HospitalInspections.org

Based on the number and nature of deficiencies cited, the facility failed to be in compliance with the Condition of Participation of Governing Body. The Governing Body failed to maintain a separate and distinct hospital, co-located with the satellite location of another hospital.

Cross-reference:

482.12(3) Standard: Governing Body: Contracted Services - the governing body failed to maintain separate hospital space, nursing and surgical services, as well as the main telephone contact number in a manner that permitted the facility to comply with all applicable conditions of participation and standards for the contracted services.

482.12(f)(1) Standard: Governing Body: Emergency Services - the governing body failed to ensure the hospital provided emergency services that addressed the needs of all patients and visitors.

FINDINGS

Based on observations, interviews and document review the Governing Body failed to ensure pediatric patients were transferred to a facility with the appropriate scope of services to meet the patient's needs, for 1 of 3 pediatric patients reviewed (Patient #1) and failed to ensure the hospital did not co-mingle staff and space.

This failure resulted in the facility transferring patients to a separately certified co-located facility without the specialized services required to care for the patients, and placed all potential patients at risk for receiving poor quality care and negative patient outcomes. The co-mingling of space and services caused confusion amongst staff and patients for both hospitals and increased the potential for poor patient outcomes.

Findings:

References

According to http://www.trauma.org/archive/scores/gpcs.html, Glasgow Paediatric Coma Score (GCS), the GCS is scored between 3 and 15, 3 being the worst, and 15 the best. A coma score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury.

According to a "Conditional license to operate a General Hospital", effective 10/01/14, patients who would be eligible for transfer from the facility to Hospital B's satellite location "include those pediatric patients with high risk and critical injuries that may include... Glasgow Coma Scale 13-15 with significant trauma."

Additionally, pediatric patients who shall not be served by Hospital B's satellite location, as they require a higher and/or specialized level of care, include pediatric patients requiring qualified personnel or equipment for the care of children not provided by the facility or Hospital B's satellite location and pediatric patients requiring neurosurgical consult or who may require neurosurgical consult at the discretion of the facility.

1. The Governing Body failed to ensure patients were transferred to a receiving facility based on the availability of specialized services and in accordance with their conditional license.

a) Record review for Patient #1 showed s/he was transferred from the facility's emergency department (ED) to Hospital B's satellite location on 01/14/15 at 4:45 p.m.

Review of the H&P (History & Physical), dated 01/14/15, showed pediatric Patient #1 was brought to the facility's emergency department (ED) by his/her caregiver after being discovered unresponsive at the home. Upon arrival, the pediatric patient had poor spontaneous breathing and was unresponsive. The patient was rapidly intubated (a breathing tube was inserted in order to provide life support). According to the H&P, Patient #1's most remarkable abnormal findings were lack of responsiveness, dilated pupils, Glasgow Coma Scale (GCS) of 3 (indicative of a severe brain injury), and multiple bruises over his/her body.

The facility transferred Patient #1 from the ED to the Pediatric Intensive Care Unit (PICU) located in Hospital B's satellite location. The H&P noted the patient had been evaluated by an adult neurosurgeon in the facility's ED. With the lack of pupillary response and the GCS of 3, the adult neurosurgeon suggested that optimal therapy would include transport to the main Hospital B in Aurora, where pediatric neurosurgery services were available.

A review of admission Flowsheet Data from Hospital B's satellite location, after the patient was transferred to the PICU by UCH Memorial Hospital Central, showed Patient #1's GCS remained at 3 on 01/14/15 at 4:45 p.m.

In compliance with the requirements set in the state's Conditional License, the pediatric patient should not have been transferred to Hospital B's satellite location with a severe brain injury, indicated by a GCS of 3, as s/he did not meet the admission criteria for the satellite location and required a pediatric neurosurgical consult. The patient should have been transferred from the facility to a facility that could provide the required services.

Review of Hospital B's physician notes, dated 01/14/15, stated transfer by air from the facility to the main Hospital B could not be accomplished due to fog. At approximately 8:00 p.m., as ground transportation was being initiated, the patient's condition dramatically worsened and s/he required emergency brain surgery. The surgery was performed by an adult neurosurgeon in the operating room (OR) of the facility, as pediatric neurosurgery services were not available at the facility or Hospital B's satellite location.

Review of the adult neurosurgery note, dated 01/15/15 at 8:56 a.m., stated the adult neurosurgeon had discussed operative findings with the critical care physician immediately after the surgery and agreed on the plan for the transfer of Patient #1 to the main Hospital B in Aurora within the next few hours. The adult neurosurgeon documented "I have discussed again with our pediatric intensivist who reports the child still has motor response to pain. I have emphasized that ongoing management needs to proceed as per plan" and the patient should be transferred.

The facility transferred Patient #1 back to Hospital B's satellite location PICU after the emergency surgery instead of to the main Hospital B in Aurora, which resulted in further delays in the patient receiving appropriate pediatric neurosurgery care.

Staff interviews and record review showed Patient #1 was finally transferred to the main Hospital B in Aurora on 01/15/15 at 10:30 a.m., approximately 17 hours after such a transfer had first been indicated and the facility inappropriately transferred the patient to Hospital B's satellite location. On 01/17/15, life support measures were withdrawn and the patient expired.

2. The facility co-mingled space with Hospital B's satellite location. Examples include:

a) On 03/02/15 at 9:40 a.m., an interview was conducted with Hospital B's Quality and Patient Safety Director (Employee B) who stated Hospital B's satellite location was a "hospital within a hospital." Employee B stated the building itself belonged to the host facility and Hospital B's satellite location was located in the East Tower of the same building.

Observations of the front entrance and main lobby of Hospital B's satellite location, on 03/02/15 at 9:56 a.m., revealed a directory which contained information for the facility and Hospital B's satellite location within the same building. The directory was labeled with signage for the facility.

The locations in the directory were not clearly marked as to what belonged to Hospital B's satellite location. During the observation, Employee B stated the directory was confusing because both facilities shared the same building.

b) A second tour of the the front entrance, main lobby, and admissions area was conducted with Employee B on 03/02/15 at 11:07 a.m. A sign for Hospital B's satellite location was on the reception desk of the facility, under signage on the wall identifying it as belonging to the facility. Employee B stated the main entrance to Hospital B's satellite location was a "common location," shared with UCH Memorial Hospital Central.

c) On 03/03/15 at 10:16 a.m., further observation of signage and postings for the facility was conducted. A large sign above the directory showed the name and logo for the host facility. Signage overhead to the right of the directory identified Hospital B, and had an arrow pointing to the right for Hospital B's registration, and an arrow pointing to the left for the facility's registration. Hospital B's satellite location was located within the UCH Memorial Hospital Central facility.

d) To the right of the main entrance, in the area identified as belonging to Hospital B's satellite location, was a door with a sign noting, "Welcome to the Birth Center" for the host facility. Two additional signs were posted to the left of the entrance to the Birth Center. One sign read "Financial Counseling" and the second read "Release of Information." The signs contained the name and logo of Hospital B. The same signs were also noted inside UCH Memorial Hospital Central's Birth Center at the Financial Counseling desk and at the Release of Information desk.

On 03/03/15 at 11:32 a.m., Employee B stated staff members who worked at the financial counseling and release of medical information desks were employees of Hospital B's satellite location. The employee stated the Birth Center was a department of the facility and that the offices for Hospital B's financial counseling and release of medical records were located inside the facility's Birth Center.

During the tour, on 03/03/15 at 11:32 a.m., an interview was conducted with Hospital B's Financial Counselor (Employee M), who stated s/he was an employee of Hospital B and s/he only provided services to patients and families associated with the satellite location. Employee M stated families entering the Birth Center, who were associated with UCH Memorial Hospital Central, stopped at his/her desk regularly to ask questions, including financial questions, and they "get frustrated because they are being shuttled all over," as the signage was confusing. Employee M stated s/he would redirect patients or families to UCH Memorial Hospital Central for admissions or financial questions that were not associated with the satellite location.

A second desk was observed with a sign that stated for release of medical records to call a stated phone number. Employee B stated the person who worked at the desk was not available right now but that office space was used by Hospital B's satellite location and not UCH Memorial Hospital Central.

e) On 03/03/15 at 11:51 a.m., a tour was conducted with Hospital B's Regulatory Director (Employee G) to observe another area of the building and two additional staff offices belonging to Hospital B's satellite location. The two offices were located on floor #2 down a hallway identified as part of UCH Memorial Hospital Central. The sign above the hallway stated, "Conscious Sedation." Down the hallway, one office was noted with signage that read, "Patient Access Registration," and a second office was noted with signage that read, "Health Information Management/Managed Care." Each of the signs contained the name and logo for Hospital B.

The Supervisor of Revenue and Financial Counseling (Employee N), who was housed in one of the offices, stated s/he was an employee of Hospital B's satellite location. The Health Information Analyst (Employee K), who was housed in the second office, stated s/he was also an employee of Hospital B's satellite location. Both staff members confirmed their offices were located in UCH Memorial Hospital Central.

f) On 03/05/15 at 08:56 a.m., observation was conducted of the surgical department of the facility with Hospital B's Regulatory Director (Employee G). The surgical department housed offices for two Registered Nurses (RNs) who were employees of Hospital B's satellite location (RN I and RN L). The surgical department was located in the North Tower of UCH Memorial Hospital Central. The office for Hospital B's Perioperative Pediatrics Service Leader (RN I) was inside the perioperative space belonging to the host facility.

On 03/05/15 at 11:45 a.m., an interview was conducted with RN I who stated s/he was an employee of Hospital B and maintained an office in the perioperative area of UCH Memorial Hospital Central's surgical department.

On 03/05/15 at 9:04 a.m., a tour was conducted of the South Tower of UCH Memorial Hospital Central's Emergency Department. An office was observed for RN J, who was an employee of Hospital B and worked as the Emergency Department Pediatric Coordinator.

On 03/05/15 at 9:05 a.m., an interview was conducted with Hospital B's Regional Vice President (VP), Southern Colorado Care System (Employee A) who stated there were two RNs (RN I and RN L) who were employed by Hospital B's satellite location and worked out of the Operating Room area of the UCH Memorial Hospital Center's facility. The VP stated the office for RN I was "embedded in the OR."

The VP further stated Hospital B's satellite location employee, RN J, was the Emergency Department Pediatric Coordinator and stated this RN worked out of the Emergency Department of the co-located facility.

Based on observations, interviews and document reviews, the facility failed to ensure services were provided in a manner that permitted the facility to comply with all applicable conditions of participation and standards for the contracted services. Specifically, the facility relied on licensed personnel from a separately certified hospital (Hospital B) to respond to pediatric and neonatal emergencies while concurrently providing services at the separate facility.

The failure resulted in the co-mingling of patient services, physical space, and personnel with a separately certified facility, Hospital B's satellite location.

FINDINGS

1. The facility used licensed personnel from the co-located Hospital B's satellite location for pediatric and neonatal emergencies, and for provision of patient care to pediatric patients in the facility's emergency department, during concurrent hours the licensed personnel worked for Hospital B.

a) A tour of Hospital B's satellite NICU was conducted on 03/02/15 at 11:39 a.m. with the Quality and Patient Safety Director (Employee B) and the Clinical Manager of Pediatrics (Registered Nurse, RN C).

During the tour, RN E stated the NICU Charge RN would respond to all code pink (neonatal resuscitation) calls in Hospital B's satellite location, as well as, all of UCH Memorial Hospital Central. S/he also stated RNs from UCH Memorial Hospital Central responded to all adult code blue (adult resuscitation) calls and MET (adult medical emergency team, also known as Rapid Response Team or RRT) calls in Hospital B's satellite location.

b) A tour of Hospital B's satellite location PICU was conducted on 03/02/15 at 12:13 p.m. with Employee B and RN C. RN C stated the MET and Code Teams from UCH Memorial Hospital Central responded to all adult emergencies which occurred in Hospital B's satellite location, and that all calls from Hospital B's satellite location for the MET and Code Teams went to a main operator employed by the host facility.

During the tour, RN F stated all PICU Charge RNs responded to all pediatric code blue calls in UCH Memorial Hospital Central and all pediatric trauma activations in the facility's emergency department (ED). S/he also stated the facility's ED RNs would come to Hospital B's satellite location PICU when called for assistance, as often as "a couple of times a month".

c) A review of the facility's main operator report, titled January 2014 METs and Code Blues, revealed the facility's MET and Code Team responded to adult emergencies in Hospital B's satellite location NICU on 01/01/14 at 2:46 p.m. and on 01/01/14 at 2:52 p.m., and to the Pediatric Medical/Surgical Unit on 04/19/14 at 3:23 p.m. and on 10/06/14 at 4:52 p.m.

Further the report noted the UCH Memorial Hospital Central's MET and Code Team responded to Hospital B's satellite PICU on 03/10/2014 at 1:26 a.m., 05/06/14 at 4:40 a.m., 05/13/14 at 3:48 p.m., 06/23/14 at 9:03 p.m., 09/13/14 at 3:14 a.m., and 12/10/14 at 8:08 p.m.

d) A review of the facility document Pediatric Codes, September 2014 through February 2015, revealed pediatric code blue calls in the UCH Memorial Hospital Central's emergency department on 09/04/14 at 1:13 p.m.; 09/05/14 at 10:40 a.m.; 09/13/14 at 8:49 p.m.; 10/13/14 at 9:41 p.m.; 10/15/14 at 4:22 p.m.; 12/23/14 at 3:41 p.m.; and 01/20/15 at 3:29 a.m.

e) An interview with the NICU Clinical Manager (RN P) on 03/05/15 at 3:53 p.m. revealed UCH Memorial Hospital Central used Hospital B's NICU charge RNs for high risk births and cesarean section deliveries in the facility's labor and delivery unit. S/he stated this occurred approximately 100 times per month.

2. The facility used licensed personnel from Hospital B's satellite location to coordinate pediatric perioperative services for patients admitted to Hospital B

a) On 03/05/15 at 8:56 a.m., a tour of the facility's surgical services offices revealed Hospital B's Perioperative Pediatrics Coordinator (RN I) maintained office space in the facility. The Regulatory Director (Employee G) stated, during the tour, that RN I performed clinical duties in the facility's operating rooms (ORs) in addition to administrative tasks for Hospital B's satellite location.

b) Review of a document provided by RN I on 03/04/15, stated his/her duties were 80% clinical and 20% meetings. According to the document, RN I worked in UCH Memorial Hospital Central's OR coordinating the right staff, equipment, instrumentation and supplies for every surgery conducted for Hospital B satellite location patients. RN I stated s/he was the communication liaison with the satellite patient's caregivers. S/he would incorporate the caregivers presence during induction of anesthesia, show them out of the OR, where to wait and communicate how long the surgery would be.

Additionally, RN I stated s/he would participate on Hospital B's committees and bring back important information to the facility's OR, make new policy changes as recommended and incorporate Hospital B's ideas as seen suited for the UCH Memorial Hospital Central OR.

c) During an interview on 03/05/15 at 11:45, RN I stated Hospital B's satellite location would send inpatients over to the co-located facility for surgical services without discharging and admitting the patients to UCH Memorial Hospital Central. Hospital B's inpatients' status in the electronic medical record showed an internal transfer for the purposes of locating the patient. S/he stated that UCH Memorial Hospital Central personnel also cared for main Hospital B in Aurora pediatric outpatients who received elective and ambulatory surgical services at the satellite location.

d) A second interview was conducted with RN I on 03/05/15 at 3:40 p.m. S/he stated the term "transfer" was used in electronic medical records of surgical patients to show when the patients were moved from Hospital B's satellite location to the UCH Memorial Hospital Central's OR. S/he stated neither facility formally discharged or admitted the satellite location's patients when they received surgical services in the co-located facility, and that no discharge or admission documents were completed for those transfers.

e) A review of medical records for Hospital B's satellite location confirmed there were no discharge documents from the satellite location for Patient's E, F, and G, or admission documents to UCH Memorial Hospital Central when the patients were transferred from the satellite location to the facility for surgery. The medical records contained the term "transfer in" and "transfer out" for the patients when they were moved between the co-located facilities.

f) A review of the Informed Consent For Operation or Procedure, for Patient's A, B, C and D, showed it contained logos and identifying information for both UCH Memorial Hospital Central and the Hospital B satellite location. There was no information on the consent which identified which hospital would conduct the surgery and which hospital the patient was admitted to for the surgical procedure.

g) During an interview, on 03/05/15 at 12:30 p.m., Hospital B's Executive Director of Perioperative Services (Employee O) stated s/he did not manage the perioperative services employees at Hospital B's satellite location, co-located with the facility. Employee O stated that two Hospital B satellite location perioperative employees (RNs I and employee O) reported directly to UCH Memorial Hospital Central's OR Manager (Employee #3). Employee O stated s/he had met with the facility's Employee #3 initially but there were currently no routinely scheduled meetings.

3. The facility shared phone services and a public telephone number with Hospital B's satellite location. The facility operator failed to identify the Hospital B satellite location when s/he fielded calls on the published number.

a) On 03/04/15 at 1:07 p.m., a surveyor called the phone number posted on Hospital B's public website for the Hospital B satellite location. This phone number was posted on the website as the main phone number for the satellite location. The operator answered, stated the name of the host facility, and did not state the name of Hospital B's satellite hospital. The surveyor stated, "I thought I was calling [Hospital B]," to which the operator stated, "We answer for both." Review of the public website for UCH Memorial Hospital Central revealed the main phone number for UCH Memorial Hospital Central was the same phone number posted for Hospital B's satellite location.

On 03/04/15 at 1:35 p.m., a second surveyor called the main phone number posted on the websites for the two separately certified hospitals. The operator answered and stated the name of the facility, and did not state the name of Hospital B's satellite location. The surveyor asked the operator to repeat the greeting and s/he did by stating only the name of the host facility.

The surveyor called the number again at 1:36 p.m., and the operator answered by stating the name of the host facility only. The surveyor stated s/he was trying to reach Hospital B, to which the operator replied, "What do you need?" The surveyor stated s/he needed some information from Hospital B. The operator then asked if the caller needed a patient room and which Hospital B site was needed. The operator stated there were two Hospital B sites in the community and stated one was on the north side of town and the other was in the central part of town (the satellite location).

Based on interviews and document reviews, the governing body failed to ensure the hospital provided emergency services that addressed the needs of all patients and visitors. The hospital relied on a separately certified, co-located satellite location (Hospital B) to provide emergency services for pediatric and neonatal patients.

This failure potentially contributed to delays in the provision of emergency medical treatment and poor patient outcomes.

FINDINGS

1. The facility used licensed personnel from the Hospital B's satellite location for pediatric and neonatal emergencies, and for the provision of patient care to pediatric patients in the facility's emergency department, during concurrent hours the licensed personnel worked for Hospital B.

a) A tour of Hospital B's satellite NICU was conducted on 03/02/15 at 11:39 a.m. with the Quality and Patient Safety Director (Employee B) and the Clinical Manager of Pediatrics (Registered Nurse, RN C).

During the tour, RN E stated the NICU Charge RN would respond to all code pink (neonatal resuscitation) calls in Hospital B's satellite location, as well as, all of UCH Memorial Hospital Central.

b) A tour of Hospital B's satellite location PICU was conducted on 03/02/15 at 12:13 p.m. with Employee B and RN C. During the tour, RN F stated all PICU Charge RNs responded to all pediatric code blue calls in UCH Memorial Hospital Central and all pediatric trauma activations in UCH Memorial Hospital Central's emergency department (ED).

c) A review of the facility document Pediatric Codes, September 2014 through February 2015, revealed pediatric code blue calls in UCH Memorial Hospital Central's emergency department on 09/04/14 at 1:13 p.m.; 09/05/14 at 10:40 a.m.; 09/13/14 at 8:49 p.m.; 10/13/14 at 9:41 p.m.; 10/15/14 at 4:22 p.m.; 12/23/14 at 3:41 p.m.; and 01/20/15 at 3:29 a.m.

d) An interview with the NICU Clinical Manager (RN P) on 03/05/15 at 3:53 p.m. revealed UCH Memorial Hospital Central used Hospital B's NICU charge RNs for high risk births and cesarean section deliveries in the facility's labor and delivery unit in case of an emergency. S/he stated this occurred approximately 100 times per month.