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Based on review of 1 of 5 medical records, documentation by case managers, MEC (Medical Executive Committee) meeting minutes and interviews, the hospital failed to ensure the discharge plan for patient #2 was reassessed for the need for continuing care (the need for a neurosurgical consult) after the hospital attempted to transfer patient #2 and the receiving hospital did not have an available bed. This was evidenced by:

1. The failure of the attending physician to attempt to transfer patient #2 to another hospital which offered neurosurgical services and had the capacity and capability to accept and treat the patient and

2. The failure of the attending physician to make an appropriate transfer by not reassessing and keeping patient #2 in a stable environment until a bed was available at Hospital A and by inappropriately discharging patient #2 from the hospital and reportedly telling the patient to drive to Hospital A for further treatment.
Findings:

Review of the closed medical record revealed patient #2 was admitted to the hospital's intensive care unit on 1/26/2010 with a diagnosis of CVA (cerebrovascular accident). Review of the History and Physical dated 1/27/2010 at 9:26 AM by patient #2's attending physician Dr. S8 revealed, "This 51 year-old truck driver who some 2 weeks ago was driving his truck and has a sudden episode of diplopia (double vision). He stopped his truck and came to my office. CT scans failed to reveal any bleeding but an MRI suggested multiple occipital infarcts. He was hospitalized (According to medical records, this occurred on 12/14/2009 and not recently). A search for origin, including cardiac origin, was unsuccessful in locating the source of the emboli. His blood pressure was controlled and he was discharged home. Neurological consultation was made and yesterday he called back and said that he had another episode of diplopia and had lost the lateral vision of his left eye. This was confirmed with visual fields and a MRI and MRA were done. Last p.m. he was observed by radiologist that he had an extremely small right vertebral artery and an apparently almost occluded left vertebral artery. Otherwise is (his) arterial circulation was normal, and he was called and brought to the hospital. I spoke with (staff neurologist). He was given Plavix and observed overnight. He showed no signs of ectopy and no new symptoms. I spoke with (neurosurgeon) today and he suggested that he would accept him in transfer and care at (Hospital A) and we are making those arrangements".

Review of the nursing admission assessment dated 1/26/2010 at 9:00 PM for patient #2 revealed, "Worst vision this week. MRI (magnetic resonance imaging) done today". The nurse indicated through a diagram of an eye that patient #2's peripheral vision was affected in both eyes and documented the patient's pupils were even and responded briskly to light.

Review of the 1/26/2010 MRA (magnetic resonance angiogram) results which was performed on patient #2 at 3:55 PM (prior to hospital admit) revealed, "Small right vertebral artery and very high-grade stenosis of the distal left vertebral artery are most likely responsible for recent infarcts in the posterior circulation distribution. Critical results". According to the report, the results were called on 1/26/2010 at 4:50 PM to the patient's attending physician, Dr. S8.

Review of the 1/27/2010 results of the CT angiogram of the head for patient #2 which was performed at 6:00 AM revealed, "Intravenous contrast was injected and attempts were made to do a computerized tomographic angiogram of the vertebral arteries. Unfortunately, the area of the vertebral artery in question is at the base of the brain where the bone is the thickest and most difficult to subtract on a CTA study. On one image there appears to be an area of narrowing in the left vertebral artery but this cannot be confirmed on additional images. I think the only way to evaluate this segment of the vertebral artery is with contrast angiography. This could be performed when an appropriate time has passed since there is an acute right occipital infarct at this time".

Further review of physician orders revealed on 1/27/2010 (not timed) Dr. S8 wrote, "Transfer to (Hospital A) per (Neurosurgeon) or nearest neurovasc (neurovascular) site get MRI (and) MRAs copied to accom (accompany)". The staff RN transcribed the order at 0940 (9:40 AM). Dr. S8 wrote a second order on 1/27/2010 (not timed) to " Discharge" the patient. The nurse signed the order at 1200 (12:00 PM).

Review of the 1/27/2010 at 09:27 AM Discharge Summary for patient #2 by Dr. S8 revealed patient #2 "had some symptoms of occipital headache, diplopia, now loss of left lateral vision, and was found on workup yesterday to have some obstruction of his left vertebral artery and a possible embolic source there. Workup here in Northern Louisiana Medical center and overnight observation showed no cardiac ectopy ....I have spoken with (neurosurgeon) and he has agreed to accept the patient in transfer to (Hospital A)".

On 4/08/2010 at 10:50 AM an interview was held with S12 RN Case Manager who confirmed she worked on 1/27/2010 and tried to get patient #2 transferred to Hospital A. S12 said when Dr. S8 came to the nurses' station he said he had spoken to the neurosurgeon at Hospital A who accepted patient #2 and to "get him over there". S12 said when she called Hospital A, the person in charge of bed assignments told her they did not have a bed in the Neuro ICU, but were expecting a discharge that afternoon. S12 Case Manager said she told Dr. S8 the hospital did not have an available bed at that time and "he was hollering to get the doctor he talked to". S12 said she called the neurosurgeon's office but he was not in. S12 said the charge nurse at Hospital A called and asked "You wouldn't send the patient without us having a bed"? S12 said she assured the charge nurse that they would not do that.

S12 said by this time Dr. S8 was so angry and he wanted her to call an ambulance to transfer the patient to Hospital A. S12 said she told the doctor they could not send the patient without a bed or a proper transfer. She said Dr. S8 called the ambulance himself and that she (S12) told the nurses when the ambulance arrived; "the patient was not to get on the stretcher".

S12 said because of the volatile situation, she called her supervisor S7 RN Director of Case Management, informed her of the situation, and asked that she come and assist her. S12 said when S7 arrived at the unit, the paramedics were there to transfer patient #2 and S7 told them they were not needed at that time and the nurses would call when the transfer arrangements were complete. S12 said Dr. S8 left after S7 RN talked with him outside the unit but returned shortly and said patient #2 was leaving AMA. S12 further stated she and S7 talked with patient #2 and informed him of the repercussions of leaving AMA and that they were doing everything they could to get him transferred. S12 said patient #2 told them he understood and would wait.

An interview was held on 4/08/2010 at 9:15 AM with S7 RN Director of Case Management who stated S12 RN called her to assist with patient #2's discharge on the morning of 1/27/2010. S7 said she did not know why Dr. S8 wanted to transfer the patient immediately because they had already contacted Hospital A and were told the hospital did not have a bed available for a transfer. S7 said when she arrived at the unit, the paramedics were already there to transport the patient to Hospital A so she told them the patient was not ready to leave and they would call them back when he was ready for transfer.

S7 RN said the charge nurse at Hospital A called the unit and said to her that she understood that they wanted to transfer a patient and that Dr. S8 had spoken with the physician (neurosurgeon) who had accepted the patient but he could not be transferred at that time because the facility did not have a bed. S7 said she told the nurse that they were not sending the patient at that time and the nurse said they expected to have a bed within a few hours.

S7 RN said Dr. S8 mentioned to her that patient #2 was going to leave AMA and that the wife and a family member were in his room when she told the patient that they were working hard to get him transferred. S7 said after she spoke with patient #2, she called Dr. S8 and left a message saying she had talked with the patient and that he was not leaving AMA. S7 said later Dr. S8 came to the unit and said he was discharging patient #2. S7 added that the patient's family told her that Dr. S8 told them to follow-up with a local neurologist whom the patient had seen in 12/09. Review of the medical record for patient #2 revealed no documented evidence that an made an appointment was made for the patient to see the neurologist.

Dr. S8 stated in an interview on 4/08/2010 at 12:50 PM that he was had treated patient #2 for "several years". He stated that the patient reported that he was "driving his truck down the road alone and saw 2 telephone poles". Dr. S8 stated in 12/09 patient #2 came to his office and he sent the patient for a CT of the head and the results were normal. S8 further stated that after the patient went home he had a "spell of double vision" and he admitted him to the hospital (12/14/2009). He reported that during that time he (S8) found out that patient #2 had 2 embolic strokes but could not determine the origin so he called the neurologist at Northern Louisiana Medical Center and he (the neurologist) placed him (patient #2) on Plavix and Aspirin (blood thinner).

Further interview with Dr. S8 revealed on 1/26/2010 patient #2 came back to his office and reported that he had a loss of peripheral vision in his left eye. S8 said he ordered an MRA (Magnetic Resonance Angiogram) and the radiologist called him on 1/26/2010 stating patient #2 had a "critical lesion at the base of the brain and a stenosed artery" so he called the patient at home and told him he needed to come back to the hospital. Dr. S8 further reported that he admitted patient #2 that evening, visited him the next morning and the patient could not see out of the left eye so he told the patient that he needed to see a neurosurgeon. S8 stated that he told patient #2 that he had a "critical lesion" but did not tell him he could" stroke out" .

During the interview Dr. S8 said he called the neurosurgeon at Hospital A and discussed the situation with him and the doctor accepted the patient for transfer. S8 stated he talked with a "fellow at (Hospital A) 2 or 3 times" because he was afraid the patient was going to "stroke out at any moment" and the resident at Hospital A told him they did not have a bed at that time.

Further interview revealed Dr. S8 said he returned to the unit several times during the day patient #2 was discharged from the hospital (1/27/2010) to see if someone from Hospital A called to inform them that they had a bed for patient. He said he knew the resident he talked to and the nurses on that shift would be leaving soon so he told the patient he needed to go to Hospital A but they did not have a bed available. S8 said he did not want the patient to leave AMA because that "would mess up everything so I discharged him. I did it for the best interest of the patient and I will do it again". The survey team asked Dr. S8 if he attempted to transfer patient #2 to another hospital that provided neurosurgical services when he was informed that Hospital A did not have a bed available, and he stated he wanted the patient to see the neurosurgeon at Hospital A because "he is the best".

On 4/07/2010 at 3:00 PM an interview was held with S4 Staff RN who stated that she did hear Dr. S8 tell patient #2 to go ahead and leave and go to (neurosurgeon) at (Hospital A). She said she and the case manager tried to tell S8 that the patient could not just leave and go to Hospital A.

In a telephone interview on 4/08/2010 at 10:10 AM, Dr. S11 Chairman of the Medical Executive Committee said she first heard of patient #2 on 1/27/2010 after the patient had left the hospital. She said later, the CEO from Hospital A called their CEO (at Northern Louisiana Medical Center) and said they (Hospital A) felt Northern Louisiana Medical Center "had dumped the patient and was calling DHH (Department of Health and Hospitals)".

Dr. S11 said the members of the MEC reviewed the case and felt patient #2's discharge was inappropriate. S11 said she called S8 and told him they felt it was an inappropriate discharge because the patient had driven himself to Hospital A and the committee felt it would have been in the best interest of the patient to remain at Northern Louisiana Medical Center until the transfer had been completed. Dr. S11 said Dr. S8 replied he felt he had done what was best for the patient, but denied he told the patient to go to Hospital A after discharge from Northern Louisiana Medical Center.