure the services provided in the Urgent and Outpatient Specialty Care location in Colorado Springs were integrated with the hospital..

A 1077 - Outpatient Services - Integration of Outpatient Services. The hospital failed to ensure continuity of care and coordinate care, treatment and services when the need of additional services was indicated for 5 of 7 patients provided services at the outpatient location in Colorado Springs

Based on interviews and document reviews the hospital failed to ensure all locations were fully integrated with the hospital to ensure continuity of care and coordinate care, treatment and services when the need of additional services was indicated for 5 of 7 patients provided services at the outpatient location in Colorado Springs (Patient's #12, #14, #15, #32 and #34).

The failure created the potential for patient harm due to a lack of continuity of care.

FINDINGS

1. The hospital's Urgent and Outpatient Specialty Care location in Colorado Springs relied on a separately certified hospital for the provision of services that were available within its integrated facilities.

a) During an interview with the Chief Medical Officer (MD #1), on 06/23/15 at 2:13 p.m., s/he stated, we never wanted to bring children out of the local area to treat. It's an inconvenience to have families travel up 70 miles for care. MD #1 stated the local hospital (a separately certified hospital) had a reputation in the community as being a strong provider of pediatric care and most families preferred to stay in the community. MD #1 added, a commitment was made to provide pediatric care in the local community from the beginning. If a parent wanted to go to the main facility we would do that but if a child could clearly be managed locally we would try to keep them locally.

b) During an interview with the Associate Clinical Manager (Registered Nurse #3, RN), on 06/25/15 beginning at 12:10 p.m., s/he stated the goal was to keep patients in the local community (of Colorado Springs) unless the local hospital was unable to care for the patient. RN #3 stated it would be stressful for patient's families to drive 70 miles (to the main hospital) if care could be provided in the local community.

c) Medical record reviews confirmed patients served at the hospital's Colorado Springs location received continued care in the local community and were not integrated with the main hospital in order to provide continuity of care between inpatient and outpatient services.

i) Patient #14 was seen on 06/08/15 at 5:42 p.m. with acute abdominal pain, fever of 38.8*Celsius (C) and rebound tenderness. According to the ED Provider Notes, an ED physician from a local hospital was consulted and agreed the patient required further work up for possible appendicitis and agreed to accept the patient.

Documentation of an ED Note, dated 06/08/15 at 7:16 p.m., noted Patient #14 was stable and in no apparent distress. The patient was "given verbal and written discharge and transfer instructions" and "discharged to home" with caregiver.

Patient #14 was referred to and traveled by personal vehicle to an outside hospital for services available within the scope of care provided by the hospital system.

ii) Record review showed Patient #12 received services, on 06/16/15 at 5:44 p.m., for a 1.5 centimeter (cm) long by 1 cm deep laceration (cut) to the inside of the upper lip. Further documentation within the History of Present Illness indicated there was little bleeding and the bleeding had spontaneously stopped. Documentation revealed there was a determination that this was a complex laceration needing sedation to repair.

At 6:58 p.m. the patient was discharged with instructions to travel by private vehicle, to the local hospital's ED for sedation and laceration repair.

The facility's failure to provide services available within their system of care demonstrated the Colorado Springs location was not integrated with the main hospital.

iii) Patient #32 received services at the hospital's Colorado Springs location on 06/19/15 at 9:02 p.m. for a traumatic injury inside his/her mouth. According to the ED Provider Notes, the patient presented for an injury to his/her throat. There was a 1 cm laceration to the left front side of the tonsil with no active bleeding. An ED physician, from a local hospital, was consulted and agreed to accept the patient for further evaluation.

At 9:58 p.m. the patient was discharged with instructions to travel to the local hospital's ED for further treatment, even though the services were within the scope of services available at the main hospital.

iv) On 06/16/15 at 10:00 p.m., Patient #15 received services for a V-shaped, 1.5 cm laceration to the right outer earlobe. The examination indicated little bleeding with spontaneous clotting of the laceration.

According to an ED Provider Note, 06/16/15 10:18 p.m., wound repair had been completed. However, the record also indicated a telephone consultation with an ED physician at a local hospital and indicated it was a complex laceration and plastic surgery may be needed to repair.

Patient #15 was discharged with instructions to travel by private vehicle to a local hospital, although services required by the patient were within the scope of services available at the main hospital.

Review of the local hospital's record showed an ED provider note, dated 06/17/15 at 12:18 a.m., in which the physician documented Patient #15's ear was irrigated with saline and closed with dermabond. No additional treatment or consults were provided.

v) On 6/10/15 at 6:49 p.m. Patient #34 presented to the hospital's Colorado Springs location with a chief complaint of sudden onset of abdominal pain and nausea. A Medical Decision Making note revealed the evaluation was consistent with a concern for testicular torsion. Pt was noted to have a history of this happening once before which had self resolved and had a history of retractile testes.

According to an ED Note, dated 06/10/15 at 9:38 p.m., the patient was alert and active, in no apparent distress, had a popsicle and apple juice around 8:30 p.m. and denied nausea and vomiting. Subsequently , Patient #34 was sent to a local hospital via private vehicle for continued evaluation.

d) The standard practice to routinely refer patients for continued care to a local hospital, for services available within the scope of care provided by the hospital system, demonstrated a failure of the facility to function as one integrated hospital system.