HospitalInspections.org

Based upon record review and interview, the hospital failed to ensure the list of contract services identified the service being provided and the scope of the service. Findings:

Review of the list of contract services revealed only the name of the entity, the date it was renewed, and a termination clause was on the list. The actual service or scope of the service was not identified.

Review of Contract R revealed the entity was to provide "certain health care services via telemedicine" and be responsible for credentialing and re-credentialing of providers. The contract failed to identify what actual service was being provided or the scope of the service. Interview on 11/06/23 at 2:50 p.m. with Staff F revealed the entity for this contract was to provide telemedicine for Neurology and confirmed the contract failed to identify this service.

Review of Contract S revealed the entity was to provide tele-radiology services. According to Section 5 of the contract a quality indicator was to be used for (a) Reporting time within contract ranges. Further review of the contract revealed there were no contract ranges identified.

Based upon record review and interview, the nutritional status for 3 of 8 swing bed patients (#2, #5, #6), failed to identify 1) an initial nutritional assessment (#2), and, 2) a reassessment of the patient's nutritional status when changes were identified (#5, #6). Findings:

Review of patient #2's medical record revealed the patient was admitted to swing bed on 10/23/23 with a Stage II skin breakdown on the left gluteal. The dietary order was for sodium control, the body mass index was below normal, and the patient's albumin was low at 2.7 (normal 3.4-5.0). Interview with Staff L on 11/8/23 at 10:05 a.m. revealed the patient's appetite would "come and go" and she would experience nausea at times. Further review of the medical record revealed there failed to be documented evidence the Registered Dietician conducted a nutritional assessment.

Review of patient #5's medical record revealed the patient was admitted to acute care on 10/10/23 with Sepsis and was changed to swing bed status on 10/16/23. The patient had a Stage III decubitus, a high lactic acid level, a low Albumin level (2.4) and fever. The first dietary noted by the Registered Dietician was on 10/24/23 and identifed the skin breakdown and the need for an increase in protein intake. On 11/6/23 the patient's Albumin level had again decreased to 2.2; however, there failed to be documentation the patient's nutritional status was reassessed.

Review of patient #6's medical record revealed the patient was admitted to swing bed on 10/18/23 after having open heart surgery. The patient had surgical wounds from the surgery, a low albumin level (2.7) and was on a puree diet. Interview on 11/08/23 at 10:30 a.m. with Staff L revealed when the patient was admitted he was on a puree diet, which the patient did not like but since the diet was changed to chopped foods his appetite was better. The nursing staff implemented supplements (Glucerna) with ice cream. Further review of the medical record revealed the Registered Dietician conducted an initial nutritional assessment on 10/24/23 however no reassessment had been conducted when there changes made to his diet.

Interview on 11/06/23 at 1:40 p.m. with Staff C revealed the Dietary Manager and the Registered Dietician conducted dietary evaluations, however, the manager was on medical leave and the Registered Dietician only visited every two weeks. There failed to be documented evidence a system was in place for patient nutritional evaluations when dietary personnel were not available.

Based upon record review and interview, the hospital failed to ensure an written transfer agreement was implemented for 3 of 4 Emergency Department Patients who required further in-patient psychiatric care (##12, #21, #22). This was evidenced by the failure to: 1) ensure a written transfer agreement was completed that stated the reason for the transfer and the risks and benefits associated with the transfer, 2) ensure the receiving facility had agreed to accept the transfer, and 3) the medical records (or copies) related to the patient's emergency medical condition were provided to the receiving hospital. Findings:

Patient #12
Review of patient #12's Emergency Department (ED) record revealed on 07/28/23 this 31 year old female presented ambulatory to the ED with the chief complaint of Suicidal Ideation. Staff N conducted the medical screening exam and documented the following on the Medical Decision Making "Pt (patient) came to ED (Emergency Department) voluntarily, c/o (complaint of) suicidal thoughts and needing help. Patient was screened and found to have a UTI (Urinary Tract Infection) as well. She FaceTime with mental health from (Hospital Q) behavioral in Ardmore and placed at the same facility per (Staff M). Patient had a normal exam, Labs are within normal limits. She will be DC (Discharged) to Marietta Police for escort to (Hospital Q) in Ardmore. Pt (patient) is stable for transport."

Further review of patient #12's ED record revealed there failed to be documented evidence a written transfer agreement was implemented to identify the risks and benefits of the transfer, that the receiving facility had accepted the patient, and medical records or copies were provided to the receiving facility.

Patient #21
Review of patient #21's ED record revealed on 09/24/23 this 60 year old male presented to the ED by EMS (Emergency Medical Services) with the chief complaint of Suicidal Ideation. Review of the History of Present Illness completed by Staff O revealed "60 year old male who presents via EMS from the casino with suicidal ideation stating that he will hang himself. Patient was seen yesterday in the ED at (Hospital T) for scrotal pain, he had workup and was started on antibiotic. Patient notes that he cannot take the antibiotic, that he cannot get it from the pharmacy as he has no money. He notes he is having defficulty urinating today because his foreskin is swollen. Patient is migrating north from Louisiana "I wanted to get away from my family". He has decided to stay in Oklahoma. Tonight he called 911 for suicidal ideations. EMS notes that they were called several times today to patient and he noted he wanted a ride..." Staff O conducted further laboratory testing and medication administration and documented on the Medical Decision Making And Plan of Care "09/24/23, 12:58 a.m. (Hospital Q) will evaluate for EOD (Emergency Order of Detention)...Medically patient has anemia which appears to be chronic as it was on admit in Texas on 08/31/23 patient left that hospital stay AMA (Against Medical Advise) so no further workup was done. He currently denies any shortness of breath, fatigue or palpitations..."

On 09/24/23 at 1:41 a.m. Staff O documented "patient is a candidate for EOD, awaiting (Hospital Q)" At 3:16 a.m. Staff O documented the patient was placed at Hospital Q in Ardmore for EOD.

Further review of Patient #21's ED record revealed there failed to be documented evidence an appropriate written a transfer agreement was implemented when the patient required further inpatient psychiatric care at another hospital.


Patient #22
Review of patient #22's Emergency Department Record revealed on 09/11/23 this 13 year old male presented to the Emergency Department with the chief complaint of Suicidal Ideation. Review of the History of Present Illness revealed Staff P documented "Patient is a 13 year old male with a known medical history of Major Depressive Disorder...that presents to the ED via POV (Private Vehicle) with c/c (chief complaint) of suicidal ideation. Mother is at bedside. Patient reports that SI has been present for the past few days. Denies having a plan, does report having access to means for self harm."

Review of the Medical Decision Making documented by Staff P revealed "(Entity V) consults completed. Nurse reports that patient needs to be inpatient. Nursing staff has sent plan of care to (Hospital U) for acceptance. Patient has been accepted to (Hospital U), state transport will take patient, waiting on state transport to pick patient up...report to RN at (Hospital U). Patient and mother have been updated on the transfer to (Hospital U). Mother and patient both voiced understanding. Advised patient and mother that now waiting on state transport, as soon as transport available will pick patient up."

Further review of Patient #22's ED record revealed there failed to be documented evidence an appropriate written transfer agreement was implemented when the patient required further inpatient psychiatric care at another hospital.

Interview on 11/08/23 at 12:30 p.m. with Staff C revealed the hospital used other entities (Hospital Q and Entity V) to conduct the psychiatric evaluation on their Emergency Department Patients. This was done by face time with the patient and the entity via telemedicine services. According to Staff C, these entities were responsible for determining if the psychiatric patient required in-patient or out-patient psychiatric care. After reviewing the Emergency Department Records for patients #12, #21 and #22, Staff C confirmed even though the psychiatric patient required further in-patient psychiatric care a written transfer agreement was not implemented and did not know why the EMTALA forms were not used.