HospitalInspections.org

1 Part benzocaine 20% 1 Part Maalox. 1 Part diphenhydramine 12.5 mg per 5 ml elixir. (this is the child dose.)

Based on review of the medical record and staff interviews it was revealed the facility failed to ensure a patient received a timely transfer and was informed of a delay in the transfer. This failure was identified in one (1) of ten (10) medical records reviewed. This failure has the potential to adversely affect all patients in need of a transfer to a higher level of care.

Findings include:

1. A review of the medical record for patient #1 revealed a twenty-nine (29) year old who was admitted on 6/30/21 to the Intensive Care Unit (ICU) with a diagnosis of acute and subacute infective endocarditis. The physician documented patient #1 admitted to using heroin prior to coming to the emergency department (ED). Patient was alert and oriented when seen by the ED physician. The ED physician had diagnosed patient #1 with sepsis and pneumonia. On 6/30/21 at 6:16 p.m. it was documented patient #1 arrived in the ICU lethargic. On 7/1/21 the social worker documented patient's mother agreed to be the health care surrogate. Patient #1 had a history of a recent aortic valve replacement at another facility. This facility was contacted for a possible transfer but refused patient #1 due to after the valve replacement, patient #1 continued to use heroin. Patient #1 was moved from the ICU to the Telemetry Unit on 7/1/21. On 7/6/21 the infectious disease (ID) physician documented diagnosis as fever, MRSA (Methicillin-resistant Staphylococcus Aureus), prosthetic aortic valve infective endocarditis with visible vegetation on echo and polysubstance abuse with ongoing heroin addiction. On 7/9/21 the ID physician documented computed tomography (CT) scan revealed small splenic infarct, continue with intravenous Vancomycin and gentamycin. On 7/14/21 the ID physician documented acute infective endocarditis of aortic valve and native tricuspid valve now involved. On 7/14/21 it was documented waiting for a bed for transfer to another facility for tertiary care. On 7/14/21 at 10:00 p.m. nursing documented, "Received notification a bed was available for transfer to another facility." On 7/14/21 at 11:30 p.m. nursing documented, "Discharge (d/c) summary and discharge order not placed in pt.'s (patient's) chart... (accepting facility) will not accept pt. (patient) until completed." No documentation was noted in the medical record the nurse notified the physician a bed was available at the accepting facility. No documentation the patient or mother was notified of the delay in transfer. A d/c summary was completed on 7/15/21 at 9:26 a.m. that stated, "Tertiary care transfer was recommended by the Infectious Disease specialist. Last night she had a bed assigned but lost her bed as she did not get transferred with the night provider." The accepting facility was called on 7/15/21 and patient #1 was accepted and transported with advanced life support emergency medical services on 7/15/21 at 4:40 p.m.

2. An interview was conducted with the Director of Regulatory/Compliance Coordinator on 11/29/21 at 3:56 p.m. When asked about nursing not notifying the physician a bed was available for the patient for transfer, they stated, "At the point of notification a bed was available for transfer to another facility, the physician should have been notified so the transfer could have occurred."

3. An interview was conducted with the Nurse Manager (NM) of the Telemetry Unit on 11/30/21 at 10:10 a.m. When asked about the incident where patient #1 was not transferred to another facility on 7/14/21, the NM stated, "I recall completely the incident, we discussed it the next morning." The NM stated they went to the Registered Nurse (RN) who works with the hospitalist, and she went to the Director of the hospitalist. The NM stated, "I was informed the hospitalist was contacted and made aware a bed was available. The nursing staff was told later that night the physician was not the transferring doctor, and the physician said the transferring doctor can do it tomorrow." An incident report was completed but they are unable to locate the incident report. The NM had a Cobra form that was completed by the hospitalist on 7/14/21 at 10:00 p.m. The NM concurred no d/c order or summary was completed for a transfer.

4. A joint interview was conducted with the Clinical Performance Nurse and the Director of the hospitalist on 11/30/21 at 11:07 a.m. When asked about the transfer to the accepting facility for patient #1 on 7/14/21, the Director stated there was no documentation the nurse told the hospitalist a bed was available. The Director stated the hospitalist said they had to finish what they were doing. The Director stated there was one (1) hospitalist to one hundred and thirty (130) patients on 7/14/21. The accepting facility requested the d/c summary. Most hospitals do not request the d/c summary for a transfer, only the Cobra form and the d/c order. The Director stated the other facility was not willing to wait for the paperwork to be completed. It was their goal to get the patient transferred. They stated a peer review was conducted and the hospitalist did not have time to do the d/c summary right away. They stated they are not sure why the other facility wanted the d/c summary. The Director of the hospitalist was shown the Cobra form where the hospitalist signed the form on 7/14/21 at 10:00 p.m. after notification a bed was available.

5. A telephone interview was conducted with hospitalist #1 on 11/30/21 at 12:06 p.m. When asked about the transfer of patient #1 on 7/14/21, they stated, "I usually don't give the order until transport is there to transport the patient." They stated this was non-emergent, the facility refused the patient until they got a d/c summary. They stated at night they try to do the d/c summary, but there was only one (1) hospitalist to one hundred and thirty (130) patients that night. They stated, "The patient's vital signs were stable, no change in the blood, the patient was on the appropriate antibiotics. I did not see the emergency that night, the patient was to go to get checked for valve replacement for potential surgery. I talked to the patient; the patient was stable."

6. An interview was conducted with the Director of Regulatory on 11/30/21 at 4:15 p.m. They concurred the facility failed to provide a timely transfer when a bed was available for patient #1 on 7/14/21.

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