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Based on record review and interviews, the hospital failed to ensure the medical staff was accountable to the governing body for the quality of medical care provided to 1 of 5 patients in a total sample of 10 (patient #1). This was evidenced by physicians identifying patient #1 as in need of an urgent airway treatment which was not available at Glenwood Hospital, then discharging the patient with instructions to go to Hospital A (acute care hospital located 98.2 miles from Glenwood) by private vehicle for further treatment. Findings:

Review of the closed medical record revealed sampled patient #1 was a 42 year-old admitted to Glenwood Regional Medical Center on 8/29/11 at 1:04 PM. Review of the 8/29/2011 History and Physical by attending physician Dr. S6 revealed patient #1 was previously hospitalized from 7/20/11-7/26/11 requiring ventilation by a endotracheal tube for 6 days after a drug overdose.

Further review revealed a local ENT (ear, nose and throat specialist) performed an outpatient fiberoptic laryngoscopy in his office prior to sending patient #1 to the hospital. According to the physician's documentation, the patient's upper airways were clear, but "may have problems at the tracheal level". Review of a copy of the form titled Established Patient Note ENT by the local ENT dated 8/29/11 at 11:55 AM revealed patient #1 had audible stridor and was anxious. "There is limited amount of airway movement, probably due to tracheal occlusion/obstruction". The ENT noted that patient #1 would be admitted to Glenwood Hospital for observation and to undergo a fiberoptic bronchoscopy.

Review of physician progress notes by consulting pulmonologist Dr. S13, revealed a fiberoptic bronchoscopy procedure was performed on patient #1 on 8/30/2011 which showed severe tracheostenosis (constriction of the trachea). S13 documented that he called an ENT physician at Hospital A who agreed to see patient #1 in her office at noon the following day (8/31/2011). S13 noted, "Will d/c (discharge) to home in AM on prednisone tonight".

Review of progress notes documented by S4 case manager dated 8/31/2011 at 11:30 AM revealed she spoke with pulmonologist Dr. S13 who gave orders to transfer patient #1 to Hospital A by ambulance to the accepting ENT physician at Hospital A. S4 documented she spoke with the transfer coordinator at Hospital A regarding the transfer and faxed information on patient #1. S4 further documented she spoke with the ENT physician Hospital A who agreed to accept patient #1 as a discharge from Glenwood Hospital and to come to the ER (emergency room) at Hospital A by private vehicle for admit and surgery the following day (9/01/2011). The record indicated S4 called pulmonologist Dr. S13 again to clarify if patient #1 was a hospital-to-hospital transfer, or a regular hospital discharge. S4 case manager noted S13 told her patient #1 was stable for discharge and to transfer her by car to the ER at Hospital A "instead of stretcher" (by ambulance). S4 documented she also called attending physician Dr. S6 to see patient #1 before discharge. Review of Nurse Notes dated 8/31/11 revealed patient #1 was discharged from Glenwood Hospital at 2:00 PM.

Review of physician progress notes documented by attending physician Dr. S6 dated 8/31/11 at 12:45 PM, revealed orders were received from the physician at Hospital A to discharge patient regularly and that he instructed the patient to present to the ER at Hospital A. S6 documented, "Patient has been instructed and understands urgency of stricture. The urgency of the stricture certainly justifies the method of transfer given logistic delays should an attempt in-patient to in-patient. Dc'd (discharged)patient in need of urgent airway treatment that cannot be provided here".

On 10/04/2011 at 9:45 AM an interview was held with S2 RN APN who rounded on patient #1 on 8/31/2011 at 9:45 AM for attending pulmonologist Dr. S13. S2 said that was her first time to see the patient who was irritated at the delays in discharge, but not in respiratory distress. S2 said during her visit with the patient, pulmonologist Dr. S13 and attending physician Dr. S6 coordinated the patient's discharge and referral to Hospital A. S2 said during the visit patient #1 had audible stridor, her oxygen saturation was 98% (level of oxygen the red blood cells are carrying to all internal organs and the normal is 95-100%), and her breathing was not labored. S2 added that the patient's stridor was caused by tracheal stenosis.

An interview with attending physician Dr. S6 on 10/04/2011 at 11:45 AM revealed patient #1 had a slit below the thoracic inlet which would require "cracking" her chest if she collapsed due to complete occlusion. S6 stated normally they do a regular transfer process (hospital to hospital by ambulance) but they deviated from the norm in order to get patient #1 into Hospital A's healthcare system to receive faster treatment for her tracheal stricture because the patient had to have immediate care. S6 said he never spoke directly to the accepting ENT at Hospital A because the arrangements for the patient were made by pulmonologist Dr. S13 and the ENT at Hospital A. S6 said many times there is a delay in transferring a patient to Hospital A and they felt that patient #1's urgency for treatment justified the diversion from the norm. Dr. S6 said he assessed patient #1 prior to her discharge and stressed the importance to her that she go directly to Hospital A. S6 said he "told the patient multiple times if something smaller than a pea occluded the only opening she had, she could die". Dr. S6 said the patient was "okay at rest to go to (Hospital A)".

On 10/04/2011 at 11:35 AM a telephone interview was held with the ENT at Hospital A who accepted patient #1 on 8/31/2011. The ENT stated she vaguely recalled the patient, but was not involved in the patient's care after she was admitted to Hospital A. Hospital A ENT said she recalled speaking with the transfer coordinator at Hospital A who reported to her that patient #1 had respiratory stridor. The ENT said she took the telephone call at the cancer treatment center where she was working that day and knew that they "were not set up for emergencies" so she told them to send the patient to the ER at Hospital A instead. The ENT stated patient #1 was a "2-way transfer" (meaning a hospital-to-hospital transfer).

In a telephone interview on 10/04/2011 at 12:50 PM, patient #1 stated that on 8/31/2011 there were several discussions about how she would go to Hospital A. She said at first she was going by car, then ambulance and eventually by car. Patient #1 said she was unsure what time she left Glenwood Hospital but she thought it took 2 hours to get to Hospital A. The patient was unsure what time she arrived at the hospital, but stated it was approximately 6:00 PM. Patient #1 stated she went directly to Hospital A upon discharge from Glenwood Hospital and did not stop for anything.

During the interview the survey team asked patient #1 if she felt safe traveling by private vehicle and she responded, "At first I was kinda nervous but I sat with the air conditioner blowing directly on me" Patient #1 continued to say that when she arrived at Hospital A, her husband let her out and went to park the car. She said as she was walking down the hall toward the ER, a doctor heard her respiratory stridor and took her to the ER "where they started vigorous treatments on me".

In a telephone interview on 10/06/2011 at 9:15 AM Dr. S12 Chief of Staff stated patient 1's discharge did not go to medical staff or governing body for review.

Based on closed medical record review and interviews, the hospital failed to provide an appropriate patient discharge by discharging 1 of 5 patients (Patient #1) in a total sample of 10 to another acute care hospital and asked the patient's family to transport her by personal auto. Patient #1 required a higher level of care not provided by Glenwood Regional Medical Center.

Findings:

Review of the closed medical record for sampled patient #1 revealed she was admitted to Glenwood Regional Medical Center on 08/29/11 at 1:04 PM. Review of the History and Physical dictated by S6 MD dated 08/29/11 revealed this patient was a 42 year old who was previously admitted to Glenwood Regional Medical Center from 7/20/11-7/26/11 at which time had prolonged ventilation via endotracheal tube (6 days) after a drug overdose. Further review revealed a local ENT(ears, nose and throat physician) had performed a fiberoptic laryngoscopy in his office prior to sending her to the hospital, that found her upper airways clear, but "may have problems at the tracheal level". Review of a copy of the Established ENT Patient Note dated 08/29/11 at 11:55 AM revealed patient #1 had audible stridor and was anxious. "Patient will be admitted to Glenwood for observation and to undergo fiberoptic bronchoscopy". Further review of the History and Physical revealed patient #1 was alert with obvious stridor that caused her to speak only limited words at a time. "There is limited amount of airway movement, probably due to tracheal occlusion/obstruction ".

Review of the consultation documentation by S13 MD (locum tenens for Glenwood Hospital pulmonology staff) dated 08/29/11 at 21:36 (9:36 PM) revealed patient #1 had a stridor after discharge from Glenwood Hospital on 7/26/11 that got worse on exertion. S13 noted the evaluation of the local ENT and re-examined patient #1. S13 documented the vital signs at that time: Blood pressure- 120/60; heart rate- 70; oxygen saturation -95% on room air and the temperature- 98 degrees orally. S13 indicated patient #1 was started on Solu-Medrol (steroid that reduces inflammation) 60 mg every 8 hours and Zithromax (antibiotic) (No dose or frequency noted) and that a CT (computed tomography) of the neck and chest without contrast with reconstructive images, looking for specifically tracheal stricture was planned. "Will proceed and keep patient #1 NPO (nothing by mouth) and do a bronchoscopy in the morning. The procedure was explained to the patient and she agreed to go ahead with procedure". Review of the procedure report revealed the flexible bronchoscopy was performed 8/30/11 at 10:18 AM and completed at 10:23 AM.

Review of physician progress notes dated 08/30/11 by S13 pulmonologist revealed following the fiberoptic bronchoscopy, he called the ENT physician at Hospital A who agreed to see patient in her office at noon on 8/31/11. "Will d/c (discharge) to home in AM; on prednisone tonight".

In an interview on 10/04/2011 at 9:25 AM, S1 LPN stated she was assigned to patient #1 on 8/31/2011; the day the patient was discharged from Glenwood Hospital. S1 said this was her first time to work with patient #1 who was "breathing funny". S1 described the patient's respiratory status as inspiratory stridor (a high pitched wheezing sound resulting from turbulent air flow in the upper airway and caused by a narrow or obstructed airway path). S1 said she knew patient #1 was scheduled for discharge that morning and to go to Hospital A by private auto for further treatment. S1 said she was concerned that the patient might go into acute respiratory distress while enroute and would not have airway management support available. She said she expressed these concerns with the patient who stated to her "No, No my husband will take me, they know I'm coming".

Continued interview with S1 revealed she contacted S4 LPN Case Manager who came to the unit to assess the situation and contacted Hospital A about the arrangements for patient #1. S1 said attending physician Dr. S6 also assessed the patient before discharge. S1 reported patient #1 was not in distress, she did not require supplemental oxygen, her vital signs were normal, and she "was not stressed out". S1 added that they generally do not discharge a patient to another acute care hospital by private vehicle. She stated she did not hear anyone discuss money for an ambulance and was not aware that a patient must pay before an ambulance company would provide services.

Review of the progress notes documented by S4 Case Manager dated 08/31/11 at 11:30 AM revealed she spoke with S13 MD who gave orders to transfer patient #1 to Hospital A via ambulance to Hospital A. S4 documented she spoke with the transfer coordinator at Hospital A and faxed information on patient #1. S4 further documented she spoke with Hospital A ENT physician who agreed to accept patient #1 as a discharge and to come to Hospital A ER (emergency room) by private auto for admit and surgery on 9/01/11. S4 called S13 again to clarify if the patient was to transfer or discharge. S13 told her patient #1 was stable for discharge and to transfer by private car to Hospital A ER instead of stretcher. S4 documented she also called S6 MD to come see patient #1 before discharging. S4 indicated bed availability was not discussed, since the decision by the doctor was to discharge patient #1.

Review of physician progress notes documented by S6 MD on 8/31/11 at 12:45 PM revealed orders were received from the ENT physician at Hospital A to "discharge patient regularly and instruct patient to present to ER at Hospital A. Patient #1 has been instructed and understands urgency of stricture/stridor. The urgency of the stricture certainly justifies the method of transfer given logistic delays should an attempt in-patient to in-patient. Dc'd patient in need of urgent airway treatment that cannot be provided here".

On 10/04/2011 at 9:45 AM, an interview was held with S2 RN APN who rounded on patient #1 on 8/31/2011 at 9:45 AM for attending pulmonologist Dr. S13. S2 said that was her first time to see the patient who seemed irritated at the delays in discharge, but was not in distress. S2 said during her visit with the patient, pulmonologist Dr. S13 and attending Dr. S6 coordinated the patient ' s discharge and referral to Hospital A. S2 said during the visit patient #1 had audible stridor, her oxygen saturation was 98% (level of oxygen the red blood cells are carrying to all internal organs and the normal is 95-100%), and her breathing was not labored. S2 added that the patient's stridor was caused by tracheal stenosis (from previous endotracheal intubation).

In an interview on 10/04/2011 at 10:02 AM S4 LPN, Case Manager, stated she was summoned to the telemetry unit on 8/31/2011 because the nurse staff was concerned about patient #1 traveling by private auto to Hospital A when she had respiratory stridor. S4 said she contacted pulmonologist S13 who ordered the patient transfer by ambulance to Hospital A. S4 further stated she called Hospital A and spoke with the transfer coordinator who spoke with Hospital A ENT (ear, nose, and throat) physician who was the accepting physician. According to S4, the coordinator called back and told her that the ENT physician had accepted patient #1 as a discharge from Glenwood Hospital and to come to the ED (emergency department) at Hospital A for admit. S4 said she called pulmonologist Dr. S13 to clarify if the patient was to be discharged or transferred to Hospital A and he stated the patient was stable for discharge and to go by private vehicle to Hospital A. S4 stated the accepting physician at Hospital A would not take patient #1 as a transfer. During the interview, S4 said she went into patient #1's room several times and there was dialogue several times among the physicians involved in the patient's care. S4 further stated the attending physician S6 assessed the patient prior to discharge and apparently felt the patient was stable enough to go by private vehicle. S6 said there was never a discussion regarding an ambulance charge. She stated if a patient was transferred to a higher level of care, the hospital paid the ambulance fee.

On 10/04/2011 at 11:35 AM, a telephone interview was held with Hospital A ENT who accepted patient #1 on 8/31/2011. The ENT stated she vaguely recalled the patient but was not involved in her care after she was admitted to Hospital A. Hospital A ENT said she recalled speaking with the transfer coordinator at Hospital A who reported to her that patient #1 had respiratory stridor. The ENT said she took the telephone call at the cancer treatment center where she was working that day and she knew that they "were not set up for emergencies " so she told them to send the patient to the ED instead. Hospital A ENT further stated patient #1 was a "2-way transfer". She further stated she was unsure about the time the patient arrive at Hospital A and she was pretty sure that she called the ED at Hospital A to inform them about patient #1.

An interview with attending physician Dr. S6 on 10/04/2011 at 11:45 AM revealed patient #1 had a slit below the thoracic inlet which would require "cracking her chest if she collapsed due to complete occlusion. He stated normally they do a regular transfer process but they deviated from the norm in order to get patient #1 into Hospital A's healthcare system to receive faster treatment for her tracheal stricture because the patient had to have immediate care. Dr. S6 reported he spoke with pulmonologist Dr. S13 so he would understand that patient #1's discharge was not the regular way to do things. S6 said that he never spoke directly to Hospital A ENT because the arrangements for the patient were made by pulmonologist S13 and Hospital A ENT. S6 said many times there was a delay in transferring a patient to Hospital A and they felt that patient #1's urgency for treatment justified the deviation from the norm.

Dr. S6 said he assessed patient #1 prior to her discharge and stressed the importance that she go directly to Hospital A. S6 said he "told the patient multiple times if something smaller than a pea occluded the only opening she had, she could die". Dr. S6 said the patient was okay at rest to go to (Hospital A).

Review of the nurse staffing pattern for the 7:00 AM-7:00 PM shift and patient #1's medical record for 8/31/2011 revealed S8 CNA worked on 6th Floor Telemetry with patient #1. In an interview on 10/04/2011 at 9:15 AM, S8 reported she could not recall patient #1 or the events surrounding the patient's discharge.

In a telephone interview on 10/04/2011 at 12:50 PM, patient #1 stated that on 8/31/2011 there were several discussions about how she would go to Hospital A. She said at first she was going by car, then ambulance and eventually by car. Patient #1 said she was unsure what time she left Glenwood Hospital but she thought it took 2 hours to get there. The patient was unsure what time she arrived at the hospital, but stated it was approximately 6:00 PM. Patient #1 stated she went directly to Hospital A upon discharge from Glenwood Hospital and did not stop for anything. Patient #1 was well aware she had an appointment at noon with the ENT at Hospital A which she missed.

During the interview the survey team asked patient #1 if she felt safe traveling by private vehicle and she responded, "At first I was kinda nervous but I sat with the air conditioner blowing directly on me and I made it just fine. I called the hospital (Hospital A) on the way to see where to go when I got there, but it wasn't because I needed any help (respiratory problems)". Patient #1 continued to say that when she arrived at Hospital A, her husband let her out and went to park the car. She said as she was walking down the hall toward the ED, a doctor heard her stridor and took her to the ED "where they started vigorous treatments on me".

On 10/05/2011 at 1:00 PM an interview was held with S3 RN Director of Case Management/Discharge and Planning who stated she was not involved with patient #1's discharge, but did speak with S4 LPN who made the arrangements for the discharge. S3 said S4 told her that patient #1 was anxious for them to finalize her discharge, but the patient was not in distress. S3 said S4 LPN did report that patient #1 was included in all discharge plans and that S4 documented the discharge evaluation and plan in the patient ' s medical record. S3 further stated this was an unusual circumstance and felt if attending physician Dr. S6 had had any qualms about sending the patient by car, he would have sent the patient by ambulance. S3 added that the patient's discharge did require a multidisciplinary approach before it was finalized.

Continued interview revealed the hospital has 5 case managers, 1 utilization review nurse, 1 social worker and 1 discharge planner. S3 added any of the staff can execute a discharge or transfer and that the staff reviewed all records for discharge needs. S3 further stated that they hold an interdisciplinary team meeting each day at 1:00 PM and discuss each patient in the hospital to identify discharge needs. S3 said discharge planning faces many challenges and starts when a patient enters the hospital and individual plans are based on a patient ' s needs and available resources and supports. S3 RN said that any type of aftercare planning begins after the doctor evaluates the patient and determines how much and what type of assistance the patient will need after a hospital stay. Continued interview revealed once the physician makes an evaluation of needs; the results of the evaluation should be discussed with the patient or his representative. S3 said case management tracks multiple quality indicators which includes readmits, transfers and areas that pose high risks such as the maternal/child unit which requires many interventions for discharge (stillborns, adoptions, no place to go after delivery, no car seat, mother less than 17 years old, etc.) and denials.

An interview on 10/05/2011 at 12:35 PM was held with S11 RN Director of 6th Floor Telemetry who reported she was not involved in patient #1's discharge. S11 recalled that on 8/31/2011 patient #1 was sitting in a wheelchair at the door of her patient room which was adjacent to S11's office. S11 said she did overhear some discussion about the patient going to Hospital A and further stated others were involved in the arrangements so she did not see the need for her input. S11 said patient #1 did not seem to have any respiratory distress at that time, but seemed to be in a hurry to leave. S11 further stated from the conversations that she heard, patient #1 did not seem to have any fear about going to Hospital A by private vehicle nor did she hear anyone discuss an ambulance or the cost of one.

S10 DON made an unsuccessful attempt on 10/05/11 to reach S13 pulmonologist by telephone. S10 reported to the survey team S13 did not answer his phone and his voice mailbox was full. S13 worked locum tenens for Glenwood Hospital's pulmonologist during the time of patient #1's 8/29-31/11 hospitalization and had worked there on 5 other occasions through the year. His credentials were verified through review by the survey team.
The survey team attempted again 10/6/11 and the call went to voice mailbox which was full.

In a telephone interview on 10/06/2011 at 9:15 AM Dr. S12 Chief of Staff stated patient #1's discharge did not go to medical staff or governing body for review. S12 further stated they would review the patient 's medical record to determine if, and where the system failure occurred.