HospitalInspections.org

Based on review of the facility policy and procedure, Medical Staff Bylaws and Rules and Regulations, USA Health University Hospital (USA), Hospital A, Medical Record (MR), Emergency Department (ED) Registered Nurse Shift Summary, transferring hospital (Hospital C and Hospital E) MR, receiving hospital (Hospital D) MR, USA Transfer Center Log, USA Transfer Center Transfer Order(s), USA On Call Schedule, USA bed census documentation, and interviews, it was determined the staff failed to ensure:

1. The facility bylaws or rules and regulations identified and approved individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED).

2. A patient at risk for suicide was deterred and/or prevented from leaving the ED prior to the completion of the MSE.

3. USA, Hospital A, failed to accept appropriate transfers from referring Hospital C and Hospital E of:

a. Patient Identifier (PI) # 23, who was experiencing abdominal pain with vomiting, and required USA 's specialized capabilities for hernias and a small bowel obstruction. USA had the capability and capacity to treat PI # 23, when contacted by the transferring hospital (Hospital C) which did not have the capability of treating PI # 23.

b. PI # 24, who had a Aortic Dissection, and required USA's specialized capabilities for Cardiothoracic surgery. USA had the capability and capacity to treat PI # 24, when contacted by the transferring hospital (Hospital E) which did not have the capability of treating PI #24.

Findings Include:

Refer to A 2406, and A 2411 for findings.

Based on review of the facility policies and procedures, Medical Staff Bylaws and Rules and Regulations, Medical Records (MR) and interviews with staff it was determined the facility failed to provide an appropriate medical screening examination within the capability of the hospital's emergency department including ancillary services routinely available to the emergency department to determine whether or an emergency medical condition exists. The examination must be conducted by individuals(s) who is determined qualified by hospital bylaws or rules or regulations. The facility failed to:

1. Identify and approve individual(s) qualified to perform the medical screening examination (MSE) for the Emergency Department (ED) in the facility bylaws or rules and regulations. This deficient practice affected five of twenty-one MR's reviewed, including Patient Identifier (PI) # 7, PI # 13, PI # 14, PI # 16, PI # 1

2. Provide an appropriate medical screening examination; and failed to Deter and/or prevent a patient at risk for suicide from leaving the ED prior to the completion of the MSE. This deficient practice affected
1 of 1 PI #12 MR's review with Suicidal Ideation who left without being seen.
These deficient practices had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: Emergency Medical Treatment and Labor Act (EMTALA) Procedure
Effective Date: 4/22

Policy Statement: Any person who comes to the hospital requesting assistance for a potential emergency medical condition/emergency services will receive a medical screening examination (MSE) performed by a qualified Licensed Independent Practitioner (LIP) to determine whether or not an emergency medical condition exist...

...MSE: For individuals seeking treatment on hospital property, the facility will provide a MSE conducted by qualified medical personnel to determine whether or not an emergency medical condition exits...

...Medical Screening Examination Qualified Medical Personnel: ...A LIP, with appropriate clinical privileges will perform a MSE, based on the patient's presenting signs and symptoms, to determine the existence of an emergency medical condition...

...Procedure if an Emergency Medical Condition Exists

...6. If a patient or a person acting on the individual's behalf refuses to consent to the MSE or treatment:

...c. Discharge of a patient who has refused the MSE or treatment may be done unless the patient is determined to be a danger to self or others. An individual expressing suicidal thoughts or gestures, if determined to be dangerous to self or others, has an emergency medical condition and must continue to receive ongoing examination and/or treatment...

Facility Policy: Suicidal, Psychiatric, Altered Mental Status, and Substance Impaired Patients, Care of
Revised Date: 4/22

Policy Statement: ...staff will provide a safe environment for patients identified as being in the at-risk population for suicide. This includes but is not limited to patients presenting with psychiatric issues (suicidal or homicidal) ...

Procedures:

...K. If the patient attempts to leave, notify Security. Staff will attempt to deter the patient from eloping. In the event that the patient tries to leave, the Medical Doctor/Registered Nurse may request for Security to mobilize a team to restrain the patient...Restraints are applied and monitored according to the restraint policy. The decision to allow the patient to elope or to be restrained is made on a case by case basis in consultation with the patient's physician, unit charge nurse and senior security officer as available. If the decision to restrain is made but restraint of the patient cannot be safely executed...the patient will be allowed to elope and local law enforcement will be contacted.

1. Review of the facility bylaws and rules and regulations revealed documentation of "2.1.3 Patient care. The management of each patient's care is the responsibility of a qualified licensed independent practitioner with appropriate clinical privileges, herein referred to as an attending physician...6.0 Emergency Department/Evaluation Center...A licensed independent practitioner with appropriate clinical privileges will assess patients in need of emergency care and determine appropriate management."

There was no documentation the facility designated a Physician Assistant (PA) and/or a Certified Registered Nurse Practitioner (CRNP) as qualified in the facility bylaws or rules and regulations to perform the MSE.

PI # 7 presented to the facility ED on 5/27/22 at 3:23 PM with chief complaint of lightheadedness and chest pain.

Review of the MR documentation revealed the MSE was conducted on 5/27/22 at 3:53 PM by a CRNP and not an ED physician.

PI # 13 presented the the facility ED on 8/10/22 at 11:55 AM with a chief complaint of a fall with a possible closed head injury.

Review of the MR documentation revealed the MSE was conducted on 8/10/22 at 12:11 PM by a CRNP and not an ED physician.

PI # 14 presented to the facility ED on 8/10/22 at 12:29 PM with a chief complaint of taking a bad batch of Spice and feels like he/she is taking their last breath.

Review of the MR documentation revealed the MSE was conducted on 8/10/22 at "immediately upon arrival" by a CRNP and not an ED physician.

PI # 16 presented to the facility ED on 9/18/22 at 9:23 AM with chief complaint left lower quadrant abdominal pain with decreased bowel movements.

Review of the MR documentation revealed the MSE was conducted on 9/18/22 at 10:12 AM by a CRNP and not an ED physician.

PI # 1 presented to the facility ED on 9/18/22 at 11:16 AM with chief complaint of abdominal pain and two episodes of vomiting.

Review of the MR documentation revealed the MSE was conducted on 9/18/22 at 11:32 AM by a CRNP and not an ED physician.

Staff interviews were conducted on 10/13/22 and 10/14/22 in which 9 of 9 staff, when asked about the MSE, verbalized CRNP's and 5 of 9 staff verbalized PA's were able to perform the MSE.

An interview was conducted with Employee Identifier (EI), # 1, Assistant Chief Nursing Officer, on 10/14/22 at 8:08 AM who confirmed there was no documentation in the facility bylaws or rules and regulations a PA and CRNP were designated as qualified to perform the MSE in the ED.



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2. PI # 12 presented to the ED on 7/20/22 at 2:15 AM with complaint of suicidal ideation.

Review of the ED Triage and Nursing Assessment dated 7/20/22 at 2:29 AM revealed the chief complaint of suicidal ideation x (times) several weeks with a suicide plan to overdose. The blood pressure was 124/99, heart rate 101, respirations 18 and temperature 98.4. PI # 12 was assigned a tracking acuity of 3 - Urgent.

Review of the Columbia-Suicide Severity Rating Scale (C-SSRS) assessment documented on 7/20/22 at 2:29 AM revealed PI # 12 was asked the following questions:

1. In the past month, have you wished you were dead or wished you could go to sleep and not wake up? PI # 12 responded, yes.
2. In the past month, have you had any actual thoughts of killing yourself? PI # 12 responded, yes.
3. In the past month, have you been thinking about how you might do this? PI # 12 responded, yes.
4. In the past month, have you started to work out (or worked out) the details of how to kill yourself? PI # 12 responded, yes.

Further review of the C-SSRS revealed PI # 12's risk level was calculated as a High Risk and a sitter/observer was assigned to the patient.

Review of the physician orders dated 7/20/22 at 2:29 AM revealed an order for 1:1 observation and Suicide Risk Initiation.


Review of the MR revealed there was no documentation of 1:1 observation and suicide risk initiation. Further review of the MR revealed no documentation a physician assessment was performed and a psychiatric consultation was ordered and/or provided for the MSE.

Review of the Discharge Information dated 7/20/22 at 4:30 AM revealed PI # 12 Left Without Being Seen (LWBS).

There was no documentation the staff witnessed PI # 12 leaving, no documentation of any efforts made to prevent the patient from leaving prior to the MSE, no documentation the MD was notified of the patient leaving, and no documentation security or local law enforcement was contacted to deter patient from leaving per the facility policy. Medical record review that on 7/20/203 was noted as "high risk on the behavioral assessment. None of the above interventions were done, and Patient #12 left without being seen by an ED Physician nor by a Psychiatrist; without being placed on precautions or an involuntary hold as was necessary.

In an interview conducted on 10/14/22 at 8:47 AM, Employee Identifier (EI) # 12, Assistant Chief Nursing Officer (CNO), confirmed there was no documentation of 1:1 observation, efforts were made to prevent the patient from leaving prior to the MSE completion, the physician was notified of the patient leaving, and security or local law enforcement was contacted to deter patient from leaving.

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Based on reviews of the facility policy and procedure, transferring Hospital C and (Hospital E) Medical Record (MR), receiving hospital (Hospital D) medical records, facility Transfer Center Log, Transfer Center Transfer Order(s), University hospital checklist, facility On Call Schedules, facility bed census documentation, and interviews, it was determined USA Health University Hospital (USA), Hospital A, refused to accept from referring Hospital C and Hospital E, an appropriate transfer of individuals who required the hospitals specialized capabilities or facilities of:

1. Patient Identifier (PI) # 23, who was experiencing abdominal pain with vomiting, and required USA 's specialized capabilities for hernias and a small bowel obstruction. USA had the capability and capacity to treat PI # 23, when contacted by Hospital C which did not have the capability of treating PI # 23.

2. PI # 24, who had a Aortic Dissection, and required USA's specialized capabilities for Cardiothoracic surgery. USA had the capability and capacity to treat PI # 24, when contacted by Hospital E which did not have the capability of treating PI #24.

This deficient practice affected 2 of 4 emergency transfer requests reviewed, who were appropriate for transfer to the facility and, which USA had the capability and capacity to treat and had the potential to affect all patients with a request for transfer to USA.

Findings include:

The facility's Policy titled, "EMTALA PROCEDURE" Origination 8/2001, Last Revised 04/2022 was reviewed. The policy stated in part, "GUIDELINES FOR ACCEPTING PATIENT TRANSFERS FROM ANOTHER EMERGENCY DEPARTMENT, stated ...As a hospital with specialized capabilities and facilities (including, but not limited to such facilities as burn unit, trauma unit, and being a regional referral center) we may not refuse to accept, from a referring hospital within the boundaries of the United States, an appropriate transfer of an individual who requires the hospital's or facilities as long as the has the capability and capacity to treat the individual."



Facility Policy: Referral Escalation Procedure
Revised Date: 2/22

Policy Statement: Escalation pathway for the referral process regarding the Transfer Center's inability to contact the on call service line physician.

Procedure:

1. Transfer Center will attempt to contact the on-call service line physician via their preferred contact method...

2. After 5 minutes, if the initial attempt for contact is unsuccessful, the Transfer Center will confirm the on-call physician of the requested service line with the operator. The Transfer Center will re-attempt contact with the on-call physician.

3. If no response after 10 minutes form the initial call, the Transfer Center will attempt to contact via a secondary method. A secondary method may be obtained from the hospital operator.

4. If no response after 15 minutes from the initial call, contact the Department Chair of the service line.

5. If no response after 20 minutes from the initial call, notify the on-call administrator...


1. Hospital A, USA Health University Hospital (USA), documentation for Patient #23:

Review of the facility Transfer Center Log documentation revealed a transfer request from Hospital C on 7/18/22 at 10:40 AM, requiring the hospital service of "GI (Gastrointestinal) Surgery" which was denied due to "...there was a delay in finding an accepting surgeon, and during the process (USA) went on TSO (Trauma System Overload diversion) and was, at that time, unable to accept the patient."

Review of the facility on-call Schedule revealed documentation the facility had the following physician's on call on 7/18/22 at 10:40 AM: a Colorectal surgeon, a general surgeon and three Gastrointestinal surgeons.

Review of the facility Transfer Center Transfer Order dated 7/18/22 revealed documentation Hospital C ED requested a transfer for PI # 23. The hospital service needed was "GI Surgery" and the level of care was "private/floor." The following were paged in response to the transfer request on PI # 23: an on-call general surgeon was paged at 10:47 AM then again at 11:11 AM and the on-call Colorectal surgeon was paged at 11:03 AM. There was no documentation the physician responded to the page.

There were no further attempts made to contact the on-call surgeons and no additional steps were completed for the transfer of PI # 23.

Further review the transfer request was declined for PI # 23, due to TSO (Trauma System Overload) diversion and there was a delay in finding an accepting surgeon.

Review of the facility bed census documentation for 7/18/22 at 10:40 AM revealed documentation the facility sixth floor had two beds and the progressive care unit had one bed, which were open and available with normal staffing.

Review of the University Hospital (USA) Capacity Checklist dated 7/18/22 revealed the facility went on TSO diversion at 11:57 PM, which was 1 hour and 17 minutes following the initial transfer request call.

In an interview conducted on 10/11/22 at 5:30 PM with Employee Identifier (EI) # 1, Assistant Chief Nursing Officer, EI # 1 verbalized the Transfer Center does not record the calls related to transfer request, so no audio files of transfer request would be available.

An interview was conducted on 10/13/22 at 5:28 PM with EI # 3, Transfer Center Nurse Manager, who verbalized had PI # 23 been accepted for transfer, the patient would have been placed on either the third, sixth or eighth floors. EI # 3 also confirmed the facility did have the capability to provide the needed service for PI # 23 on 7/18/22 and after reviewing all documentation related to the transfer request and census information, confirmed the facility did have the capability and capacity to accept PI # 23 for transfer at the time of the initial call.

A second interview was conducted on 10/14/22 at 1:10 PM with EI # 1, who confirmed the facility had two beds on the sixth floor and one bed on the progressive care unit which were open and available at the time of the initial transfer request call.

Hospital C, Transferring Hospital documentation:

PI # 23 presented to Hospital C's Emergency Department (ED) on 7/18/22 at 7:46 AM with a Computed Tomography (CT) verified left and right abdominal hernias and small bowel obstruction.

Review of the Physician note dated 7/18/22 at 7:51 AM revealed documentation PI # 23 presented to the ED with mid-abdominal pain over the past 2 days with multiple episodes of nausea and/or vomiting and a history of hernias and physical exam findings of a blood pressure of 179/107, heart rate 77, pain at an 8 on a 1-10 scale, mid-abdominal distention and tenderness with guarding, large ventral hernia on the left side which was firm and tender, 2 ventral hernias on the right side in the upper and lower abdomen with tenderness.

Further review of the Physician note dated 7/18/22 at 7:51 AM revealed documentation the ED physician discussed PI # 23's findings with the facility surgeon who verbalized the patient would require a transfer to USA, Hospital A, who had multispeciality services available. The ED physician documented USA was contacted to initiate a transfer of PI # 23, USA responded hours later they could not accept transfer and alternate arrangements to transfer PI # 23 to Hospital D, Receiving Hospital were made.

PI # 23 was transferred to Hospital D for further care via ambulance and underwent an Exploratory Laparotomy with extensive lysis of adhesions, three reductions of ventral abdominal wall hernia, reduction of close loop bowel obstruction, excision of abdominal wall scar, suture repair of small bowel serosal injury for a diagnosis of Incarcerated Ventral Abdominal Wall Hernia, Loss of Abdominal Domain and Small Bowel Obstruction. PI # 23 was discharge to a skilled nursing facility on 9/6/22.


2. Hospital A, USA Health University Hospital (USA), documentation for Patient #24:

Review of the facility Transfer Center Log documentation revealed documentation of a transfer request from Hospital E on 5/6/22 at 2:05 PM, requiring the hospital service of "CVT (Cardiothoracic)" which was denied due to the CVT on-call surgeon called back at 3:07 PM and stated"...recommended the pt. (patient) go to a closer facility with the type of aortic dissection that she/he has ...did not feel like it was safe to transport the pt. across that distance when other facilities were closer..."

Review of the facility on-call Schedule revealed documentation the facility had CVT surgeons on-call from 5/6/22 at 6:00 AM to 5/7/22 at 6:00 AM.

Review of the facility Transfer Center Transfer Order dated 5/6/22 revealed documentation Hospital E, ED requested a transfer for PI # 24. The hospital service needed was "CVT" and the level of care was "ICU (Intensive Care Unit)/Critical Care." Two CVT surgeons were paged in response to the transfer request on PI # 24, one (Employee Identifier (EI) # 8) at 2:22 PM and the second (EI # 9) at 2:30 PM. EI # 8 returned the page at 3:07 PM and stated he/she "...recommended the pt go to a closer facility with the type of aortic dissection...did not feel like it was safe to transport the pt across that distance when other facilities were closer..." then asked and was provided the phone number for the referring physician. There was no documentation of a phone call to the referring physician.

Further review of the facility Transfer Center Transfer Order dated 5/6/22 revealed documentation the transfer was declined for "...timeframe unacceptable."

Review of the facility bed census documentation for 5/6/22 at 2:22 PM, the time the first physician was paged, revealed documentation the facility Medical ICU had one bed and the Surgical ICU had 3 beds which were open and available with normal staffing.

Review of the University Hospital (USA) Capacity Checklist dated 5/6/22 revealed no documentation the facility was on diversion from 5/6/22 at 2:00 PM through 3:07 PM.

An interview was conducted on 10/13/22 at 1:27 PM with EI # 3, Transfer Center Nurse Manager, who verbalized if PI # 24 been accepted for transfer, the patient would have been placed in Medical ICU if the patient required chest cavity to be opened or any ICU if the patient had not required chest cavity to be opened. EI # 3 also confirmed the facility did have the capability to provide the needed service for PI # 24 on 5/6/22 and after reviewing all documentation related to the transfer request and census information, confirmed there were open and available beds in the Medical ICU and Surgical ICU and the facility did have the capability and capacity to accept PI # 24 for transfer at the time of the initial call.

Hospital E, Transferring Hospital:

PI # 24 presented to Hospital E's Emergency Department (ED) on 5/6/22. A triage was performed at 8:17 AM with a chief complaint documented of cough, throat pain, chest pain and "all over" pain for 2 days.

Review of the Physician note dated 5/6/22 at 8:44 AM revealed documentation PI # 24 presented to the ED with pain all over for several days reporting a sore throat, dysuria, chest pain, back pain and not feeling well. Further review revealed "chest x-ray concerning for mass. CT (Computed Tomography) of chest showed aortic dissection. Patient was given IV Metoprolol... (Hospital D, Receiving Facility identified) agrees to accept in transfer."

Review of the nursing ED notes dated 5/6/22 at 2:42 PM revealed documentation the patient was accepted by Hospital D.

Review of the nursing ED notes dated 5/6/22 at 4:02 PM revealed documentation the patient was transferred to Hospital D's Cardiac ICU via air ambulance.

Hospital D, Receiving Hospital:

PI # 24 was admitted to Cardiac ICU and underwent an Ascending Aorta replacement, Hemiarch replacement with circulatory arrest, and Valva resuspension (heart procedure to replace a thickened aortic valve that can't fully open https://www. Mayoclinic.org) and repair for a diagnosis of Type A Dissection, DeBakey Type 2(a tear in the
inner most layer of aortic wall. https://www.update.com) then discharged home on 5/12/22 in stable condition.

Interviews:

An interview was conducted on 10/13/22 at 11:30 AM with EI # 7, Transfer Center Coordinator, who recalled the transfer request for PI # 24. EI # 7 verbalized he/she remembered speaking with EI # 8, CVT Surgeon and trying to facilitate a call between the physician and the facility physician but EI # 8 just wanted to number to the physician at Hospital E, Transferring Hospital. EI # 7 also verbalized the physician (EI # 8) recommended the patient go to another facility.

An interview was conducted on 10/13/22 at 1:42 PM with EI # 8, CVT Surgeon, who was unable to recall PI # 24 specifically but verbalized his/her role in the transfer in process was to consider the condition of the patient and the patient's location, to ensure the transfer would be safe for the patient and make sure the facility can handle the type of patient that is being transferred. EI # 8 also verbalized he/she would deny a transfer if the patient is unstable and there is a hospital closer to which the patient could make the trip.


The facility failed to ensure their policy and procedure was followed as evidenced failing to accept from referring hospitals within the boundaries of the United States an appropriate transfer of Patient #23 and Patient #24 who required USA Health University Hospital specialized capabilities (Cardiothoracic Surgery and Gastrointestinal Surgery) or facilities.