HospitalInspections.org

Based on document review and staff interview, the facility failed to follow it's policies when facility staff delayed stabilizing treatment for a patient based on health insurance in 1 of 30 patients' medical records (Patient #6) selected for review. Additionally, the facility failed to follow it's policies when the facility failed to provide prompt transfer in 1 of 6 patients' medical records (Patient #14) selected for review who required specialty care for an acute heart attack. The facility identified an average of approximately 380 patients per month who requested emergency medical care at the facility.

Findings include:

1. Review of the policy "TRANSFER OF PATIENT TO ANOTHER FACILITY", revised 3/15/04, revealed in part, "If the physician determines ... the patient should be transferred to another facility for further care, ... The patient must ... not require immediate need for surgery."

2. Review of the undated policy "Emergency Examinations and transfers policy", revealed B. No Delay- Provision of the medical screening examination and further examination and treatment may not be delayed in order to inquire about the individual's method of payment or insurance status, and C. Further Examination and Treatment-If the individual has an emergency medical condition, further medical examination and treatment within the capabilities of the staff and facility must be provided to attempt to stabilize the emergency medical condition.

3. Review of Patient #6's medical record revealed Patient #6 presented to the facility's Emergency Department (ED) on 4/3/13 at 7:36 PM complaining of abdominal pain. ED Physician A examined Patient #6 and ordered diagnostic tests. After reviewing the diagnostic tests, ED Physician A diagnosed Patient #6 with acute appendicitis (an acute inflammation of the appendix requiring surgical removal of the appendix before the appendix ruptured and caused a life threatening infection).

ED Physician A spoke with Surgeon B. Surgeon B ordered the facility's operating room staff to prepare to perform emergency surgery on Patient #6. ED Physician A documented Surgeon B found out Patient #6 had "Iowa Cares" insurance, and requested ED Physician A transfer Patient #6 to another facility. ED Physician A documented Patient #6 then requested a transfer to Receiving Hospital B. Patient #6 did not receive surgical care for the acute appendicitis at the facility, but was transferred to Receiving Hospital B.


4. During an interview on 5/3/13 at 10:05 AM, ED Physician A stated Surgeon B asked ED Physician A to find out what type of health insurance Patient #6 had. When Surgeon B found out Patient #6 had Iowa Cares insurance, he instructed ED Physician A to transfer Patient #6 to a hospital that accepted Iowa Cares insurance. ED Physician A stated he offered to arrange a transfer for Patient #6 to either of the 2 hospitals in the state which accepted Iowa Cares insurance. Patient #6 chose to have ED Physician A transfer them to Receiving Hospital B. ED Physician A arranged to transfer Patient #6 to Receiving Hospital B for emergency surgery.

5. Review of Patient #14's medical record revealed Patient #14 presented to the facility's ED complaining of Chest Pain at 7:11 PM. Nurse D performed an EKG (electrical tracing of the heart rhythm) 5 minutes after Patient #14 arrived in the ED. The initial EKG indicated Patient #14 was having a heart attack.

Approximately 1 hour after Patient #14 arrived at the facility, ED Physician E spoke with Cardiologist F on the telephone. ED Physician E requested to transfer Patient #14 to Receiving Hospital A. Cardiologist F accepted care for Patient #14 when Patient #14 arrived at Receiving Hospital A. Cardiologist F requested Patient #14 go directly to the ICU at Receiving Hospital A.


6. During an interview on 5/1/13 at 5:30 PM, ED Physician E stated he examined Patient #14 and the EKG tracing. ED Physician E determined Patient #14 was having a heart attack, and required specialized care not available at the facility. ED Physician E spoke with Cardiologist F on the telephone, and informed Cardiologist F about Patient #14, the diagnostic tests and results performed on Patient# 14, and Patient #14's medical history. Cardiologist F did not request ED Physician E to administer any medications to Patient #14, and accepted care for Patient #14 after Patient #14 arrived at Receiving Hospital A.

7. During an interview on 5/6/13 at 3:02 PM, Cardiologist F stated he received a phone call from ED Physician E. Patient #14 was in the facility's ED, and was complaining of chest pain. Patient #14 also had ST elevation on the EKG (an early sign of a heart attack). ED Physician E didn't know what was going on with Patient #14. The first blood test (troponin I) for a heart attack was negative (the test can take several hours after the start of a heart attack to show a positive result). ED Physician E stated Patient #14 had the ST elevation on the EKG, but believed Patient #14's EKG always had the ST elevation in the EKG rhythm from a prior heart attack (after a heart attack, the ST elevation normally does not stay in an EKG rhythm). Cardiologist F accepted care for Patient #14 when Patient #14 arrived at Receiving Hospital A. Cardiologist F requested ED Physician E transfer Patient #14 directly to the ICU at Receiving Hospital A.

Cardiologist F stated originally he was not worried about Patient #14, since ED Physician E wasn't sure what was going on with Patient #14. ED Physician E's description of Patient #14's symptoms sounded very vague. Cardiologist F felt Patient #14 did not arrive at Receiving Hospital A as quickly as Cardiologist #14 would have liked. Additionally, if Cardiologist F knew all the information about Patient #14's condition, Cardiologist F would have requested Patient #14 receive Heparin (a medication to thin the blood) and faster transportation to Receiving Hospital A.

Based on document review and staff interview, the facility failed to provide all appropriate stabilizing treatment in 1 of 30 patients' (Patient #14) medical records selected for review. The facility identified an average of approximately 380 patients who presented to the Emergency Department per month who requested emergency medical care.

Failure to provide all appropriate stabilizing treatment potentially resulted in the patient not receiving treatments to decrease the potential damage from a heart attack.

Findings include:

1. Review of Patient #14's medical record revealed Patient #14 presented to the facility's ED complaining of Chest Pain at 7:11 PM. Nurse D performed an EKG (electrical tracing of the heart rhythm) 5 minutes after Patient #14 arrived in the ED. The initial EKG showed Patient #14 was having a heart attack. ED Physician E examined Patient #14 9 minutes after Patient #14 arrived in the ED. Thirty minutes after Patient #14 arrived, ED Physician E ordered facility staff to perform tests on Patient #14. ED Physician E also ordered treatment for Patient #14's low blood pressure.

Approximately 1 hour after Patient #14 arrived at the facility, ED Physician E spoke with Cardiologist F on the telephone. ED Physician E requested to transfer Patient #14 to Receiving Hospital A. Cardiologist F accepted care for Patient #14 when Patient #14 arrived at Receiving Hospital A. Cardiologist F requested Patient #14 go directly to the ICU at Receiving Hospital A.

Approximately 2 hours after Patient #14 arrived at the facility, ambulance staff arrived to transport Patient #14 to Receiving Hospital A. Patient #14 arrived at Receiving Hospital A approximately 3 hours after Patient #14 arrived at the facility's ED.

2. Review of the undated policy "Emergency Examinations and transfers policy", revealed the facility was required to provide all stabilizing treatment for patients who presented to the facility and requested emergency medical care.

3. During an interview on 5/1/13 at 5:30 PM, ED Physician E stated he examined Patient #14 and the EKG tracing. ED Physician E determined Patient #14 was having a heart attack, and required specialized care not available at the facility. ED Physician E spoke with Cardiologist F on the telephone, and informed Cardiologist F about Patient #14, the diagnostic tests and results performed on Patient# 14, and Patient #14's medical history. Cardiologist F did not request ED Physician E to administer any medications to Patient #14, and accepted care for Patient #14 after Patient #14 arrived at Receiving Hospital A.

4. During an interview on 5/6/13 at 3:02 PM, Cardiologist F stated he received a phone call from ED Physician E. Patient #14 was in the facility's ED, and was complaining of chest pain. Patient #14 also had ST elevation on the EKG (an early sign of a heart attack). ED Physician E didn't know what was going on with Patient #14. The first blood test (troponin I) for a heart attack was negative (the test can take several hours after the start of a heart attack to show a positive result). ED Physician E stated Patient #14 had the ST elevation on the EKG, but believed Patient #14's EKG always had the ST elevation in the EKG rhythm from a prior heart attack (after a heart attack, the ST elevation normally does not stay in an EKG rhythm). Cardiologist F accepted care for Patient #14 when Patient #14 arrived at Receiving Hospital A. Cardiologist F requested ED Physician E transfer Patient #14 directly to the ICU at Receiving Hospital A.

Cardiologist F stated originally he was not worried about Patient #14, since ED Physician E wasn't sure what was going on with Patient #14. ED Physician E's description of Patient #14's symptoms sounded very vague. Cardiologist F felt Patient #14 did not arrive as quickly as Cardiologist #14 would have liked. Additionally, if Cardiologist F knew all the information about Patient #14's condition, Cardiologist F would have requested Patient #14 receive Heparin (a medication to thin the blood) and faster transportation to Receiving Hospital A.


5. Review of the Physician Peer Review, dated 5/21/13, documented the medical screening examination was too lengthy and delayed treatment for an acute heart attack. Patient #14 was kept at a rural hospital for more than 2 hours for unnecessary testing. The initial EKG verified the acute heart attack and need for urgent transfer to a hospital with a cardiac (heart) specialty center. The delay could have had serious outcomes for the patient.

Based on document review and staff interview, the facility delayed stabilizing treatment in 1 of 30 patients' (Patient #6) medical records selected for review. The facility identified an average of approximately 380 patients who presented to the Emergency Department per month who requested emergency medical care.

Findings include:

1. Review of Patient #6's medical record revealed Patient #6 presented to the facility's Emergency Department (ED) on 4/3/13 at 7:36 PM complaining of abdominal pain. ED Physician A examined Patient #6 and ordered diagnostic tests. After reviewing the diagnostic tests, ED Physician A diagnosed Patient #6 with acute appendicitis (an acute inflammation of the appendix requiring surgical removal of the appendix before the appendix ruptured and caused a life threatening infection).

ED Physician A spoke with Surgeon B. Surgeon B ordered the facility's operating room staff to prepare to perform emergency surgery on Patient #6. ED Physician A documented Surgeon B found out Patient #6 had "Iowa Cares" insurance, and requested ED Physician A transfer Patient #6 to another facility. ED Physician A documented that Patient #6 requested a transfer to Receiving Hospital B. Patient #6 did not receive surgical care for the acute appendicitis at the facility, but was transferred to Receiving Hospital B.

2. Review of the policy "TRANSFER OF PATIENT TO ANOTHER FACILITY", revised 3/15/04, revealed in part, "If the physician determines ... the patient should be transferred to another facility for further care, ... The patient must ... not require immediate need for surgery."

3. During an interview on 5/3/13 at 10:05 AM, ED Physician A stated he diagnosed Patient #6 with acute appendicitis, and requested Surgeon B to perform an appendectomy (surgical removal of the appendix) on Patient #6. ED Physician A stated Surgeon B requested ED Physician A to prepare Patient #6 for emergency surgery.

4. During an interview on 5/2/13 at 2:05 PM, ED Nurse C stated she had requested the on-call surgical staff come to the facility to perform an emergency appendectomy on Patient #6 at Surgeon B's request. After ED Nurse C had requested the on-call surgical staff to come to the facility, Surgeon B called the ED, and requested to know Patient #6's health insurance coverage. After Surgeon B learned Patient #6 had Iowa Cares insurance, he requested to transfer Patient #6 to another hospital.

5. During an interview on 5/3/13 at 10:05 AM, ED Physician A stated Surgeon B asked ED Physician A to find out what type of health insurance Patient #6 had. When Surgeon B found out Patient #6 had Iowa Cares insurance, he instructed ED Physician A to transfer Patient #6 to a hospital that accepted Iowa Cares insurance. ED Physician A stated he offered to arrange a transfer for Patient #14 to either of the 2 hospitals which accept Iowa Cares insurance. Patient #6 chose to have ED Physician A transfer them to Receiving Hospital B. ED Physician A arranged to transfer Patient #6 to Receiving Hospital B.

6. Review of the Physician Peer Review, dated 5/21/13, revealed Patient #6 had acute appendicitis, an emergency medical condition. Stabilizing treatment required an appendectomy. The hospital staff were capable of doing the surgery but transferred the patient instead. A delay in treatment resulted from the unnecessary transfer of Patient #6 to another hospital, more than 100 miles away, for surgery.