HospitalInspections.org

Based on review of the facility policy and procedure, Hospital A (Flowers Hospital), Medical Record (MR) transferring hospitals, Hospital B and Hospital D medical records (MR), receiving hospital, Hospital C MR, facility Inbound Transfers and Declines, Transfer Center Call Summaries, Transfer Center Recording Audio File Transcripts, facility General Medical Surgical floor (floor 4 North, 4 South, and 6) bed census, facility floor 4 North, 4 South, and 6 staffing analysis, Ambulance Run Report(s) and interviews with staff it was determined the facility failed to:

1. Prevent a patient presenting with psychotic symptoms from leaving the Emergency Department (ED) prior to the completion of the MSE, including Patient Identifier (PI) # 4.

2. Reassess a patient diagnosed with Audio Hallucinations to demonstrate mental capacity to sign out Against Medical Advice (AMA), including PI # 4.

3. Ensure the on-call physicians for Oral Maxillofacial surgery accepted 2 patients, including PI # 23 and PI # 24, when contacted by the transferring hospital (Hospital B and Hospital D) which had no available Oral Maxillofacial surgery consult, when Flowers Hospital had the capability and capacity to treat the patients.

Based on review of Medical Records (MR) and interviews with staff it was determined the facility failed to prevent a patient presenting with psychotic symptoms from leaving the Emergency Department (ED) prior to the completion of the Medical Screening Exam (MSE).

The deficient practice affected 1 of 4 patients reviewed who left AMA (Against Medical Advice), including Patient Identifier (PI) # 4 and had the potential to affect all patients served by the facility ED.

Findings include:

1. PI # 4 presented to the ED on 1/22/21 at 5:47 PM. Review of the MR revealed:

Review of the ED Triage note dated 1/22/21 at 5:54 PM, revealed documentation of a chief complaint of "stts (states) hearing voices, stts the voices are people (she/he) knows and are alive, stts telling (her/him) bad things about (herself/himself). Pt (patient) has hx (history) Bipolar...

Review of the Physician ED Note dated 1/22/21 at 6:02 PM revealed the PI # 4 had a past medical history of Bipolar Disorder, presented to the ED secondary to hearing voices which PI # 4 had been in a Behavior Medicine Unit secondary to the voices, the voices tell her/him about what is happening during the day and in the past, the voices are people he/she knows and not his/her own voice, wanted her/his head checked for chip, a psychiatrist prescribed Lithium on 1/22/21 but she/he had not started taking it yet due to wanting to make sure she/he was okay and not chipped. The ED documented Psychiatric assessment of "...judgement: Impaired by abnormal thoughts, Abnormal/Psychotic thoughts: Obsessive, hallucinations auditory..."

Further review of the Physician ED Note dated 1/22/21 revealed a reexamination/reevaluation was documented as "patient refused blood work and decided to leave AMA." There was no documentation of the time the reexamination/reevaluation was conducted and no documentation the physician reassessed the patient to demonstrate mental capacity to sign out AMA.

Review of the Nursing Note at 7:20 PM revealed documentation of "...pt decided to leave AMA after not wanting to get stuck for blood work. I explained the benefits of staying with (her/him) and the patient still decline. Pt stated (she/he) was feeling better and that (she/he) did not want to get stuck for blood. (MD identified) informed pt of benefits of staying and the possible consequences of leaving and patient still wanted to leave. Pt signed AMA form and left."

Review of the facility AMA form revealed PI # 4 signed the AMA form at 7:20 PM.

Review of the ED Discharge Information revealed PI # 4 departed the ED at 7:20 PM with a discharge disposition of AMA.

Review of the January 2021 Emergency Call Roster revealed documentation the facility had a physician on-call for the speciality of Psychiatry.

Review of the MR revealed no documentation the patient received an examination by a psychiatrist or a physician's order for a psychiatric consult. The patient was permitted to leave prior to the necessary psychiatric workup which would have been part of the MSE.

An interview was conducted on 6/3/21 at 1:18 PM with Employee Identifier (EI) # 1, Chief Quality Officer, who confirmed there was no documentation of a physician's order for a psychiatric consult nor the patient received an examination by a psychiatrist. EI # 1 also confirmed the facility did have a on-call Psychiatrist on 1/22/21.

Based on review of the facility policy and procedure, Medical Record (MR) and interviews with staff it was determined the facility failed to reassess a patient diagnosed with Audio Hallucinations to demonstrate mental capacity to sign out AMA (Against Medical Advice).

The deficient practice affected 1 of 4 patients reviewed who left AMA, including Patient Identifier (PI) # 4 and had the potential to affect all patients served by the facility Emergency Department (ED).

Findings include:

Policy: Refusal of Care by Patients AMA
Revised: 1/1/16

Policy: Management of the patient in the ED who refuses care.

Procedure: Whenever a patient refused care prescribed by the ED physician or the consulting physician, careful documentation of the incident should be performed to include the following items:

...4. Assessment of competency or mental capacity of the patient to understand the physician's instructions to give or withhold consent...

1. PI # 4 presented to the ED on 1/22/21 at 5:47 PM. Review of the MR revealed:

Review of the ED Triage note at 5:54 PM, revealed documentation of a chief complaint of "stts (states) hearing voices, stts the voices are people (she/he) knows and are alive, stts telling (her/him) bad things about (herself/himself). Pt (patient) has hx (history) Bipolar...

Review of the Physician ED Note at 6:02 PM revealed the PI # 4 had a past medical history of Bipolar Disorder, presented to the ED secondary to hearing voices which PI # 4 had been in a Behavior Medicine Unit secondary to the voices, the voices tell (her/him) about what is during the day and in the past, the voices are people (he/she) knows and not (his/her) own voice, wanted her/his head checked for chip, a psychiatrist prescribed Lithium on 1/22/21 but she/he had not started taking it yet due to wanting to make sure she/he was okay and not chipped. The ED documented Psychiatric assessment of "...judgement: Impaired by abnormal thoughts, Abnormal/Psychotic thoughts: Obsessive, hallucinations auditory..."

Further review of the Physician ED Note revealed a reexamination/reevaluation was documented as "patient refused blood work and decided to leave AMA." There was no documentation of the time the reexamination/reevaluation was conducted and no documentation the physician reassessed the patient to demonstrate mental capacity to sign out AMA.

Review of the Nursing Note at 7:20 PM revealed documentation of "...pt decided to leave AMA after not wanting to get stuck for blood work. I explained the benefits of staying with (her/him) and the patient still decline. Pt stated (she/he) was feeling better and that (she/he) did not want to get stuck for blood. (MD identified) informed pt of benefits of staying and the possible consequences of leaving and patient still wanted to leave. Pt signed AMA form and left."

Review of the facility AMA form revealed PI # 4 signed the AMA form at 7:20 PM.

Review of the ED Discharge Information revealed PI # 4 departed the ED at 7:20 PM with a discharge disposition of AMA.

Review of the MR revealed no documentation the patient was reassessed by a physician to determine the patient could demonstrate mental capacity to sign out AMA.

An interview was conducted with Employee Identifier (EI) # 1, Chief Quality Officer, who confirmed there was no documentation the patient was reassessment by a physician to determine the patient could demonstrate mental capacity to sign out AMA.

Based on review of the facility policy and procedure, transferring hospitals, Hospital B and Hospital D medical records (MR), receiving hospital, Hospital C MR, facility Inbound Transfers and Declines, Transfer Center Call Summaries, Transfer Center Recording Audio File Transcripts, facility General Medical Surgical floor (floor 4 North, 4 South, and 6) bed census, facility floor 4 North, 4 South, and 6 staffing analysis, Ambulance Run Report(s), Emergency Department (ED) physician call consults, and interviews, it was determined Flowers Hospital (Hospital A) failed to ensure the on-call physician for Oral Maxillofacial surgery accepted 2 patients, when contacted by the transferring hospital (Hospital B and Hospital D) which had no available Oral Maxillofacial surgery consult, when Flowers Hospital had the capability and capacity to treat the patients.

This deficient practice affected 2 of 5 declined transfer request reviewed, including Patient Identifier (PI) # 23 and PI # 24.

Findings include:

Policy: Emergency Medical Treatment and Active Labor Act (EMTALA) Policy
Revised: 2/5/21

...IV. Transfer of Individuals...

G. No Refusal of Transfer from Other Facilities: A hospital that is not in diversionary status may not refuse or fail to accept a request for appropriate transfer or admission of an individual with an EMC (Emergency Medical Condition) if the individual requires a specialized service...if the hospital has the capacity to treat the individual, and the transferring facility does not have the specialized services needed. The hospital must accept the determination by the transferring facility, hospital or MP (Qualified Medical Provider) that the patient has an EMC. Any failure or refusal could represent a violation of the Hospital's obligations under EMTALA...


1. PI # 23 presented to Hospital B, Transferring Hospital Emergency Department (ED) on 5/7/21 and a ED physician assessment was performed at 9:44 PM with a chief complaint documented as right eye swelling and pain, bilateral jaw pain, and lower lip swelling. The ED physician assessment documented the patient was asleep when he/she got "...jumped. Patient reports that (he/she) got hit several times in the face and had a brief loss of consciousness for an unknown amount of time...At this time patient complains of headache and facial pain as well as dental pain... positive for dental pain...jaw pain...positive for nausea...Head:...contusion present...Jaw: tenderness, swelling and pain on movement present...Nose: nasal deformity, septal deviation, signs of injury and nasal tenderness present...Right Sinus: Maxillary sinus tenderness and frontal sinus tenderness present. Left sinus: Maxillary sinus tenderness and frontal sinus tenderness present...Mouth:...injury present...Dentition: dental tenderness and gingival swelling present..." The ED physician documented diagnoses of Closed Fracture of Nasal Bone, Closed Fracture of Mandible, unspecified laterality, Unspecified Mandibular Site, and Closed Fracture of Maxillary Sinus.

Review of the Maxillofacial Computerized Tomography (CT) Scan dated 5/7/21 at 10:39 PM revealed impression documentation of right mandibular angle and left mandibular body fractures, right lamina papyracea fracture, gas within the right orbit, and left anterior nasal bone fracture.

Review of the ED Course documentation dated 5/7/21 at 11:48 PM revealed documentation of "attempting to contact Flowers (Hospital A) for transfer as we do not have a oral/facial specialist."

Review of the ED Course documentation dated 5/8/21 at 1:10 AM revealed documentation of "per transfer line (Flower on-call Oral Maxillofacial Surgeon identified) is unable to take patient due to him/her reportedly only excepting (accepting) old trauma fractures verses new trauma fractures. Hospital C, Receiving Hospital,...accepted the patient as a transfer due to lack of oral facial specialist at our hospital."

Hospital A, Flowers Hospital documentation:

Review of the 2021 Inbound Transfers and Declines revealed documentation a transfer request was received from Hospital B, Transferring Hospital, on 5/7/21 on PI # 23 for a "Fracture - Facial/Face" and was documented as a "MD (Medical Doctor) Decline."

Review of the Transfer Center Call Summary dated 5/7/21 at 11:24 PM revealed a call from Hospital B to request a transfer of PI # 23 to Flowers Hospital due to multiple facial fractures from an assault.

Further review of the Transfer Center Call Summary dated 5/7/21 at 11:59 PM revealed documentation Employee Identifier (EI) # 5's, On-call Oral Maxillofacial Surgeon, was contacted and "answering service states the MD on call does not treat new traumas only old traumas."

Review of the Transfer Center Audio Recording Transcript of the Transfer Center Call dated 5/7/21 revealed audio recording documentation of Hospital B calling Flowers Hospital to request a transfer on PI # 23 due to multiple facial fracture from an assault, the transfer center identifying EI # 5 as the on-call physician and EI # 5's answering service return call to the facility transfer center stating "...they (EI # 5's practice group) only handle previous traumas right now...they're not handling new trauma..."

An interview was conducted on 6/3/21 at 3:08 PM with EI # 1, Chief Quality Officer, and EI # 2, Assistant Chief Nursing Officer, who verbalized a patient with a facial fracture requiring the services of an Oral Maxillofacial Surgeon would be place on 4 North "if it was clean" and either 4 South or 6th floor if it was not clean.

Review of the Census Report dated 5/7/21 at 11:24 PM revealed documentation 4 South had 10 available beds, 4 North had 5 available beds and 6th floor had 5 available beds.

Review of the Staffing Analysis dated 5/7/21 for the 11 PM to 7 AM shift revealed documentation of "staffing for the dates in question is within typical patterns and ratios as compared with a monthly average.

Ambulance Run Report documentation:

Review of the Ambulance Run Report dated 5/8/21 revealed:

The ambulance was dispatched to Hospital B, transferring hospital at 1:51 AM.

At 3:29 AM, the ambulance left Hospital B enroute to Hospital C, receiving hospital.

Review of the narrative section revealed documentation of "...pt (patient) is the victim of an assault and has multiple facial and eye injures...is to be taken to Birmingham for higher level of care that inst (isn't) offered here at local hospital...appears to be in moderate distress and has swelling noted to (his/her) right and left eye and also (his/her) jaw...transported emergency to (Hospital C identified)."

At 6:00 AM, the ambulance documented arrival at Hospital C.

Hospital C, Receiving Hospital documentation:

Review of the MR dated 5/8/21 revealed:

PI # 23 arrived to Hospital C on 5/8/21 with a chief complaint of assault in prison.

At 6:47 AM, a Computed Tomography (CT) Maxillofacial without contrast was performed with the following conclusions documented:

"1. No acute intracranial process.

2. Comminuted right lamina papyracea fractures with resultant trace right ethmoid and maxillary hemosinus...

3. Mildly displaced fractures of the left mandibular body and right mandibular angle.

4. Moderate right buccal and preseptal soft tissue hematomas.

5. Small left frontal scalp hematoma..."

At 10:56 AM, an Oral Maxillofacial Surgical Consult was performed with the following findings: "...pt (patient) is presenting to (Hospital C identified) ED now s/p (status post) assault in prison resulting in facial injuries...pt endorses +LOC (positive loss of consciousness). Pt states...having pain in...lower jaw...Head: moderate perioral and periorbital swelling noted, small L (left scalp hematoma, Orbits (R (right) medial wall fx (fracture), no step or deformation noted)... Mouth: ...Occlusion (R posterior open bite with premature contact of L occlusal surfaces... fracture involvement of tooth...) Eye: ...minor chemosis noted on R eye, with subconjunctival hemorrhage. Neck: minor L submandibular swelling noted..." The Oral Maxillofacial Surgeon recommend the following: saline nasal spray and sudafed as needed for 2 weeks, antibiotic medication for 7 days, avoid blowing nose for 4 weeks, avoid activities that increase pressure in the sinuses, such as exercises, bending over, straining, and sneezing, no submerging of the head in water for 48 hours, non chew diet only, pack oozing site with gauze with patient biting packing for 1 hours, peridex mouth rinse twice a day or warm saltwater rinse as needed and to have patient follow up outpatient on 5/11/21 for management of mandibular fracture....

PI # 23 was discharged home with diagnosis of Assault, Mandible Fracture, and Closed Blow-out Fracture of Right Orbital Floor on 5/8/21.

Interviews:

An interview was conducted with EI # 4, Oral Maxillofacial Surgeon, on 6/4/21 at 1:08 PM to inquire if the practice group of the 5/7/21 facility on-call Oral Maxillofacial Surgeon, performed surgery on new traumatic mandibular fractures, due to the on-call physician who responded to the actual call being unavailable for interview. EI # 4 was asked as an Oral Maxillofacial Surgeon, would you be able to perform a surgery for a new traumatic mandibular fracture? EI # 4 stated, "yes." EI # 4 was then asked at any point, has your group stopped performing surgery on new traumatic mandibular fractures in the last 3 months? EI # 4 stated, "no." EI # 4 then was asked to identify the Oral Maxillofacial Surgeons in his/her group. EI # 4 identified EI # 5, 5/7/21 facility on-call Oral Maxillofacial Surgeon, as 1 of 3 oral Maxillofacial surgeons in his/her group.

An interview was conducted with EI # 2, Assistant Chief Nursing Officer, on 6/4/21 at 11:31 AM who confirmed the facility had 10 available beds on 4 South, 5 available beds on 4 North and 5 available beds on the 6th floor along with staffing within typical patterns compared to the monthly average on 5/7/21. EI # 2 also confirmed the facility had the capability to accept PI # 23 for transfer.

An second interview was conducted with EI # 2, on 6/4/21 at 1:33 PM. EI # 2 was asked is EI # 5, privileged to perform the surgery required in the transfer request call and if so, provide the surgery name listed on the privilege form. EI # 2 stated "yes" and identified "open reduction facial fractures with hardware and reduction of facial fractures" documented on EI # 5's privileging form as the surgeries required for PI # 23. EI # 2 was then asked would you expect the facility and physician to accept this transfer? EI # 2 stated, "yes."


2. PI # 24 presented to Hospital D, Transferring Hospital ED on 5/17/21 at 6:25 PM with a chief complaint of complaint of left sided dental pain for 2 weeks with the patient receiving two antibiotics.

Review of the Triage Note dated 5/17/21 at 6:54 PM revealed the following vital signs and assessment findings: Blood pressure (BP) 141/85, Pulse (P) 112, Respirations (R) 20, Temperature (T) 99.7, Pain scale 7/10 to the jaw.

Review of the ED physician assessment dated 5/17/21 at 8:50 PM the ED physician assessed PI # 24, "...the patient presents with dental pain. The onset was 1 week ago. The course/duration of symptoms is constant and worsening... Location: Left lower molar. The character of symptoms is pain and swelling... Associated symptoms: hoarse voice difficulty swallowing..." Further review revealed documentation of ".... presents to the ED due to left lower dental pain that has been ongoing for the past week. Pt states...placed on penicillin with no improvement...within the past day (he/she) feels like... throat has swollen up and is now having trouble swallowing...also reports voice change...overall sick appearing. Significant pain to the left side of...cheek. Significant trismus, unable to open (his/her) teeth more than a few millimeters...does have a mildly muffled voice...The ears, nose, mouth and throat assessment was documented as "...significant trismus, can not open teeth more than 3 mm (millimeters), mildly muffed voice..." The ED physician documented diagnoses of Dental Abscess, Dental Pain, Sepsis, and Trismus.

Review of the Computerized Tomography (CT) Scan dated 5/17/21 at 9:16 PM revealed impression documentation of "Soft tissue abscess posterior medially to the 3rd maxillary molar which has a tooth abscess. This abscess is seen medial to the...angle of mandible. It measures 2.3 x (by) 2.2 by 3.7 cm (centimeters)."

Review of the ED physician Calls-Consults dated 5/18/21 at 11:51 PM revealed documentation of "...phone call, consult, Flowers in Dothan, spoke with OMFS (Oral Maxillofacial Surgery), they will not accept the patient because they 'know we have OMFS coverage in (Hospital D city identified)'

Review of the Reexamination/Reevaluation ED physician note dated 5/18/21 at 12:01 AM revealed documentation of "CT shows abscess medial to the mandible... Trying to transfer to outside facility. We do not have OMFS or ENT (ears, nose throat)... At this point we have...called Flowers in Dothan.

Review of the ED Discharge Documentation revealed PI # 24 was transferred to Hospital E, 61 miles further than Flowers Hospital from Hospital D, on 5/18/21 at 1:01 AM via ambulance.

Hospital A, Flowers Hospital documentation:

Review of the 2021 Inbound Transfers and Declines revealed documentation a transfer request was received from Hospital D, Transferring Hospital, on 5/17/21 on PI # 24 for a "Abscess" and was documented as a "MD (Medical Doctor) Decline."

Review of the Transfer Center Call Summary dated 5/17/21 at 11:48 PM revealed a call from Hospital D to request a transfer of PI # 24 to Flowers Hospital due to "...dental pain for 2 weeks, dental abscess, soft tissue abscess..."

Further review of the Transfer Center Call Summary dated 5/7/21 at 11:58 PM revealed documentation EI # 4, On-call Oral Maxillofacial Surgeon, was contacted at 12 midnight "...declined...states...will not accept, (Hospital D identified) is 90 minutes from Flowers and they have 5 oral surgeons..."

Review of the Transfer Center Audio Recording Transcript of the Transfer Center Call dated 5/17/21 revealed audio recording documentation of Hospital D calling Flowers Hospital to request a transfer on PI # 24 due to left sided dental pain for 2 weeks, dental abscess and a soft tissue abscess. EI # 4 was heard to ask where Hospital D was and once the location was identified by the transfer center staff stated, "...they have oral surgeons in (city of Hospital D identified). I mean that's an hour and a half from here and I have never accepted a patient from (city of Hospital D identified)." EI # 4 further stated, "I don't even know why they would be calling down here. They've got oral surgeons in, I know personally, they've got 5 oral surgeons...and then the next closest town...they've got 3...which is 30 minutes from (city of Hospital D identified)."

An interview was conducted on 6/3/21 at 3:08 PM with EI # 1, Chief Quality Officer, and EI # 2, Assistant Chief Nursing Officer, who verbalized a patient with a dental abscess requiring the services of an Oral Maxillofacial Surgeon would be place on 4 North "if it was clean" and either 4 South or 6th floor if it was not clean.

Review of the Census Report dated 5/17/21 at 11:48 PM revealed documentation 4 South had 11 available beds, 4 North had 4 available beds and 6th floor had 4 available beds.

Review of the Staffing Analysis dated 5/17/21 for the 11 PM to 7 AM shift revealed documentation of "staffing for the dates in question is within typical patterns and ratios as compared with a monthly average.

Ambulance Run Report documentation:

Review of the Ambulance Run Report dated 5/18/21 revealed:

The ambulance was dispatched to Hospital D, Transferring Hospital at 12:22 AM.

At 1:06 AM, the ambulance left Hospital D enroute to Hospital E, Receiving Hospital for "Immediate response to (Hospital D) to transport a pt (patient) to (Hospital E) ER (Emergency Room) for specialized care not offered at (Hospital D), pt came into (Hospital D) ER today with jaw pain, (Hospital D) found a mandible abscess aprox (approximately) 3 cm (centimeters) in diameter, pt is being transported by ambulance for continuous monitoring of the pt airway..."

At 3:18 AM, the ambulance documented arrival at Hospital E.

Interviews:

An interview was conducted with EI # 4, Flowers Hospital on-call Oral Maxillofacial Surgeon, on 6/4/21 at 1:08 PM. EI # 4 was asked per the facility policy, when can a transfer request be declined? EI # 4 stated, "something I don't do or outside of my realm..." EI # 4 was asked do you recall receiving a transfer request from (hospital D identified), on PI # 24? EI # 4 stated, "... I remember... they said it was a hospital in (Hospital D city identified). I said, why would they be transferring here they have coverage. I always thought with EMTALA you send to the closest facility. I told (her/him) there were 3 closer facilities, why would they send here. I haven't gotten a transfer from (Hospital D city identified) in 21 years..."

An interview was conducted with EI # 2, Assistant Chief Nursing Officer, on 6/4/21 at 11:31 AM who confirmed the facility had 11 available beds on 4 South, 4 available beds on 4 North and 4 available beds on the 6th floor along with staffing within typical patterns compared to the monthly average on 5/17/21. EI # 2 also confirmed the facility had the capability to accept PI # 24 for transfer.

An second interview was conducted with EI # 2, on 6/4/21 at 1:33 PM. EI # 2 was asked was there a reason the facility could not accept the transfer on 5/17/21 of PI # 24? EI # 2 stated, "no." EI # 2 was asked per facility policy, can the on-call physician and facility decline a transfer due to distance or because the requesting facility has a closer physician? EI # 2 stated, "no."