HospitalInspections.org

Based on interview and record review the facility failed to comply with 489.24 by failing to ensure that patients with emergency medical conditions (EMC) who required specialized capabilities or facilities were accepted to their hospital within the capacity and capability of the hospital. The facility failed to ensure that an inclusive certification for transfer was completed. The facility failed to ensure that a medical screening exam was completed timely.

For all potential transfers into the Emergency Department (ED), the hospital failed to ensure that procedures were in place to evaluate the hospital's capacity and capability before refusal of a patient from an outside ED that required specialized services. (Refer to A 2411)

For Patient 1, the hospital failed to follow their own procedure for "Code Capacity" in the ED prior to refusing a patient for no ED capacity. (Refer to A 2411)

For Patient 3, the hospital failed to have a plan for accepting patients to the Medical Intensive Care service that took into consideration what the hospital had done in the past to accommodate patients. (Refer to A 2411)

For Patients 8, 5, 9, and 7 the hospital failed to ensure that the process for determining capacity and capability did not cause a delay in transfer of the patient.. (Refer to A 2411)

For all patients who needed medical intensive care services transfer into the hospital for higher level of care, the facility failed to maintain an on-call list of physicians who are available to provide necessary treatment to patients needing a transfer to the facility for a higher level of care. (Refer to A 2404)

For Patient 10, the facility failed to start the screening exam and document where the patient was for 1 hour after being brought in by ambulance on a 72 hour hold for being a danger to others. (Refer to A 2406)

Based on interview and record review, the facility failed to ensure that an appropriate medical screening exam was initiated timely for 1 of 32 sampled patients, Patient 10. The patient was brought in by ambulance on a 72 hour hold for being a danger to others. The facility failed to start the screening exam and document where the patient was for 1 hour. This failure had the potential to cause any patient in the Emergency Department (ED) to be at risk for injury.

Findings:

A review of the medical record for Patient 10 revealed that he came into the Emergency Department (ED) on 5/8/10 at 15 minutes after midnight on a 72 hour hold with diagnoses that included bipolar affective disorder (severe mood swings, from severe depression to periods of manic behaviors).

A review of the 72 hour hold (5150) placed by the Police Department (PD) revealed that the patient was a danger to others. The report documented that the patient threatened to kill a family member.

A review of the ambulance record, dated 5/8/10, revealed that the patient was released to the hospital at 8 minutes after midnight.

A review of the nursing documentation revealed that a triage assessment was completed on 5/9/10 at 1:49 AM. There was a nurses note at the same time documenting that the patient was brought in by ambulance and that he had "hit the wall and threatened father". There was no documentation from when the ambulance released the patient at 8 minutes after midnight to the triage assessment at 1:49 AM.

A review of the facility policy titled "Psychiatric Patient Detention", dated 11/07/10, revealed the following:

"2. The patient shall be instructed to remain in the room.
3.2 Security shall be present for all 5150 holds, if needed."

An interview was conducted with the Clinical Supervisor of the ED (CSEC) on 5/17/10 at 1:35 PM. She confirmed that there was no documentation regarding the patient's placement or the patient's status for over one hour. The CSED stated that she could not find any documentation to show if the patient was placed in a room or if security was alerted to the potential for harm to other patients. She stated that the patient should have been watched especially since he was on a 72 hour hold for being a danger to others.

Based on observation, interview, and record review the hospital failed to ensure that patients with emergency medical conditions (EMC) who required specialized capabilities or facilities were accepted to their hospital within the capacity and capability of the hospital.

The hospital failed to ensure that procedures were in place to evaluate the hospital's capacity and capability before refusal of a patient from an outside Emergency Department (ED) that required specialized services, for a universe of all potential transfers.

The hospital failed to follow their own procedure for "Code Capacity" in the ED prior to refusing a patient for no ED capacity for one of 32 sampled patients, Patient 1.

The hospital failed to have a plan for accepting ED transfer patients to the Medical Intensive Care Service that took into consideration what the hospital had done in the past to accommodate patients when the service was at capacity for 1 of 32 sampled patients,
Patient 3.

The hospital failed to ensure that the process for determining capacity and capability did not cause a delay in transfer of the patient for 4 of 32 sampled patients, Patients 8,5,9, and 7.

These failure placed patients at risk for further deterioration of their emergency medical condition, including death.

Findings:

On 5/11/10 a visit was made to the hospital's transfer center. The center was staffed by Registered Nurses (RN) and clerical coordinators. The "guidelines" for Emergency Department (ED) to ED transfer was reviewed with the Director of the Transfer Center (DTC). The process was as follows:

A call comes in from a sending hospital ED.

There were 4 medical conditions that the call went directly to the receiving hospital's ED. The four were STEMI (heart attack with certain changes on the heart tracing), multiple system trauma, acute stroke (brain attack) that met certain conditions, and snake bite.

If these four conditions were not met, the coordinator took the patient information and requested a fax of the patient's medical information from the sending hospital.

The coordinator then, gave the information to an RN within 15 minutes.

The nurse determined if the call was "emergent/urgent/time sensitive". If the call was determined to fit this criterion, the RN called the sending hospital for "clinical" information.

The call was then connected to the "Service-line MD for potential ED to ED transfer" (Service-line MD was the physician service that would be responsible for care of the patient). If the patient was accepted, the transfer center was to place the information into a system for identifying open beds in the hospital.

A review was conducted of the requests for transfer from outside EDs from 5/7/10 at 5 PM through 5/10/10 at 5 AM. A review was conducted, with the DTC, of requests that either were refused or had time delays in acceptance. There were 9 records reviewed. The review and associated interviews of 6 of the 9 requests were as follows:

1. Patient 1- A review of the patient placement worksheet revealed that the sending hospital placed a call on 5/7/10 at 5:16 PM stating a "Suprasellar mass or aneurism" (brain mass or bulging blood vessel). The sending hospital was requesting transfer for a "higher level of care". The RN in the transfer center called the sending facility and spoke to the MD. The transfer center RN then called the ED and was told that the ED was at capacity and refused the patient.

The DTC stated that the RN did not follow the transfer center's guidelines. She stated that the RN should have called neurosurgery (brain surgery) service.

The Director of the ED (DED) stated, during an interview on 5/13/10 at 1:55 PM, that the ED never closes to admissions, per the facility's county Emergency Medical Services policy. She stated that the practice of calling the ED saturated (at capacity) was no longer allowed.

During an interview with ED MD 2, the ED attending physician, on 5/13/10 at 1:05 PM, he stated that he did close the ED when he felt there were too many patients in triage, waiting and the hospital was full. He stated that the house supervisor told him when the hospital was full. He stated there was no documentation of when he determined the hospital was full and he stopped accepting patients.

During an interview with the Chief Patient Care Director on 5/12/10 at 2:25 PM, she stated that the facility's ICU beds had not been completely filled any time in 2010.

During an interview with the DTC on 5/11/10 at 10:30 AM, she stated that the East Campus Hospital had 8 ICU beds, and sometimes no patients or just one to two patients.

An interview was conducted with the clinical supervisor of the ED (CSED 1) on 5/19/10 at 11 AM. She stated that the ED should call "Code Capacity" (a process established by the hospital to prevent the ED from becoming at capacity by admitting or transferring patients in the ED) before they can say that they are at capacity. A review was conducted of the ED's daily staffing sheets. The sheets described the patient flow of the day and would be the place to document if a "Code Capacity" was called. On 5/7/10 there was no "Code Capacity" called. CSED 1 confirmed that on 5/7/10, when a transfer was refused for ED capacity, there was no "Code Capacity" called.

2. Patient 3- A review of the patient placement worksheet revealed that the sending hospital placed a call on 5/9/10 at 11:48 PM stating "seizures (multiple) epilepticus" (continuous seizures that are a life-threatening emergency). The transfer center RN called the Medical Intensive Care Unit (MICU) service. The MICU MD stated that the service could not accept any patients that night. The worksheet further documented that the service was accepting other patient's from the ED that night.

The DTC stated that with the information available to the RN, this patient had an EMC and the RN should have called the ED for acceptance.

The DTC stated that the hospital had only two MICU service teams. The teams included an attending physician and residents. The teams could only accept up to 15 patients each; however, the MICU teams routinely accepted above their 15 patients if patients needed to be admitted to their service, if the patients were in their own ED. She stated that the teams would not accept patients above their 15 if the patient was coming from an outside ED. The DTC stated that the facility had to "save beds" for their own patients.

An interview was conducted with Physician A, one of the two MICU attending physicians, on 5/13/10 at 3 PM. He stated that the MICU service can only have 15 patients at a time for each team and that the two teams were frequently at their 15 patients each. That would equal 30 patients. The physician was asked how they could take call for the ED if they were at capacity. He stated that they often took above their capacity for patients in their own ED. He stated that they would not take patient's from outside EDs if they had 30 patients total; however, they would take more patient's in their own ED.

3. Patient 8- A review of the patient placement worksheet revealed that the sending hospital placed a call on 5/9/10 at 9:12 PM stating "large brain bleed". The document review revealed that at 9:16 PM a fax of the patients brain tracing was requested from the sending hospital. The next documentation was at 10:12 PM and revealed that the RN documented that he was "Waiting for FAX info (information); nothing sent, called (name) who reported pt (patient) going to (another hospital)."

The DTC stated that she had reviewed this case with the RN. She stated that the RN should not have waited for the fax from the sending hospital, as this appeared to be a very time sensitive case and the sending hospital's call should have been transferred directly to the ED.

The failure of the facility to accept Patient 8 caused a potential for critical injury to the patient with an emergency medical condition.

4. Patient 5- A review of the patient placement worksheet revealed that the sending hospital placed a call on 5/8/10 at 2:47 PM stating "Motorcycle accident - Left femur fracture (mid shaft deformity) + LOC {level of consciousness}". The worksheet documented that the information was sent to the pediatric ED "after" 3 PM and that the information was sent back to the transfer center "after" 4 PM with the need for an orthopedic (bone) referral. The worksheet documented that the sending facility was notified at 5:30 PM that the patient was accepted. (This was nearly 3 hours after the first call.) The sending hospital canceled the transfer without reason.

The Director of the ED (DED) stated, during an interview on 5/13/10 at 1:55 PM, that in the case of other facilities' EDs seeking transfer due to a patient with multiple trauma, STEMI, strokes, snakebites and all pediatric patients, the calls were transferred to the ED for the ED physicians to handle. She stated that she was not sure who made decisions about which transfer circumstances were to be reviewed by the ED physicians.

The DED was interviewed at the same time about the case of Patient 5. She stated that the call from the transferring hospital should have gone to the ED physician. She stated that her recollection of the case was that the orthopedist approved the transfer, but when they called the transferring hospital back, they cancelled the transfer request.

She stated that the ED had no history of being told the admitting team was saturated and could not admit another patient.

The delay in accepting Patient 5 of nearly 3 hours had the potential to cause critical injury to a patient with an emergency medical condition.

5. Patient 9- A review of the patient placement worksheet revealed that the sending hospital placed a call on 5/8/10 at 3:13 PM stating "CABG (heart surgery) Injury". The document revealed the following:

At 4:15 PM, the ED physician at the sending hospital called the RN at the transfer center and requested a "ED/ED transfer since pt maybe having a STEMI/failed CABG."

At 4:30 PM, the RN called a heart surgeon at who said the case should have gone to the cardiologist (heart, not surgical, physician).

At 4:50 PM, the RN called a cardiologist.

At 5:45 PM, the cardiologist called back and the case was explained by the RN to the cardiologist at the transfer center.

At 7:50 PM, the ED physician at the sending hospital was connected with the cardiologist at the receiving hospital and the patient was accepted.

An interview was conducted with the RN (RN A) who took the call at 4:15 PM from the ED physician of the sending hospital on 5/8/10 at 11:50AM. She stated that she did not connect the sending hospital's ED physician to the receiving hospital's ED because the physician did not say for sure that the patient was having a STEMI. She confirmed that if the patient was having a STEMI or a failed heart surgery that it was an EMC. She confirmed that at 4:15 PM on 5/8/10, the patient was confirmed by the sending hospital as having an EMC and that she did not transfer the sending physician to the ED.

In the same interview the RN was asked who determined if a patient had an EMC. She stated that the RN at the transfer center decided if it was an EMC by reviewing the documents that were faxed by the sending hospital. She stated that the RN also reviewed the patient's vital signs to help determine if a EMC exists.

At the same time, the DTC confirmed that the nurse decided if the patient had an EMC. She stated that there were no guidelines or protocols for the nurse to decide. The DTC confirmed the hospital's physician's education (described below) that documented that the sending hospital determines if an EMC exists and not the RN at the receiving facility.

A review of the facility's education for physicians regarding EMTALA regulations revealed conditions that the hospital was "compelled" to accept a transfer:

"The individual has been determined by the treating physician (or other qualified medical professional) at the transferring hospital to have an emergency medical condition ..."

6. Patient 7- A review of the patient placement worksheet revealed that the sending hospital placed a call on 5/9/10 at 6:50 PM stating "Subdural hematoma (collection of blood from bleeding on the brain) ..." A review of the RN's documentation on the worksheet revealed several calls made to the receiving facility's neurosurgery (brain surgery) service. The patient was accepted as an ED to ED transfer at 7:53 PM, over 1 hour after the facility called with a patient who had an EMC.

The DTC reviewed the worksheet and confirmed the delay. She also stated that the RN should have called the receiving ED for transfer right away.

During an interview with DTC on 5/13/10 at 10:35 AM, she stated that 1 ? years ago, the Transfer Center started taking ED transfer request calls. She stated that there was no written documentation that the Transfer Center had been granted the ability to manage requests for ED to ED transfers.

The DTC explained that the Transfer Center designed protocols for determining how telephone calls requesting patient transfer from another facility, including another facility's emergency department, were handled. She stated that the protocols were discussed with representatives of the ED, but she was unable to provide information about when they had been discussed. She stated that the patient transfer protocols had not been presented for approval and had not been approved by representatives of the ED, the medical staff or the governing body.