HospitalInspections.org

1. Based on interviews with staff, reviews of medical records, facility Baptist Medical Center-Princeton (BMC-P) Bylaws, Medical Staff Rules and Regulations and Emergency Department Unattached Call Schedules, BMC-P on call Hospitalist and on call neurologist Employee Identifier (EI) # 15 failed to accept the transfer of Patient Identifier (PI) # 26; an emergency patient at H #1, who was diagnosed with a subdural hematoma and determined to be in need of specialized neuro-surgical services (available at BMC-P on 7/27/2012. Refer to Findings under A 2411.

2. Based on staff interview, the hospital failed to adopt and enforce a policy related to Recipient Hospital Responsibilities to ensure compliance with the requirements of 489.24

THE Findings include:
There was no policy and procedure for the Receiving Hospital Responsibilities related to EMTALA presented to the surveyors. EI# 2, the Director of Compliance and Risk Management, stated on 8/14/12 at 9:25 AM, there was no policy for Recipient Hospital Responsibilities, in the ED policy and procedures.

Based on interviews with staff, reviews of medical records, facility BMC-P Bylaws, Medical Staff Rules and Regulations and Emergency Department Unattached Call Schedules, BMC-P on call Hospitalist and on call neurologist Employee Identifier (EI) # 15 failed to accept the transfer of Patient Identifier (PI) # 26; an emergency patient at H #1, who was diagnosed with a subdural hematoma and determined to be in need of specialized neuro-surgical services (available at BMC-P) on 7/27/2012.
This deficient practice affected 1 of 26 (PI # 26) sampled ED patients and had the potential of affecting other patients requiring neurological specialized and stabilizing treatment at Hospital 2's emergency department (ED).

The findings include:

BMC-P's MEDICAL STAFF RULES & REGULATIONS
The Medical Staff Rules and Regulations revision adopted by the Active Medical Staff on April 5, 2011 were reviewed on 8/14/12. The following information was taken from the Medical Staff Rules and Regulations.

"4.1 Coverage - All Medical Staff Physicians are responsible for Emergency Department coverage as assigned by the Chairperson of the Department to which they are assigned.
4.2 Alleged Inappropriate Response - The protocol for handling alleged inappropriate response by Medical Staff Physicians when consulted on emergency patients shall be as follows:
4.2.1 Inappropriate response shall be defined as follows:
4.2.1.1 The response of the Medical Staff Physician places the welfare of the patient in jeopardy.
4.2.1.2 The response of the Medical Staff Physician leaves either the Hospital or the Emergency Physician in medico- legal jeopardy ..."


BMC-P's Emergency department Unattached Call Schedules

The Emergency Department Unattached Call Schedules were reviewed for the months of January through August 2012. The following on call physicians were verified for the Hospitalist and Neurosurgery on 7/27/12.

Hospitalist 7/27/12
(1) 6 AM to 6 PM - Employee Identifiers (EI) # 9, EI # 10, EI # 11, EI # 12
(2) 6 PM to 6 AM - No EI #

Neurosurgery
EI # 15


REVIEW OF PI # 26's RECORD FROM HOSPITAL # 1 (transferring Hospital)
On 7/27/12, Hospital #1 informed the Chief Medical Officer (CMO), Employee Identifier (EI) # 8 at (BMC-P) that an ED (Emergency Department) Physician, EI # 18, at hospital # 1, had attempted to request a transfer to (hospital # 2) and the Hospitalist nor the neurosurgeon would accept the patient, PI # 26, who required neurosurgical services.

PI # 26 came to Hospital # 1 by ambulance from home. The EMS (Emergency Medical Services) provider (local ambulance), provided documentation of the emergency. A call came into their system at 8:45 AM. The ambulance arrived at the home of PI # 26 at 8:56 AM. PI # 26 was assessed at 8:57 AM, by the EMS staff. PI # 26's right and left eye were reactive to light "Oxygen (O2) at 15 liters a minute (LPM) ... opens eyes to painful stimulation ... blood pressure (BP) 220/110."(Normal B/P reading is top number less than 120 and bottom number less than 80). At 9:16 AM, EMS staff initiated an intravenous catheter (IV) and gave a bolus of 200 cc (cubic centimeters) of Normal Saline (NS). PI # 26 was given Narcan (drug used to counter the effects of narcotics overdose) 2 mg (milligrams) IV at 9:18 AM, with no response. The EMS arrived at destination to hospital # 1 at 9:45 AM according to the computerized documentation.

The hand written Emergency Physician Record note for PI # 26 was timed at 9:30 AM by EI # 18, ER Physician. "Depressed level of consciousness ... withdraws (to) deep stimuli ... rhonchi (lung sounds caused by secretions & narrowing airway) ... bradycardia (heart rate less than 60) ... CT Scan (computerized axial tomography- special x-ray) ... TCC (Trauma Communication Center) ... (Hospital # 3) no beds ... spoke with (BMC-P, Neurosurgeon, EI # 15), refused patient ... Clinical Impression: Intubation, Hypertensive Crisis, CVA (cerebrovascular accident- Stroke) hemorrhagic ... large (right) ... with shift. Dispo (disposition) time: 11:05 AM ... critical."

Hospital # 1's computerized documentation for the Triage time was 9:32 AM. PI # 26's BP was 230/114, pulse 46 and respirations 16 and the "Chief Complaint was AMS Altered Mental Status (Change in Brain function).."

The Neurological Assessment completed at 9:35 AM by EI # 19, ER Nurse, revealed, "Pt (patient) presented to the ED with snoring respirations. Pt will follow commands with left hand and stick out tongue to command. Pt right arm only to DPS (deep painful stimuli). PERRL (pupils equal, round, reactive to light and accommodation). Pt Vomited."

PI # 26 was sent for a CAT (computerized axial tomography) Scan of the Head at 9:42 AM. Results to ER physician, "Impression: Findings consistent with a huge acute right- sided acute subdural hematoma producing marked mass effect and midline shift (a shift of the brain pass the center line) as detailed above. These results call to Dr. (EI # 18) at 9:52 AM."

Cardene (medication used to treat high blood pressure) IV was started at 10:00 AM and was titrated from 50 ml/hr (milliliters an hour) to 20 ml/hr BP was stabilized at 150/93 by 11:41 AM.

PI # 26 was intubated at 10:03 AM., a Foley was inserted at 10:05 AM., and a Nasogastric tube was inserted at 10:30.

According to the time line supplied by Hospital # 1 the TCC (Trauma Communications Center) was contacted at 10:10 AM, to assist with transfer to higher level of care- Neurosurgery capability. EI # 18 was informed by Hospital # 3 no neurosurgery ICU (Intensive Care Unit) beds available. At 10:25 AM, EI # 18 the ER physician called EI # 15, neurosurgeon at BMC-P and the neurosurgeon refused to take the patient. At 10:40 EI # 18, ER physician called a neurosurgeon, EI # 20 at hospital # 3 and EI # 20 neurosurgeon, accepted PI # 26 for emergency neurosurgery. EI # 18 also called administration at hospital # 1 and informed of the possible EMTALA violation by BMC-P.

The reassessment documentation by EI # 19, ER nurse at 10:57 AM revealed, "Squeeze her left hand to command, stick out tongue to command, move right side to DPS. PERRLA."

The Patient Transfer Form dated 7/27/12 at 11:02 AM, contained documentation "2. Reason for Transfer A. For equipment or services not available at this facility (List) higher level of care (with) specialty MD (Medical Doctor) availability ... 3. Hospital Acceptance A. Name of destination hospital. (Hospital # 3) ... c. Accepting MD: (EI # 20) ... vitals at transfer: BP 182/114 ... ."

PI # 26 was transported at 11:41 AM, to Hospital # 3's ED by local EMS ambulance. PI # 26's BP was 159/93, pulse 85, and remained intubated with 12 respirations a minute at discharge from Hospital # 1.

According to the time line supplied by Hospital # 1 at 11:50 AM, a representative from BMC-P called ED and agreed to accept patient- informed of existing transfer arrangements with hospital # 3.

The EMS ambulance accepted PI # 26 on 7/27/12 at 12 noon. The documentation provided contained "Pt on vent and had IV's of Cardene and NS.

PI # 26 was triaged at hospital # 3 at 12:19 PM. The Primary Assessment was completed at 12:32 PM, PI # 26 "following commands to neurosurgery MD ... BP 171/103."

According to the time line supplied by Hospital # 1 at 12:20 PM, EI # 15 neurosurgeon from hospital # 2 called EI # 18, ER physician from hospital # 1, to inquire about patient (PI # 26) and disposition, informed of transfer to (Hospital # 3).


REVIEW OF PI # 26's RECORD AT HOSPITAL # 3

The Emergency Medicine Note for Hospital # 3 dated 7/27/12 at 12:25 PM., contained documentation "The patient is a 61 year old . . . female transferred from (hospital # 1) to Neurosurgery ... At some point earlier today she was found unresponsive in bed. She was taken to (hospital # 1), where she was found to have a large right subdural hematoma (increase in pressure within the skull when blood collects in the space between the skull and the brain) with a shift. She was lethargic and intubated and given Lasix there for cerebral edema (large amount of fluid/water on the brain). She was transferred to Neurosurgery and (EI # 20, Neurosurgeon at Hospital # 3) ... Physician Examination: The patient is stable and blood pressure 170/101 ... She is awake and follows commands. She does not move her right side. ... Impression: 1. Right subdural hematoma with midline shift."

An Operating Room Scheduling Form Dated 7/27/12 contained the following information: "Start Time: emergency ... Pre- op Diagnosis: Right sided subdural hematoma ... Exact Procedure Planned: Right sided craniotomy for evacuation of subdural hematoma." PI # 26 underwent an operation to remove the Hematoma and following the surgery was able to make her own decisions. PI # 26 was discharged to a local rehab facility on 8/1/12.


INTERVIEWS WITH FACILITY STAFF and PHYSICIANS

EI # 18, ED Physician (worked on 7/27/12, at Hospital # 1) was interviewed on 8/16/12 at 9:57 AM and stated PI # 26 was brought into the ER (Emergency Room) with a Subdural Hematoma. "I attempted to transfer the patient and called TCC. They called (Hospital # 3) and they (Hospital # 3) had no beds. (Hospital # 3) said they could perform the surgery but wouldn't have a (neurosurgery) bed." Then a call was placed to BMC-P but TCC had wrong number. The ER Clerk placed a call to BMC-P and was transferred to the ER and was told needed to talk to Neurosurgeon, then was transferred to Hospitalist and was told needed to talk to neurosurgeon. "I was connected to (EI# 15), neurosurgeon on call for BMC-P. I told him what I had and told him the patient's condition. (EI # 15) said 'Patient sounds brain dead'. I told him no sir she is not brain dead. I paralyzed her to intubate her for medical purposes. He (EI # 15) said she sounds brain dead. He (EI # 15) eventually said he would consult but would not accept the patient. (EI# 20) Neurosurgeon at (Hospital # 3) made a bold move and had the patient transferred to (Hospital # 3) without a bed to get the patient transferred. Later (EI# 15, Neurosurgeon for BMC-P) called and said he thought the patient was "brain dead" was why he did not accept but would consult. I called (EI# 22, ER physician at Hospital # 3) to accept the patient so (EI # 20, Neurosurgeon at Hospital # 3) could see patient at (Hospital # 3).

EI # 19, ED Registered Nurse (RN) with background in neurology (who worked on 7/27/12, at Hospital # 1) was interviewed on 8/16/12 at 10:16 AM and stated PI # 26 was brought into the ER and was not moving left side but could stick out her tongue. Went to Dr. (EI # 18) and he ordered the CAT scan of the brain. "(EI # 18) was attempting to transfer patient to BMC-P and I overheard (EI # 18) say that (PI # 26) was not brain dead. I had (BMC-P) ED Nurse Manager (EI # 6) call me and talk to me about (PI # 26). I told (EI # 6) the patient would be transferred to (Hospital # 3)." EI # 19 was asked what was (PI # 26) appearance when transferred to hospital # 3; EI # 19 stated, "(PI # 26) on ventilator, semi comatose, moved left side, and could stick out tongue."

EI # 15, Neurosurgeon for BMC-P, was interviewed on 8/14/12 at 4:30 PM and was asked if a patient had been declined for transfer from hospital # 1; EI # 15 responded, "They described the patient as almost brain dead, only a gag reflex and on a ventilator. They told me they had called (hospital # 3) and they did not have a bed. They told me they had already called the Hospitalist here and they had refused because they needed a specialist. I didn't think with all that was going on with the patient that I could take this patient to surgery but I would be happy to consult on the patient. I then called the hospital administrator who called another administrator and our administrator called me back and told me to have the patient sent to the ER for assessment and go from there. I then called the hospital back and they already had a bed for the patient somewhere else."

EI # 22, ED Physician worked on 7/27/12, at Hospital # 3, was interviewed on 8/21/12 at 9:47 AM. EI # 22 stated, "I reviewed notes on PI # 26 when I told I would be interviewed about (PI # 26). She was following commands, then neurosurgeon to see her, one side not moving, but following commands. (PI # 26) went to OR from the ED."

EI # 21, RN ER Nurse on 8/16/12 for Hospital # 3, was interviewed on 8/16/12 at 3:25 PM and ask if remembered PI # 26, a patient seen in the ER on 7/27/12. EI # 21 was offered PI # 26's 7/27/12 ER medical record for review. EI # 21 did not remember PI # 26 but stated "the patient was given the highest acuity level (according to the ER record documentation)."

EI # 20, Neurosurgeon for Hospital # 3, was interviewed on 8/16/12 at 1:40 PM and was asked if a patient had been transferred from hospital # 1 to Hospital # 3 on 7/27/12; EI # 20 responded, "They (hospital # 1) call me all the time. I told them to send (PI # 26) to the ER and we would see her in the ER." EI # 20 was asked if anything unusual happened prior to the patient arriving at Hospital # 3's ED; EI # 20 responded, "Not that I know of. (PI # 26) had craniotomy (surgical removal of a part of the skull to expose the brain) (7/27/12) to remove clot. We had to take her back to the OR 2 days later- she woke up very well and went to rehab 2 days later and I think she may have left rehab now. Im not sure."

EI # 13, Hospitalist on 7/27/12 for BMC-P, was interviewed on 8/15/12 at 11:35 AM and was asked if a patient was declined on 7/27/12. "I have never declined a patient. The only reason I have ever declined is due to no bed available. EI # 13 was asked if the patient had a subdural hematoma what was the process? EI # 13 responded, "If patient is subdural hematoma- neurosurgery has to be the driver and the Hospitalist can then accept.

EI # 10, Hospitalist on 7/27/12 for BMC-P, was interviewed on 8/15/12 at 9:55 AM and was asked if a patient was declined on 7/27/12; EI # 10 responded, " I usually take it (transfer). I took two bleeding at the same time. I accepted both of them."

EI # 11, Hospitalist on 7/27/12 for BMC-P, was interviewed on 8/15/12 at 9:38 AM and was asked if a patient was declined on 7/27/12; "I didn't take call that day, (EI# 10 and EI # 12) were taking call."

EI # 9, Hospitalist on 7/27/12 for BMC-2, was interviewed on 8/15/12 at 9:25 AM and was asked if a patient was declined on 7/27/12, "(EI # 10) took call that day. I didn't."

EI # 12, Hospitalist on 7/27/12 for BMC-P, was interviewed on 8/15/12 at 10:05 AM and was asked if a patient was declined on 7/27/12, EI # 12 responded, "I don't remember what calls (came to beeper)." EI # 12 was asked if anything unusual occurred on 7/27/12; EI # 12 responded, "No."

EI # 17, Chief Nursing Officer for Hospital # 1 was interviewed on 8/16/12 at 9:36 AM and stated PI # 26 was brought into the ER on 7/27/12. EI # 17 presented a time line of the events on 7/27/12 related to PI # 26.

9:31 AM Presentation (PI # 26 in Hospital # 1's ER)
9:32 AM Triage
9:30 AM EDP (Emergency Department Physical) Exam (EI # 18)
9:52 AM CT Head Results (+ Large SDH w/ Shift) = large subdural hematoma with shift.
10:10 AM TCC contacted to assist with transfer to higher level of care - Neurosurgery capability- (hospital # 3) -no beds in Neuro ICU (Intensive Care Unit)
10:25 AM (EI # 18) discussed with (EI # 15 neurosurgeon (Neurosurgery) from BMC-P) - refused transfer
10:40 AM (EI# 18) discussed with (EI # 20, neurosurgeon from hospital # 3) accepted transfer. Administration notified of possible EMTALA violation by (BMC-P)
11:00 AM Transfer to (hospital # 3) confirmed with (EI# 22, ER physician for hospital # 3, on 7/27/12)
11:10 AM (Local EMS provider) contacted for transfer to (Hospital # 3)
11:50 AM Representative from (BMC-P) called ED and agreed to accept patient - informed of exiting transfer arrangements with (hospital # 3)
11:51 AM Transfer accomplished via (Local EMS provider) to (hospital # 3)
12:20 PM (EI # 15, neurosurgeon, for BMC-P) called (EI # 18, ER Physician, for Hospital # 1) to inquire about patient and disposition, informed of transfer to (hospital # 3).

EI # 17 explained all hospitals use the TCC system because it shows the availability for Trauma, stroke, and heart attack beds. TCC provides us direction as to where to send the patient. Every hospital has a computer system and green means accepting that type of patient, yellow limited availability, and red for divert the patient. EI # 17 was asked who makes the call to the receiving hospital; EI # 17 stated any staff member could call. The staff will call the hospital, find out who is on call, get the number for the on call physician, and the staff member gives the information to the ED physician. Then it is physician to physician for exchange of information. EI # 17 was asked how long does the request to transfer usually take; EI # 17 stated "It doesn't take very long. The system is updated every 15 minutes. The physician to physician call may take longer."

EI # 8, Chief Medical Officer for BMC-P, was interviewed on 8/15/12 at 10:55 AM and was asked how would an outside hospital transfer a patient to this facility; EI # 8 responded, "Call the hospital and ask for the hospital specialty and person with bed control. They have to have a bed." EI # 8 was asked if the hospital had declined a transfer of a patient on 7/27/12; and EI # 8 responded "On, 7/27/12 I know we declined a (Hospital # 1) patient by (EI # 15, Neurosurgeon)." EI # 8 was asked what the reason for decline; and EI # 8 responded, "This was an acute neuro patient and is not an appropriate patient for the Hospitalist ... (neurosurgeon) should have accepted patient."

EI # 8 was asked if there was an investigation for this incident; EI # 8 responded, "We discussed but not written." EI # 8 stated "(EI # 2, Director of Compliance) might have a report."


EI # 2, Director of Compliance and Risk Manager for BMC-P, was interviewed on 8/15/12 at 11:15 AM and was asked if there was an investigation of the 7/27/12 incident of (EI # 15, neurosurgeon) refusing a transfer patient from hospital # 1. EI # 2 responded, "I do not have a written investigation. EI # 8, Chief Medical Officer, felt like we had rectified the situation by calling (hospital # 1) back and trying to accept the patient ... I agree that we were in violation and will be entering it in as one."

EI # 7, Director of Quality Management for BMC-P, was interviewed on 8/17/12 at 10:34 AM and was asked if the Quality Department had an investigation into the incident on 7/27/12. EI # 7 stated, "I do not but (EI # 2, the Director of Compliance and Risk Management) might have something."


EI # 24, RN Nursing Supervisor on 7/27/12 for BMC-P, was interviewed on 8/14/12 at 2:24 PM, and was asked what the process was for when another hospital calls to place a patient here; EI # 24 responded, "The other hospital would call the switchboard for a list of the "on call" doctors and must be physician to physician. I cannot accept a patient. I have to have physician call and request bed."

EI # 23, RN Flexi Pool ER Charge Nurse (CN) on 7/27/12 for BMC-P, was interviewed on 8/14/12 at 1:15 PM, and was asked what process is used when an outside hospital wanted to transfer a patient to your hospital. EI # 23 stated, "The CN takes that call (ER to ER) still have to have an accepting medical doctor (MD)." How do you know there is an accepting MD; EI # 23 responded, "Usually the accepting MD calls and lets the CN or HS (House Supervisor) know (about the patient)."


EI # 25, RN ER Charge Nurse (CN) on 8/14/12 for BMC-P, was interviewed on 8/14/12 at 9:30 AM., during an observation 8/14/12 of the TCC system used by the hospital. EI# 25 was asked what the process of the TCC system was; EI # 25 stated, "The TCC shows which hospitals are on divert. The red light means to divert."

There was no evidence of an investigation provided or plan of correction put into place prior to or while surveyors were on site.


Summary:
PI # 26 was refused transfer to BMC-P by the Hospitalist and On-call Neurosurgeon for specialized medical/surgical treatment for a subdural hematoma from H # 1 on 7/27/12.
BMC-P staff interviews revealed H # 2 failed to have a policy and procedure for the acceptance of emergency patients to BMC-P.
BMC-P's medical by laws and the rules and regulations did not specify what the medical staff and Hospitalist role were related to emergency department patients. The Medical By Laws and Rules and Regulation did not indicate the procedure for the ED staff to follow for determining who would take the call from a transferring hospital and accept the appropriate transfer from another hospital.