HospitalInspections.org

Based on review of Emergency Room (ER) Logs, medical record review, review of medical staff rules and regulations, facility investigation documentation, and interview, the facility failed to maintain an accurate Emergency Room Log for one patient (#6) and failed to report a violation of EMTALA (Emergency Medical Treatment and Active Labor Act) for one patient (#20) of twenty sampled patients.

The findings included:

Please refer to A-2401 for failing to report a delay in treatment.

Please refer to A-2405 for failing to maintain an accurate ER Log.

Based on review of facility policy, review of Medical Staff Rules and Regulations, review of a Tennessee Medical Services for Children Model Interfacility Pediatric Transfer Agreement, medical record review, review of facility investigation, and interview, the facility failed to report a delay in treatment at a transferring facility for one patient (#20) of twenty sampled patients.

The findings included:

Review of facility policy most recently revised in October 2009 revealed, "...Title: Emergency Department General Policies...To guide the delivery of emergency care by the provision of written policies and procedures as well as current reference material..."

Review of facility policy most recently revised in August 2008 revealed, "...Title: Patient Transfer Policy and Procedure (Interinstitutional)...Emergency Medical Conditon...Medical Screening...Stabilize...Capabilities of a medical facility... There is physical space, equipment, supplies, and services that the hospital provides...Capabilities of staff of a facility A level of care that the personnel of the hospital can provide within the training and scope of their professional licenses...Transfer..."

Review of Medical Staff Rules and Regulations dated 2011 revealed, "...All patient transfers must be in compliance with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA)..."

Review of a Tennessee Emergency Services for Children Model Interfacility Pediatric Transfer Agreement provided by the Chief Nursing Officer on August 28, 2012, revealed, "...Both parties agree that all transfers shall be conducted in compliance with all applicable laws and regulations, including but not limited to ...EMTALA..."

Medical record review of the transferring facility's Initial Assessment Form dated August 7, 2012, revealed, " ...Presentation Time: (8:43 p.m.) Triage Time: (8:48 p.m.) ...Grandmother states post op (after surgery) bleeding from T&A x (Tonsillectomy and Adenoidectomy times) 2 weeks ago ..."

Medical record review of the transferring facility's Flowsheet dated August 7, 2012, at 8:48 p.m., revealed, "Temp 99.9 ...Pulse 109 BP (blood pressure) 97/60 Resp (respirations) 24 O2 Sat (oxygen saturation) 98 ..."

Medical record review of the transferring facility's Pediatric Assessment dated August 7, 2012, at 8:51 p.m., revealed, " ...denies presence of pain ...alert and aware of surroundings ...vascular status intact ...Airway is clear and respiratory effort is unlabored ..."

Medical record review of the receiving facility's Pediatric Critical Care Referral dated August 7, 2012, at 10:31 p.m., revealed, " ...Diagnosis/Condition at Time of Call - Tonsillectomy 2 wks (weeks) ago ...now with bleeding as well discussed with (surgeon) ...not on call, the unassigned ENT to take care of it (surgeon) talked with (on-call ENT) And will not come to take care of ...patient ...Discussed with (receiving facility's ENT) ...may transfer here ..."

Medical record review of the transferring facility's Flowsheet dated August 7, 2012, at 10:35 p.m., revealed, " Temp 98.7 ...Pulse 115 BP 105/55 Resp 20 O2 Sat 97..."

Medical record review of an EMS report dated August 7, 2012, revealed, " ...Location (transferring facility) ...Received ...(11:23 p.m.) ...Arrive Dest (destination) 08/08/2012 (12:30 a.m.) ...transported to (receiving facility) ..."

Medical record review of of an Emergency Provider Record dated August 8, 2012, at 1:58 a.m., revealed," ...Chief Complaint: oral bleeding ...duration:tonight ...(transferring facility's) ER record reviewed ...4:10 (a.m.) ...no bleeding. Tonsils dry without blood ...Discussed with ...ENT Time: (4:21 a.m.) ...Clinical Impression Dehydration Tonsillar Bleeding ...(4:22 a.m.) admitted OBS (observation) improved stable ..." Medical record review of a physician's progess note dated August 8, 2012, at 8:50 a.m. revealed, "Childrens ENT specialists ...bleeding last night ...transferred ...no bleeding since arrival ...begin clear liquids - will observe through AM (morning) ..." Medical record review revealed the patient was discharged from the facility on August 8, 2012, with discharge instructions to follow-up with the surgeon.

Interview with the Vice President of Legal Services on August 28, 2012, at 9:45 a.m., in his office, revealed an anonymous caller made him aware of an ENT (Ear, Nose, Throat specialist) who refused to report to the transferring facility to care for a child with a post-op bleed. Continued interview revealed the caller was a physician and he stated, " ...asked the caller if he'd reported the refusal and the caller said he didn't have to ...had administrator call administrator (at transferring facility) to discuss problems regarding issues with doctors involved."

Interview with the Medical Director of the Emergency Department on August 28, 2012, at 11:00 a.m., in a nursing administration conference room, revealed a matter involving the transfer of (Patient #20) had been brought to his attention, and he stated, " ...one of their on-call docs (doctors) did not come in. In response to this I talked to doc who did (the) referral ...He indicated the physician (Emergency Room physician at transferring facility) was having trouble up there and he talked with (the) M.D. (Medical Doctor) who had done surgery and that M.D. would not come in. He (surgeon) had called for MDs for unassigned patient and (on-call ENT) wouldn't come in ...Our responsibility is if we suspect a violation is to report. We did internal investigation and had letter drafted and a letter was forwarded to (administrator) of the hospital as to how to proceed. Draft letter was done yesterday. Took a while to get info (information) from all the docs."

Review of a draft letter to the transferring facility dated August 27, 2012, and provided by the ED Medical Director on August 28, 2012, revealed, " ...wanted to make you aware of a transfer to our facility ...involving (Patient #20) ...found to have some persistant bleeding and (patient's) ENT surgeon ...was contacted ...According to the report we received from (ER physician at transferring facility), (surgeon) indicated that he was unable to assist ...and advised that he contact the on call ENT physician for unassigned patients. It was then communicated to (ER physician at transferring facility) that the on call ENT surgeon for unassigned patients was unavailable ...as (patient) had an assigned ENT physician ...agreed to accept this patient in transfer ...Our concerns are primarily with the significant potential for risk that this patient incurred with the delay in treatment for this emergent situation which could have required immediate attendance by an ENT surgeon ..."

Interview with the receiving facility's physician responsible for the referral of Patient #20 on August 29, 2012, at 10:30 a.m., in a nursing administration conference room, and in the presence of the VP of Legal Services, the Chief Nursing Officer (CNO), and M.D. #5, revealed he was aware an on-call ENT at the transferring facility failed to respond to the facility to treat Patient #20, and he stated, "If patient needs more care than they can provide (accepting the patient) is the spirit of EMTALA. I did not consider this an inappropriate transfer."

Interview with M.D. #5 on August 29, 2012, at 10:30 a.m., in a nursing administration conference room, and in the presence of the receiving facility's physician responsible for the referral of Patient #20, the CNO, and the Vice President of Legal Services, revealed the facility had annual education regarding EMTALA, and he stated, " ...part of it is to report violations related to EMTALA."

Interview with the Vice President of Legal Services on August 29, 2012, at 10:30 a.m., in a nursing administration conference room, and in the presence of the facility's physician responsible for the referral of Patient #20, the CNO, and M.D. #5, confirmed the facility failed to report a delay in treatment at the transferring facility related to the failure of an on-call ENT to respond to the call of an ER physician. He stated, "Not enough red flags to raise questions about EMTALA ..."

C/O: #30342

Based on review of Emergency Room (ER) Logs, medical record review, and interview, the facility failed to accurately maintain an ER log for one patient (#6) of twenty sampled patients.

The findings included:

Review of an ER Log dated May 19, 2012, revealed, "...(Patient #6)...routine discharge..."

Medical record review of an Emergency Room Provider Record dated May 19, 2012, revealed, "...tried to hang self...neck pain...past history bipolar...will admit to (psychiatric facility)...Clinical Impression Suicide Attempt Needs Screen..."

Medical record review of a Certificate of Need for Emergency Involuntary Admission dated May 19, 2012, revealed, "...I am a licensed physician...consulted with the mental health crisis team in my area...attempting to hang...self from a tree...To unsafe to go home..."

Medical record review of a nurse's note dated May 20, 2012, at 1:05 a.m., revealed the patient was transferred to a psychiatric facility by law enforcement.

Interview with the Chief Nursing Officer on August 28, 2012, at 2:17 p.m., in a nursing administration conference room, confirmed the facility failed to maintain an accurate ER log for Patient #6.