HospitalInspections.org

Based on hospital policy and procedure review,closed DED (Dedicated Emergency Department) medical record reviews, staff and physician interviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to ensure an appropriate transfer and providing a patient's complete and accurate medical history to the receiving hospital in 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED). (Patient #11).

The findings include:


1. The hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11).

~cross refer to 489.24(e)(1)-(2), Appropriate Transfer - Tag A2409.

Based on hospital policy review, medical record review, staff and physician interviews,
the hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11).


The findings include:

Review of the hospital's policy, "EMTALA: Treatment of Patients with Emergency Medical Conditions", revised 11/19/2014, revealed, "...C. Discharge or Transfer When Emergency Condition Exists: 1. If the Provider determines that at emergency medical condition does exist, the patient may be discharged or transferred from (Hospital A) when the patient has been stabilized...b. Stabilized for transfer means, within reasonable medical probability, that no material deterioration of the condition is likely to result from or during the transfer of the patient to another facility, and that the receiving facility has the capability to manage the patient's condition and any reasonably foreseeable complications of that condition...3. The transfer must be effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...5. (Hospital A) must send to the receiving medical facility a copy of all medical records available at the time of transfer related to the emergency medical condition for which the patient has presented, including records related to the patient's medical history, the emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests or diagnostic studies...".

Closed DED record review of Patient #11 revealed an 11 year-old female who presented to Hospital A's DED via private vehicle on 01/23/2015 at 1717 with suicidal ideation. Record review revealed Patient #11 was triaged by RN (Registered Nurse) #2 at 1721. Review revealed documentation by RN #2 at 1729, "patient here for evaluation of statements made to school counselor that she had tried to hang herself in November and December from her bunk bed". Review revealed documentation of home medications as Focalin (treats attention deficit hyperactive disorder), Zyrtec (treats allergies) and Albuterol inhaler (treats asthma).

Further review revealed vital signs were obtained and documented at triage as within normal range. Record review revealed no documentation of medical history obtained at triage. Review of Patient #11's laboratory results revealed a whole blood glucose obtained at 1726 as 281 (high) and a urinalysis collected at 1840 with glucose 500 mg/dL (abnormal). Record review revealed a MSE was started by Physician #2 at 1941. Review of Physician #2's dictated MSE revealed, "...History of Present Illness This 11 year-old female brought in for evaluation of suicidal ideation...Problem List/Past Medical History Chronic No Chronic Problems Historical No historical problems. Medications Focalin..., ProAir...Zyrtec...Lab Results ...Glucose Lvl (level): 256...Medical Decision Making ...Based on patient's history and physical I do believe patient benefit from inpatient psychiatric evaluation treatment. ...I did review patient's laboratory work no significant abnormalities are noted at this time...". Further review of Patient #11's laboratory results revealed a whole blood glucose obtained at 1927 as 196 (high). Further record review revealed an order by Physician #1 at 2227, "Family to provide home insulin dose and Lantus as scheduled for this juvenile with insulin-dependent diabetes". Review of Patient #11's medication administration record revealed no documentation that the patient received insulin while in the DED. Further record review revealed an "Authorization for Transfer Form" dated 01/24/2015 at 1023. Review of the transfer form revealed, "...MEDICAL CONDITION Diagnosis Suicidal (handwritten)..REASON FOR TRANSFER Medically Indicated (box checked)...Patient Stable (box checked) The patient has been examined and any medical condition stabilized such that, within reasonable clinical confidence, no material deterioration of this patient's condition...II. RISK AND BENEFIT FOR TRANSFER Medical Benefits Adolescent Psych (handwritten) Obtain level of care/service NA at this facility Inpatient adolescent (handwritten) Benefits outweigh risks of transfer (box checked)...Medical Risks MVA (handwritten) Deterioration of condition en route (box checked) Worsening of condition or death if you stay here (box checked)...III Mode/Support/Treatment During Transfer as Determined by Physician - Mode of transportation Agency CCSD (County Sheriff Department handwritten) Support/Treatment during transfer None (box checked)...ACCOMPANYING DOCUMENTATION -sent via Transporting Agency (box checked)...". Review of the transfer form revealed no check mark in the boxes marked copy of pertinent medical record, lab/x-ray/EKG. Further review of the transfer form revealed report was given to (First Name of Person at Hospital B) by RN #3 at 1130. There was a lack of evidence that the transfer plan and risks and benefits were discussed with the patient's mom and the transferring hospital should have made it clear that the patient had diabetus that she was being treated for and on medication for and that she had an elevated glucose level. Record review revealed no documentation of what information other than vital signs were reported to the receiving hospital. Further record review revealed Patient #11 was transferred to Hospital B on 01/24/2015 at 1140 under IVC (involuntary commitment) via sheriff's deputy.

Closed medical record review from Hospital B for Patient #11 revealed she was admitted on 01/24/2015 at 1535 (3 hours, 55 minutes after leaving Hospital A). Record review revealed the DED record sent from Hospital A contained IVC papers, lab results and Physician #1's MSE documentation. Review revealed no documentation in the record related to diabetes from Hospital A to Hospital B. Review of the physician's discharge summary from Hospital B revealed, "...The patient was admitted and evaluated medically and psychiatrically. She had type 1 diabetes mellitus and had an extremely high blood sugar. She was originally continued on her homolog [sic], Lantus (insulin)...but her blood sugar was still high. In consultation with our internal medicine doctor, she was sent to local medical hospital for treatment and was admitted to the pediatric unit at (Hospital C), so was discharged from our care...". Review revealed Patient #11 was transferred from Hospital B to Hospital C's DED on 01/24/2015, arriving to Hospital C's DED at 1850 (3 hour,15 minutes after admission to Hospital B) after the attending psychiatrist obtained a medical consult to manage her diabetes.

Closed medical record review from Hospital C for Patient #11 revealed a reported blood sugar of 426 (high) at 2023 on 01/24/2015. Review revealed Patient #11 was admitted to Hospital C's pediatric unit for hyperglycemia and management of diabetes and discharged to Hospital D's behavioral health unit on 01/27/2015. Review of the transfer summary to Hospital D dictated on 01/27/2015 revealed, " ...Labs were drawn, and she did not have ketogenic acidosis but had a blood sugar of 426 ...she received 5 units of Humalog in the emergency department for her blood sugar, and she then dropped her blood sugar to 35 ...She had blood sugars in the 280s and 300s overnight, which were not corrected, and her regular insulin doses were restarted for breakfast in the morning ... " .

Interview on 02/05/2015 at 0930 with RN #1 revealed the RN was the triage nurse in Hospital A's DED on 01/23/2015 when Patient #11 presented to the DED with suicidal ideation. Interview revealed, "she (Patient #11) told me that the reason she wanted to hurt herself was because she didn't like being different. When I asked her why she was different, she said it was because she had diabetes". Interview further revealed, "I didn't document that she had diabetes. I should have". Interview further revealed, "I did do her blood sugar in triage. It was 281. That is abnormal. I don't remember telling her primary nurse that she had diabetes". Interview revealed RN #2 did not report the high blood sugar to the DED physician.

Interview on 02/05/2015 at 0900 with Physician #2 revealed, "I don't really remember her. I get my past medical history on a patient by reading the nurses' notes. A blood sugar of 256 could be high. I had no reason to clarify or ask further questions". Interview further revealed, "there is no normal for an emergency department".

Interview on 02/04/2015 at 1500 with Physician #1 revealed the DED physician was working in Hospital A's DED on 01/23/2015. Interview revealed, "the nurse asked if the patient's mother or father could check her (Patient #11) blood sugar and give insulin. I told her they (parents) could manage her diabetes". Interview further revealed, "Patients are not allowed to keep their home meds (medication) at the bedside in the ED. We were really busy so the parents could do a better job of managing her diabetes overnight than we could". Interview further revealed, " a blood sugar of 256 should have been noticed".

Interview on 02/05/2015 at 0910 with RN #2 revealed she was Patient #11's primary nurse in Hospital A's DED on 01/23/2015 beginning at 1900, until 01/24/2015 at 0700. Interview revealed, "I found out she was diabetic from her Mom. I took her fingerstick blood sugars a couple of times and I was in her room when she administered her own insulin after she ate a peanut butter and jelly sandwich. (Physician #1) told me it was ok for her mother to manage her insulin. I was concerned about the patient administering her own insulin. I did not document this in her record".

Telephone interview on 02/05/2015 at 1030 with RN #3 revealed he was the RN who discharged Patient #11 with the deputy sheriff for transfer to Hospital B on 01/24/2015. Interview revealed, "she had a bag with insulin supplies, syringes and snacks with her when she left in the deputy's car. I checked her sugar before she left. Her mother told me she gave 1.5 units to cover her for breakfast. I'm not sure what kind of insulin it was and I don't know if we even had that kind of insulin here. I should have documented in her record but I got busy and forgot". Further interview revealed, "I gave report to the intake person at (Hospital B). I told them she was diabetic. I told them we were sending her supplies with her".

In summary, Patient #11 presented to Hospital A's DED with suicidal ideation. The hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11).


NC00103823
NC00103336

Based on hospital policy review, medical record review, staff and physician interviews,
the hospital staff failed to ensure an appropriate transfer by failing to: provide a patient's complete and accurate medical history to the receiving hospital and failing to discuss the transfer plan with the patient's mother for 1 of 4 sampled patients presenting to the hospital's Dedicated Emergency Department (DED for (Patient #11).


The findings include:

Review of the hospital's policy, "EMTALA: Treatment of Patients with Emergency Medical Conditions", revised 11/19/2014, revealed, "...C. Discharge or Transfer When Emergency Condition Exists: 1. If the Provider determines that at emergency medical condition does exist, the patient may be discharged or transferred from (Hospital A) when the patient has been stabilized...b. Stabilized for transfer means, within reasonable medical probability, that no material deterioration of the condition is likely to result from or during the transfer of the patient to another facility, and that the receiving facility has the capability to manage the patient's condition and any reasonably foreseeable complications of that condition...3. The transfer must be effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer...5. (Hospital A) must send to the receiving medical facility a copy of all medical records available at the time of transfer related to the emergency medical condition for which the patient has presented, including records related to the patient's medical history, the emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, results of any tests or diagnostic studies...".

Closed DED record review of Patient #11 revealed an 11 year-old female who presented to Hospital A's DED via private vehicle on 01/23/2015 at 1717 with suicidal ideation. Record review revealed Patient #11 was triaged by RN (Registered Nurse) #2 at 1721. Review revealed documentation by RN #2 at 1729, "patient here for evaluation of statements made to school counselor that she had tried to hang herself in November and December from her bunk bed". Review revealed documentation of home medications as Focalin (treats attention deficit hyperactive disorder), Zyrtec (treats allergies) and Albuterol inhaler (treats asthma).

Further review revealed vital signs were obtained and documented at triage as within normal range. Record review revealed no documentation of medical history obtained at triage. Review of Patient #11's laboratory results revealed a whole blood glucose obtained at 1726 as 281 (high) and a urinalysis collected at 1840 with glucose 500 mg/dL (abnormal). Record review revealed a MSE was started by Physician #2 at 1941. Review of Physician #2's dictated MSE revealed, "...History of Present Illness This 11 year-old female brought in for evaluation of suicidal ideation...Problem List/Past Medical History Chronic No Chronic Problems Historical No historical problems. Medications Focalin..., ProAir...Zyrtec...Lab Results ...Glucose Lvl (level): 256...Medical Decision Making ...Based on patient's history and physical I do believe patient benefit from inpatient psychiatric evaluation treatment. ...I did review patient's laboratory work no significant abnormalities are noted at this time...". Further review of Patient #11's laboratory results revealed a whole blood glucose obtained at 1927 as 196 (high). Further record review revealed an order by Physician #1 at 2227, "Family to provide home insulin dose and Lantus as scheduled for this juvenile with insulin-dependent diabetes". Review of Patient #11's medication administration record revealed no documentation that the patient received insulin while in the DED. Further record review revealed an "Authorization for Transfer Form" dated 01/24/2015 at 1023. Review of the transfer form revealed, "...MEDICAL CONDITION Diagnosis Suicidal (handwritten)..REASON FOR TRANSFER Medically Indicated (box checked)...Patient Stable (box checked) The patient has been examined and any medical condition stabilized such that, within reasonable clinical confidence, no material deterioration of this patient's condition...II. RISK AND BENEFIT FOR TRANSFER Medical Benefits Adolescent Psych (handwritten) Obtain level of care/service NA at this facility Inpatient adolescent (handwritten) Benefits outweigh risks of transfer (box checked)...Medical Risks MVA (handwritten) Deterioration of condition en route (box checked) Worsening of condition or death if you stay here (box checked)...III Mode/Support/Treatment During Transfer as Determined by Physician - Mode of transportation Agency CCSD (County Sheriff Department handwritten) Support/Treatment during transfer None (box checked)...ACCOMPANYING DOCUMENTATION -sent via Transporting Agency (box checked)...". Review of the transfer form revealed no check mark in the boxes marked copy of pertinent medical record, lab/x-ray/EKG. Further review of the transfer form revealed report was given to (First Name of Person at Hospital B) by RN #3 at 1130. There was a lack of evidence that the transfer plan and risks and benefits were discussed with the patient's mom and the transferring hospital should have made it clear that the patient had diabetus that she was being treated for and on medication for and that she had an elevated glucose level. Record review revealed no documentation of what information other than vital signs were reported to the receiving hospital. Further record review revealed Patient #11 was transferred to Hospital B on 01/24/2015 at 1140 under IVC (involuntary commitment) via sheriff's deputy.

Closed medical record review from Hospital B for Patient #11 revealed she was admitted on 01/24/2015 at 1535 (3 hours, 55 minutes after leaving Hospital A). Record review revealed the DED record sent from Hospital A contained IVC papers, lab results and Physician #1's MSE documentation. Review revealed no documentation in the record related to diabetes from Hospital A to Hospital B. Review of the physician's discharge summary from Hospital B revealed, "...The patient was admitted and evaluated medically and psychiatrically. She had type 1 diabetes mellitus and had an extremely high blood sugar. She was originally continued on her homolog [sic], Lantus (insulin)...but her blood sugar was still high. In consultation with our internal medicine doctor, she was sent to local medical hospital for treatment and was admitted to the pediatric unit at (Hospital C), so was discharged from our care...". Review revealed Patient #11 was transferred from Hospital B to Hospital C's DED on 01/24/2015, arriving to Hospital C's DED at 1850 (3 hour,15 minutes after admission to Hospital B) after the attending psychiatrist obtained a medical consult to manage her diabetes.

Closed medical record review from Hospital C for Patient #11 revealed a reported blood sugar of 426 (high) at 2023 on 01/24/2015. Review revealed Patient #11 was admitted to Hospital C's pediatric unit for hyperglycemia and management of diabetes and discharged to Hospital D's behavioral health unit on 01/27/2015. Review of the transfer summary to Hospital D dictated on 01/27/2015 revealed, " ...Labs were drawn, and she did not have ketogenic acidosis but had a blood sugar of 426 ...she received 5 units of Humalog in the emergency department for her blood sugar, and she then dropped her blood sugar to 35 ...She had blood sugars in the 280s and 300s overnight, which were not corrected, and her regular insulin doses were restarted for breakfast in the morning ... " .

Interview on 02/05/2015 at 0930 with RN #1 revealed the RN was the triage nurse in Hospital A's DED on 01/23/2015 when Patient #11 presented to the DED with suicidal ideation. Interview revealed, "she (Patient #11) told me that the reason she wanted to hurt herself was because she didn't like being different. When I asked her why she was different, she said it was because she had diabetes". Interview further revealed, "I didn'