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Based on the review of clinical records, Policies and Procedures, Emergency department outgoing transfer logs, Physician credentialing files/Core Privileges, and staff interviews, it was determined that JFK inappropriately transferred two (2) individuals as evidenced by failing to provide treatment that was within the facility's capacity and capability to minimize the risk to the health of individuals, and failure to ensure all medically necessary transfers were in accordance with policy and procedures. This failure affected 2 of 20 sampled patients (#1 and #3) who presented to JFK Medical Center Emergency Department (ED) and were subsequently inappropriately transferred to receiving facilities (65 miles away) for continued care of their emergent medical conditions. Please refer to deficient practice cited in this report at A-2409.

Based on review of clinical records, Policies and Procedures, Emergency department outgoing transfer logs, Physician credentialing files/Core Privileges, and staff interviews, it was determined that JFK inappropriately transferred two (2) individuals as evidenced by failing to provide treatment that was within the facility's capacity and capability to minimize the risk to the health of individuals, and failure to ensure all medically necessary transfers were in accordance with policy and procedures. This failure affected 2 of 20 sampled patients (#1 and #3) who presented to JFK Medical Center Emergency Department (ED) and were subsequently inappropriately transferred to receiving facilities (65 miles away) for continued care of their emergent medical conditions.

The findings include:

1. JFK Emergency Department Outgoing Transfer Logs
The hospital's Outgoing Transfer log revealed that on 9/26/2015 at 10:25 a.m., that Patient #3 was transferred to a tertiary hospital, and the diagnoses was listed as "Airway Obstruction." The category needed was ENT (Ear, Nose and Throat, Surgery, and Anesthesia. Further review revealed that Patient #1 was transferred to a tertiary hospital on 9/26/2015 at 6:11 p.m., with a diagnosis of " Ruptured Globe " (tear in the outer surface of the eyeball severe pain and loss of vision). The service needed was Ophthalmology (Branch of medicine concerned with the study and treatment of disorders and diseases of the eye.

2) JFK Medical Record Review for Patient #3.
Review of the clinical record revealed Patient #3 presented to the ED on 9/26/15 at 0557 hours with a chief complaint of shortness of breath (SOB) for 1 week according to the ED Triage notes. The objective Assessment was documented as, " Audible Wheeze, Congestion, Cough. " The ESI (Emergency Severity Index- acuity of patient health-level 2 -Emergent-High risk of deterioration or signs of a time critical problem) level as was listed as 2/Emergent.
The physician assessed the patient at 0558 hours. The ED physician documents the patient has an abnormal thyroid (enlarged). The patient presents with increasing SOB times two months. The patient has no private MD (PMD) or medical evaluation.
The patient's vital signs on admission were as follows: Blood Pressure (B/P) 198/114, (optimal normal blood pressure 120/80 ) pulse 98, respirations 24 and Oxygen Saturation 99% on room air. The patient had no wheezing or rhonchi.
The medical screening exam (MSE) included Complete Blood Count (CBC), Platelet Count, Chemistry, Coagulation studies. The lab results were within normal limits except for elevated Basophils (blood cells that digest bacteria). The patient had a Neck/Soft Tissue (Computerized Tomography-computerized images of the neck) and Chest X-ray.
The Radiologist discussed the findings with the ED physician at 0720 hours. The Neck Soft Tissue exam revealed: Prominent focal prevertebral soft tissue widening and proximal airway narrowing. CT (computerized tomography) with contrast is recommended. The chest x-ray noted: No evidence of acute pulmonary findings.
A CT of the neck with contrast was done at 0730 hours. The findings were reported to the ED physician at 0828 hours. The " Impression: Markedly heterogeneous and enlarged thyroid gland with severe mass effect on the adjacent airway. The mass is most severe in the subglottic region where the airway is narrowed down to approximately 5 x 5 millimeters (mm). Thyroid malignancy is not excluded. There are some prominent lymph nodes on both sides of the neck. Follow-up is recommended. "
The patient had Arterial Blood Gas (ABG-sampling of blood levels of oxygen and carbon dioxide within the arteries) drawn at 0958 hours. The results PH 7.49 (H), pCO2 32.6 (L), pO2 81.4, Bicarbonate 24.5, Oxygen Saturation 97.0 %3 and Base Excess 1.8 on room air. The physician writes at 0610 hours the patient presenting with complaints of SOB but on exam, mild stridor (noisy breathing), will eval (evaluate).
The ED physician re-evaluated the patient at 0715 and 0815. He documented the results of the CT of the neck. The ED physician documented the patient is stable.
The patient received the following medications between 0625- 0858 hours Hydralazine (medication used to treat high blood pressure) HCL 10 milligrams (mg) intravenously (IV) times 2 doses; Albuterol/Ipratroponin (drug used to treat wheezing and SOB) per inhalation; and 2 doses of Decadron (medication used to treat inflammation) 8 mg IV.
The ED physician documented he called consults with Ear, Nose and Throat (ENT)/Otolaryngology, Anesthesia, ICU and Surgery, they will come to the ED and evaluate the patient. The times that the consults were called were not documented. There was no documentation in the clinical record to indicate the Cardiothoracic surgeon or the ICU (Intensive Care Unit) Physician came to the ED to evaluate patient #3 on 9/26/2015.
The patient received additional medications Pipercillin sodium/Tazobactam Sodium (medication antibiotic used to treat infections) 3.375 Gram (GM) IV in 100 ml. of Normal Saline and Epinephrine (S-2 2.25% solution) 1 ml. at 1004 and 1023 hours respectively.
The On- Call ENT (Ear Nose and Throat) physician, Dr. B__, documented a History and Physical (H&P) at 1023 hour on 9/26/15. The patient with history of progressive dyspnea for 1-2 months now. She developed increased dyspnea, cough productive yellow mucus, and noisy breathing yesterday. The patient's daughter brought her to the Emergency Room (ER) this morning. The ER team noted stridor on her arrival in the ER. She received Decadron (medication used to treat inflammation) 16 mg. IV in ER with relief of dyspnea and noisy breathing.
The ENT physician reviewed the results of the CT of the Neck, Chest X-ray and medications. The ENT physician documented the patient has no stridor or respiratory distress. The Oxygen Saturation is 98% on 2 Liters of Oxygen.
At 1030 hours the ENT physician documented an examination was performed using a Flexible Fiberoptic Laryngoscopy at the bedside without sedation or anesthetic. There is no edema or lesions. External compression and narrowing of the upper to mid trachea was visualized.
The findings were reviewed with the ED physician and On-Call Physician for Anesthesia (a physician trained wide variety of areas, i.e., perioperative and airway management). The tracheal airway narrowing made it not technically feasible to intubate her. The thickness of the of thyroid mass made it unsafe to undertake an awake tracheostomy. Dr. F__, Thoracic Surgery was contacted regarding cardiac bypass and sternal split. Dr. F___, agreed to helicopter transfer to a tertiary Hospital/Center (a hospital or Medical Center with specialized consultive care). The patient and her daughter were apprised of the consensus plan. Both were in agreement to transfer to a tertiary center for a higher level of care. Dr. GI___, (ED Physician) initiated the transfer from the ER (JFK Medical Center). The transfer was rapidly accepted.
At 1050 hours the On-Call physician for Anesthesia, Dr. Gu___, consults. The On-Call physician for Anesthesia wrote " called to ER emergently by ER physician for patient with stridor secondary to thyroid nodule airway compression. " Dr. Gu___, documented in part, " Minimal stridor on respiration ...Good air exchange. Per history, patient has had longstanding goiter and compression that was now aggravated by upper respiratory infection. Patient had received racemic epinephrine during admission. " The On-call Anesthesia Physician wrote that the patient was in " no acute distress. "
The plan per the Anesthesiologist: " Given the degree of airway compression and the need for very narrow tube, the patient would need to be potentially difficult intubation and ventilation. There is not a good fall back if intubation failed or ventilatory issues developed. Given that the patient is currently stable with good vital signs and responsive to the medical management and given the potential for severe morbidity or mortality, the recommendation for transfer to [Tertiary Hospital] was made. Case was discussed with ENT and Cardiothoracic (CT). Per Dr. B__, the ENT, the patient is not a candidate for awake tracheostomy. Dr. F___, felt that there was not a good local option for managing this patient. The ER physician, ENT, CT Surgery all in agreement with plan to transfer. Process initiated by ER physician. "
The ED physician documented on a fourth progress note, (not timed) on page 8 of 8. He wrote after consultation and multiple evaluations: Ear, Nose and Throat (ENT), Anesthesia, ICU and Surgery believes the patient needs higher level of care. The patient to transfer via helicopter for definitive management. The patient never had a desaturation (when the blood does not have enough oxygen) or difficulty breathing during her stay. Stable at the time of transfer.
The ED physician also documented on what was identified as page 9 of 8 pages revealed the following: Patient is transferred to [Tertiary Hospital]. The disposition time 1916 hours on 9/26/15. The ED physician documented all vital signs were reviewed; counseled patient and family (diagnosis, lab results, need for transfer). The ED physician documented the following:
TRANSFER
Transfer request call: 0941
Transfer date: 9/26/15
Call returned at 0955.
Spoke with: Emergency physician
Receiving Hospital: [Tertiary Hospital]
Transfer accepted: Yes
Transfer accepted by Dr. A__.
The medical record lacked evidence of the consults made by the CT (Cardio Thoracic) surgeon and the ICU Physician.
Review of the Patient Transfer Center ' s document titled: Pre Admit Face Sheet, verified the ED physician, Dr. GI___, called the Transfer Center on 9/26/15 at 0953 hours. The Call Center's documentation revealed the following: ED physician wants us to begin the process for a possible Emergent transfer to [Tertiary Center ED] for airway stabilization. Patient may need tertiary facility to have this done. The sending ED physician possible is contacting Cardiothoracic (CT) surgery first and then will update us. Dr. GI___, requests we contact [Tertiary Center Hospital]. Patient will need potential intubation and ventilatory support.
At 0958 hours the call center documented: the unit secretary (US) stated the CT surgeon, Dr. F___, could not handle the case.
At 1025 hours: The US updated on case status- accepting information given. Advised we are awaiting word from Trauma Hawk to see if they will accept the case. Also the nurse will need to go through US to connect to [Tertiary Hospital] Transfer Center to give report.
10:40 hours: Call to US- Nurse (names) from Trauma Hawk did speak with her.
The Date/Time of decision: 9/26/15 at 1005 hours.
1006 hours: Dr. A___, the ED physician accepted the patient after conference call with sending physician. Accepting Service and Provider: Otolaryngology, Head & Neck Surgery
1008 Hours: Awaiting call back from Trauma Hawk to see if they can accept this case. Advised it was Emergent.
Date/Time of decision: 9/26/15 at 1042 hours.
Transfer Priority: Capability- Service offered outside physician scope.
Trauma Hawk arrived at JFK 1049 hours.
Reason for Transfer: Outside physician scope to manage this particular problem. The ED physician, Dr. GI___, requested tertiary facility. He advised their ENT, Anesthesia and CT Surgery department felt they were not able to manage this patient.
Review of the JFK Transfer Sheet reveals the reason for transfer: Medically indicated is checked. The Risk and Benefits for Transfer: Obtain a level of care/service unavailable at this facility, Service: ENT/Anesthesia/Surgery.

2a. Tertiary Hospital Medical Record Review for Patient #3.
Review of the medical record revealed that patient #3 was seen by the ED physician on 9/26/2015 at 11:50. The ED physician documented on the ED Physician Note, " Patient presents with ear, nose throat, problem, transferred from palms west and stridor goiter airway compromise ...Physical Examination: ...General: Mild distress ...Neck: Supple, thyromegly, painful range of motion, stridor ...Ears, nose, mouth, and throat ...Throat: severe ...Cardiovascular: Tachycardia (fast heart rate). " The ED physician documented that at 11:55 that ENT consults had been called prior to patient #3 ' s arrival. Patient #3 was on 9/26/2015 at 12:05 to an in-patient unit under the care of an Otolaryngology (Physician trained in medical and surgical management and treatment of patients with disorders of ear, nose and throat and relates structures of the neck and head- ENT Physician ) specialist. On 9/27/2015 the ENT physician was consulted and documented in part on the History and Physical, " CHIEF COMPLAINT: Shortness of breath. History: 49 ... air transferred from JFK ...after she presented with severe SOB and stridor ...At JFK she was found to be in respiratory distress and with obvious stridor. She was not able to voice (talk) ...Plan: -Plan for total thyroidectomy (removal of the thyroid gland by surgery), central neck dissection-CT (cardio thoracic) consult for possible sternotomy (heart surgeon performs surgery through small incisions on the right side of your chest.)-Nasopharyngeal fiberoptic intubation (management of difficult airway to secure the airway) is preferred method securing airway if patient decompensated.- tracheostomy tray at bedside at all times in case of need for emergency surgical airway. " Patient #3 was subsequently taken to surgery for a total thyroidectomy.
3. JFK Medical Record Review for Patient #1.
Review of the clinical record revealed sampled Patient #1 presented to the ED on 9/26/15 at 1359 hours with a chief complaint of left eye pain.
A Medical Screening Exam (MSE) reveals the patient has an atraumatic, 2 cm. bleeding mass protruding outwardly from the left eye. The patient has been blind in the left eye for 3 years due to Glaucoma. The patient's visual acuity on the right eye is 20/20 with an ocular pressure on the right of 8,10. The patient was seen here on 9/23/15 and diagnosed with conjunctivitis and perceptual cellulitis of left eye that was seen on the CT Scan of the orbits. The patient was told to follow-up with Dr. S___, from Ophthalmology the next day. The patient did not have a ride to the Ophthalmologist office and did not keep the appointment.
The patient had lab work drawn (CBC, Chemistries, Coagulation studies, and a CT of the Orbits with/without contrast. The impression per radiologist: Markedly abnormal appearance of the left orbit. Suspect retinal detachment.
A call was placed to the On-Call Ophthalmologist (A medical Doctor who treats problems of diseases of the eye), by the ED Physician. The time the call was returned is 1354 hours.
A re-evaluation note by the ED Physician reveals Dr. S___, at the bedside.. He requested CT of Orbits with contrast. The results were evaluated by the Ophthalmologist. The Ophthalmologist writes the patient needs surgery which he does not feel comfortable managing at JFK. Patient will be transferred to (the Tertiary Hospital). Dr. S___, spoke to the residents on call (Eye Institute) who cross cover at (Tertiary Hospital). Aware the patient is on his way.
The Ophthalmologist came in to see the patient and dictated an H&P at 1711 hours on 9/26/15. The Ophthalmologist documents he received a call for consult at 1400 hours. The ED physician said I had to come right in to see the patient. The ED Physician got me out of the barber chair.
The Ophthalmologist did a repeat CT Scan plus an CT Angiogram. The interpretation is that the eye has ruptured and there is vitreous coming forward. The impression: Radiology evidence of spontaneous globe rupture.
The Ophthalmologists documents we have given the patient IV antibiotics and pain medications. The ED Physician is going to arrange transfer to have him taken to the Eye Institute (Miami). I offered to call the resident there, but she said she could take care of it, but had to go through the Transfer Center first. I told her if it is impossible to get him that he could be transferred to the Tertiary Hospital and the residents from the Eye Institute would take care of him there as well. We also believe there are some friends of the family members they may drive him to the Eye Institute. We might leave this to the capable hands of the ED staff.
Review of the Call Centers Log reveals Dr. S___, the ON-Call Ophthalmologist, called Dr. P___, at the Eye Institute at 1742 hours. The Eye Institute would accept to their ER by ambulance.
At 1755 hours a discussion between the Call Center and Dr. S___, reveals Dr. S___, stated we are back to trying the Tertiary Hospital. At 1719 the transfer center notifies JFK, another physician heard the case and they will call back after consulting with the specialist.
At 1758 hours the physician at the Eye Institute will accept the patient. The Transfer Priority: Capability - Service not offered at sender ED.
The Date/Time of acceptance 9/26/15 at 1807. The reason for transfer- Capability: Ophthalmology Ruptured Globe.
Review of the Certificate of Transfer reveals the Reason for Transfer: On Call physician refused or failed to respond within a reasonable period of time. The Medical Benefits: Obtain a level of care/services unavailable at this facility, Specialized Ophthalmology.
A second physician, unknown specialty, Dr. Fr___, documents the transfer reason: Transfer to Higher Level of Care. Patient Status: Stable Consent was obtained.
3a. Tertiary Hospital Medical Review of the Medical Record for Patient #1.
The medical record revealed that Patient #1 arrived to the facility on 9/26/2015 at 8:20 p.m., via ambulance. The ED Note-Physician dated revealed that Patient #1 was immediately seen upon arrival to the ED. The ED physician documented in part, " The patient presents with eye drainage and globe rupture. The onset was just prior to arrival. The course/duration of symptoms is constant ...Location: Left eye ...symptoms is drainage and bleeding. The degree of symptoms is severe ...Therapy today: prescriptions medications including Dilaudid (medication for pain) ...Review of Systems ...Eye Symptoms: Pain, discharge ...Physical Examination ...Eye: extrusion of material from left globe ...Impression and Plan: Diagnosis Ruptured Globe ...Condition: Guarded ...Patient was given ...Educational materials: MEDICAL SCREENING EXAMINATION, Non Urgent ...Follow up with ...Eye Institute.
4. Policy and Procedure Review
The facility ' s Policy & Procedure Manual, the section entitled, " EMTALA-FL Transfer Policy " Effective Date, 05/31/2012, 5/13, Reviewed Date 6/15 was reviewed. The transfer policy specified in part, " b. A Transfer will be an appropriate transfer if: 1. the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual ' s health... "
5. Credentialing Files/Core Privileges for Specialty Physicians review- for Patient #1 and #3
Review of the Credentialing files verified ENT Core privileges included: admission, evaluation, diagnose and provision of both surgical and non- surgical for patients with illnesses, injuries, and disorders of the head and neck to include the thyroid, Parathyroid and lymphatic system.
Core privileges for Ophthalmology include: admission, evaluation, diagnose, consults and provision of both surgical and non- surgical for patients with illnesses, injuries, and disorders of the eye.
Core privileges for Anesthesia include: management of patients with difficult airway and support life functions and vital organs under stress of anesthesia.
The CT physician is privileged for Cardio-Vascular Surgery to treat the heart and related blood vessels. The CT is privileged to diagnose, treat, and consult for patients with illnesses, and disorders of the thoracic cavity including the chest wall.
6. Interviews
Review of the medical records were conducted with the Risk Manager (RM). The RM verified at 1400 hours on 10/15/15 there were no hand written or electronic documentation to support consults or visits were made by the CT Surgeon and/or by ICU physician, as documented by the ED physician and Call Center for Patient #3.
The Assistant Medical Director (AMD) for the ED stated on 10/16/15 at 1100 hours the response time for the ON-Call physician is 30 minutes. The time the calls were made to the consults and the response time are documented in the Call Log. The AMD stated if the On-Call physician is unavailable we can go by the chain of command, Department Chair or the Administrator On - Call. The AMD stated, in response to patient #3, initially stated the On-Call physician (CT) needs to come in to see the patient. The AMD stated, in response to patient #1, if it's pretty obvious if they feel it's something they can't handle it requires a university level of care setting. The AMD stated, "I think [tertiary Hospital] is the closest." The AMD also stated at 1120 hours, in response to no evidence to support the CT surgeon came in to see patient #3, "I think that's fine. I'm not sure the CT needs to come in. "
An interview with the ED physician, Dr. GI___, was conducted on 10/16/15 at 1150 - 1205 hours. The ED physician stated after speaking with a General Surgery resident, CT, ENT and Anesthesia, patient #3 needed University/Tertiary level facility. The ED physician was asked the name of the General Surgery resident that was consulted because the record lacked evidence of that consult. The ED physician could not recall the name of the resident. The ED physician, in response to questioning related to the reason for the transfer to the tertiary level facility stated, "They were out of the scope of practice because of the risk. The services were unavailable because they (ENT, Anesthesia and CT) felt they could not do it (surgery) here (JFK). The specialty services felt they did not have the capability and capacity. "
Interview with the 9/26/15, On-Call CT surgeon, Dr. F___, was conducted on 10/16/15 1400 - 15 hours. A second CT surgeon, Dr. N___, and the Anesthesiologist, Dr. GU___, were present at the time of the interview. Dr. F__, stated, "I never spoke to the ED physician. I was called by resident and asked a question. I was asked what I thought about putting a patient on Cardio-Bypass/Heart Lung Machine to do surgery (Tracheostomy/Thyroidectomy). The CT stated there was no indication for the use of the Cardio-Bypass/Heart Lung Machine. The CT stated emphatically, "I Was Not a Consult." The Anesthesiologist verified the CT was not a consult.
Dr. N___, the CT surgeon stated, "We work on the Heart and Lungs only and not on the Neck. A Thoracic or ENT needed to manage the case. Dr. Gi___, (ED physician) needs to make that decision. Can you imagine putting a patient on the Cardio-Bypass Heart Lung Machine at the bedside in the ED. "
The Anesthesiologist Dr. GU__, stated at 1410 hours, "There was no fall back we could not get an intubation tube in and ventilate the patient. The ED physician wanted to do the surgery at the bedside. It was Saturday and there were not enough services/personnel available to do a surgery at the bedside without anesthesia. The airway was too compressed. ENT needs to intervene. There was no consideration of a Thoracic Surgeon to do the tracheostomy."
A telephone interview with the ENT, Dr. B___, was conducted on 10/16/15 at 1415 hours. The ENT stated, " In my assessment, plan, and multiple consults with General Surgery, Anesthesia and CT, led to making the decision to transfer. Dr. F___, he could not manage the patient here at JFK. The ED MD communicated with the tertiary facility. There was no hesitation per the receiving facility to accept the patient. I scoped the patient because of the narrowing of airway. The thyroid tissue was compressing the trachea. The General Surgeon recommended we need evaluation by all disciplines before we admit. I felt we consulted everyone as to the appropriateness."
The facility failed to ensure that their transfer policy and procedure was followed as evidenced by failing to ensure that medical treatment was provided that was within its capacity to minimize the risks to Patients #1 and #3 health and safety on 9/26/2015. As this resulted in inappropriate transfers for patient #1 and #3 on 9/26/2015.