HospitalInspections.org

Based on review of medical records, policy and procedures, transfer logs and on call schedules, Medical Staff Bylaws, and interviews, the facility failed to ensure level of care within the facilities capacity was provided for 1 of 20 patients reviewed, Patient #1. The facility's on call physician failed to come to the Emergency Department t(ED) to provide further evaluation as treatment as requested by the ED physician, and failed to admit the patient. As this resulted in an inappropriate transfer to another facility.

Refer to Tag A2409

Based on review of medical records, policy and procedures, transfer logs and on call schedules, Medical Staff Bylaws, and interviews, the facility failed to ensure level of care within the facilities capacity was provided for 1 of 20 patients reviewed, Patient #1. The facility's on call physician failed to come to the Emergency Department t(ED) to provide further evaluation and treatment as requested by the ED physician, and failed to admit the patient. As this resulted in an inappropriate transfer to another facility.

Findings include:

The medical record for patient #1 was reviewed. Review of the Emergency Provider Report dated 9/19/2022 for Patient #1 reads, "PCP (Primary Care physician) Phys: No primary or family physician. Free text HPI (history of presenting illness) notes: 19/M (19-year-old male) with recent cardiothoracic surgery presents to OHH (Oak Hill Hospital) ED (emergency department) with Chest pain, shortness of breath and b/l (bilateral) shoulder pain. Patient recently had aortic arch repair surgery with graft and valve repair. He was discharged yesterday. Patient with Ehlers Danlos syndrome (a syndrome that affects the skin, joints and blood vessel walls). He is having 7/10 pain currently and difficulty breathing. He is too weak to ambulate. Patient denies nausea and vomiting. Presentation: Chief complaint: Chest pain, Shortness of breath.
Hx (history)obtained from: Patient, Mother, Sudden onset: yes, Onset occurred: today, Symptom duration: since onset, Migration/Movement: Chest to shoulders. Additional medical History: Aorta aneurysm (an enlargement of the aorta, the major blood vessel that delivers blood to the body); additional surgical history: Thoracic aortic aneurysm repair (surgery to remove the damaged part of the aorta and replacing that with a graft). Free text PE (physical examination) Notes: Constitutional: Alert and oriented and responds to questions. Ill appearing fatigued and unable to ambulate under his own power. Card (cardiac): tachycardic (high heart rate), short of breath, increased labor of breathing, slightly diminished breath sounds on left side."

Review of the CTA (Computerized tomography angiography chest) with contrast dated 9/19 at 9:10 PM read: "Impression: Superior mediastinal low-density fluid collection with associated air collections likely representing post-surgical seroma (seroma-fluid buildup after surgery https://www.webmd.com). Correlate clinically. Trace pericardial effusion (buildup of fluid around the heart). Large left pleural effusion with associated atelectasis in the left lung base. trace right pleural effusion with subpleural atelectasis. no evidence of pulmonary embolus. "

Review of the physician reevaluation reads, "Patient is tachycardic. O2 sat (oxygen saturation) at 91-94%. He is lethargic and unable to ambulate on his own. Chest pain and shortness of breath concerning given that he was discharged yesterday and recently had surgery. Will order EKG (electrocardiogram), CBC (complete blood count), CMP (comprehensive metabolic panel), Trops (cardiac troponins), CXR (chest x ray) CTA chest, give pain medication and fluids and reevaluate. CT surgeon who completed patient surgery contacted to inform that his patient was here. He was told that we were working patient up, and asked if there was anything specific he would want completed and he said, "work him up" and promptly hung up the phone."

Review of the Physician on Call schedule for 9/19/2022 revealed that Medical Doctor #1 was on call that day.

Review of the reevaluation/Progress #1 dated 9/19/2022 at 2148 (9:48 PM) reads: "Spoke with [Physician name] (CT (cardiothoracic) who performed procedure) to inform him of his patient CT results. I informed him of left sided pleural effusion as well as mediastinal hematoma causing compression of his RT (right) pulmonary artery. He told me that I should place a tube to drain fluid or just send him home. He recommended contacting interventional radiology for placement of tube."

Review of the reevaluation / Progress #2 physician progress note dated 9/19/2022 at 2200 (10:00 PM) reads, "I spoke with ICU (Intensive care unit) attending on call who says that this is a post-surgical complication, and that CT surgery should be managing this and therefore refused admission under their service. I will contact the Administrator on call for guidance on how to proceed as Medical Director#1 who is on call on 9/19/2022 - is refusing admission. "

Review of the re-evaluation / Progress #3 physician progress note dated 9/19/2022 no time reads," I spoke with interventional radiology who states that patient symptoms are likely being caused by compression of the Rt (right) main pulmonary artery and that their service is unable to place a drain in this location, but that the Medical Director (Medical Director #1 name) of CT surgery could and should manage this complication. I have initiated a transfer process to [hospital initials]."

Review of the re-evaluation progress note #4 dated 9/19/2022 at 2342(11:42 PM) read, "Reeval (Re-evaluation) status Unchanged, Transfer Center contacted me to that [ hospital initials] is on baypass(sp) at this time and unable to accept transfer but that [Hospital name] has CT surgery. Will contact [ Hospital name] - for transfer at this time. "
Patient discharge and departure note reads:" Clinical impression: Primary impression: Mediastinal hematoma, secondary impression: pleural effusion, shortness of breath. Disposition decision: Transfer; Request time: 2345 (11:45 PM); Request date 9/19/2022; Receiving hospital [Hospital name] Acceptance time: 0022 (12:22 AM) Acceptance date: 9/20/2022; Patient status: Stable w/i(within) capabilities. Critical Care Note: Patient was critically ill due to: Pt (patient) with connective tissue disorder presents with shortness of breath- found to have a mediastinal hematoma and pleural effusions. Free text depart notes: 11:56 PM [ Physician name] (CT surgeon of {hospital name] - refused transfer at this time. The transfer center will contact AOC (administrator on call) at this time. 00:23 (12:23 AM) 9/20/2022- Transfer Center contacted me to tell that [ Physician name] has accepted the transfer at this time."

Review of the transfer form signed dated 9/20/2022 titled" EMTALA memorandum of Transfer" reads, "Emergency medical condition (EMC) identified: I. Medical condition [diagnosis]: mediastinal hematoma. c). [ Patient stable for transfer] The patient has been examined and any medical condition stabilized such that within reasonable clinical confidence, no material deterioration of this patient's condition is likely to result from or occur during transfer. II. reason for transfer: on call physician refused or failed to respond within a reasonable period of time. (the on-call physician name and address were not filled in)
III. Risk and benefits for transfer [ Medical benefits]: Obtain level of care/service unavailable at this facility. Service: Cardiothoracic Surgery. IV: Mode/support during transfer as determined by physician: Mode of transportation for transfer ALS (advanced life support), Agency: Bay flite authorizing Physician Signature [ MD #2's name] date: 9/20/2022 Time: 0034 (12:34 Am) Helicopter. VI. Time of transfer: 0114 (1;14 AM) date 9/20."

During an interview on 10/3/2022 at 11:26 AM Medical Doctor #1(Medical Director Name) stated, "I remember [Patient #1's name] well, he had an aortic dissection in Connecticut, they had replaced the ascending aorta, but the aortic root was left intact. When we saw him he had an enlarged aortic root. He was worked up and decided he was best served with redo surgery, removing valve, conduit and replacing the graft. I did the surgery, and it went well. He had pain issues and concerns as many young kids do. He was slow with mobilization but did well. He had a pleural effusion before he left, my partner discharged him. Pleural effusion is very common with redo surgery. We elected not to drain while he was hospitalized, left it up to time for the body to absorb. Many times, we treat this as an outpatient without ever requiring drainage. We administer diuretics as needed. I was called by a resident who said he was seeing one patient of ours and he was giving me a heads up and I did say okay do a workup. I went back to sleep and got another call that he had a pleural effusion. He reviewed the CT scan with me, and I told the resident to treat as outpatient, that I didn't want to drain the effusion and I would see in the office. I might have said well if you want to drain it go ahead or send him home so I can see him in the office in the morning. After that I received another call from the ED attending, [Medical Doctor #2's name], she was going to admit to me. I explained that we don't admit that we would admit to medicine and get an IR (interventional radiology) consult to place a pigtail. She was upset about that and told me that she was going to call the administrator on call. I did get a text from the administrator on call, and I responded but not until 4:30 or 5:00 AM, I did not respond to the text, I just didn't hear it. I was not asked to come and see the patient nor was I in knowledge that he would be transferred. Had anyone told me that they were transferring the patient I absolutely would have admitted the patient then and there. We do and did have the ability to treat this patient and frankly we should have. There was no reason this patient was transferred when we did the surgery and manage our patients. But once the surgery is completed and the patient is discharged anything that would not require surgical intervention is handled by medicine with a consult to our group. I do not routinely admit patients post operatively but I have at times. I was contacted by the administrator on call via text, but I did not respond to him until about 4:30 or 5 AM, I responded that I would admit the patient, but he was already transferred. "

During an interview on 10/3/2022 at 12:08 PM Staff A, Registered Nurse (RN) stated, "We were busy that night and patients were beginning to stack up in the lobby. So, when I saw the tracker that he (Patient #1) had chest pain, I went to the lobby and brought him back. I triaged him in the room and placed him as an ESI of 2, so he would get bed placement and could be seen quickly. His mom was with him, he told me that he had discharged yesterday after having open heart surgery and was having chest and rib pain when breathing. The doctor was in the room and ordered an ECG (electrocardiogram), CT of the chest. I was not involved in the transfer. The Charge nurses do transfers, the docs (doctors) will tell them they need a transfer, and they arrange for it with the transfer center."


During an interview conducted on 10/3/2022 at 12:25 PM Staff B, RN stated," I was not involved in the transfer to the other hospital. [ MD #2's name] handed me paperwork and told me that the transfer was happening, so I arranged transfer. I asked her to tell me what diagnosis, where to go and how they want him transferred. She stated that the transfer was happening for continuity of care, post op, felt that the complicated case needed evaluation. I would not investigate further the circumstances of the transfer."



During an interview on 10/3/2022 at 1:10 PM Medical Doctor #2 stated, "I do absolutely remember [Patient #1's name] he was a 19-year-old who came in about 8:30 with complaints of chest pain, palpitations and shortness of breath. He had cardiothoracic surgery 7 days prior to coming and had just discharged the day before. He had same day symptoms when he came for evaluation he was tachycardic (fast heart rate), tachypneic (fast breathing) with bilateral shoulder pain. My initial thought and concern was for PE (pulmonary embolism). I ordered basic labs, CBC (complete blood count), CMP (comprehensive metabolic profile), he was placed on a monitor and a CT was done. Once the I saw the results, I reached out to surgeon and suggested that he look at the CT that it revealed a large left pleural effusion and a mediastinal hematoma that was concerning for pulmonary artery compression. I was very concerned about the mediastinal hematoma which looked to possibly account for his symptoms. I called again when I didn't hear from him and told him of my concerns related to the hematoma, and post-surgical complications. I told him that I wanted admission to his service. He was not agreeable. He (MD #1) told me to call interventional radiology for tube placement. I tried to get the ICU attending to admit him, but they would not manage the patient under their service. The AOC (administrator on call) was called by the Nursing supervisor, who told him (the nursing supervisor) to talk to interventional radiology, [ MD's name] we discussed case with him (MD), he would not put any drain in, stating we don't do that type of a tube. They thought that [MD "1's name] should take care of this himself. [MD#1's name] repeatedly informed me that the patient would not be admitted to him, he (MD#1) told me 3 separate times he would not admit this patient. I initiated the transfer. [ Hospital name] was on bypass. [ Hospital name] had a CV (cardiovascular) surgeon, so I presented case to them. I spoke to ER [ MD's name] and we presented the case to the CT surgeon. They initially refused transfer, stating the surgery had been done here and we needed to care for the patient here. After that the transfer center loops in the AOC at that point. The transfer center and AOC spoke to [MD's name] at [ Hospital name] and they accepted the transfer. I completed the transfer forms, spoke to the family and updated them and went home. [MD #1's name] stated, "Under no circumstances are you to admit to my services." It was my opinion that he (Patient #1) needed a Cardiothoracic surgical evaluation of the mediastinal mass, and he was not stable, needed further evaluation, and he was in no condition to leave and go home. He (Patient #1) was tachycardic at times up to 130 and tachypneic with any movement. At 5 AM [MD #!'s name] finally responded with a text stating "we will admit the patient." By that time, he was already transferred. I knew this was an EMTALA, I told him (MD #1) that his not seeing the patient, refusing admission would be a possible EMTALA violation, this was patient abandonment. I felt strongly that this patient should be seen and evaluated by his surgeon for his post operative complication. I felt he needed a cardiothoracic surgeon to determine that he was stable, and no additional testing or procedures needed to be done. I asked him 3 different times to admit this patient. I handled all of the transfer and told the charge nurse, there was no need to involve everyone in this situation. I have been trained on what is an EMTALA. I brought this concern to the ED (Emergency department) medical director. I texted the medical director early on in the process and then didn't have any more contact with him. I probably should have called him. When I calmed down about the situation, I sent a formal E mail on Thursday, to the AMD (Assistant Medical Director), New AMD and MD (Medical Director)."



During an interview on 10/3/2022 at 3:13 PM the Emergency Department Medical Director stated, "I found out about this transfer after the fact. I was told that [ MD #2's name] had concerns, issues getting one of the cardiothoracic surgeons patients admitted. I did recommend getting the hospitalist, remember telling her to admit to hospitalist on call and consult the surgeon. I found out sometime within the next day that the patient was transferred to another hospital. She did send an email related to what happened and recommended that the case go to peer review. The patient should not have been transferred; do I think they should have stayed, "yes", but that is a loaded question. I had a physician who felt a patient should be admitted, who needed to be seen and get treated by a cardiothoracic surgeon. So, I think he should not have put her in a position to have to make that decision. I had a physician who stayed hours beyond her shift change to get the best done for a patient. What should have happened was that [MD #1's name] should have admitted his patient and taken care of his post-operative complications. I think that "yes" it is an EMTALA violation technically, but we did treat and stabilize the patient. We did everything that we could to get the patient taken care of to the best of our ability. I think [ MD #2's name] was passionate about getting her patient taken care of. There were other options, she could have admitted the patient to the hospitalist, and they could have consulted Cardiothoracic surgery. That ultimately is what should have happened. But she was stuck with a CT surgeon that refused to see one of his patients, she was concerned that this was a surgical complication that may have needed additional surgery. I do not know if the patient was unstable, I have not reviewed the chart. A lot has happened since then, we were preparing for the storm. Typically, when we need transfers to another hospital we let the Charge nurse know and they begin the preparation, call the transfer center and arrangements are made and we will confer with the transferring facility physicians. I am not sure why [ MD #2's name] did the calls herself, I would say dedication and wanting to get the appropriate care for a patient when a surgeon was declining to admit a patient."

During an interview on 10/3/2022 at 3:30 PM the (Chief Executive Officer) CEO stated, "I was on call the night of the 19th. I did receive a call from the nursing supervisor that [ Medical Doctor #1's name] was refusing to admit a patient. I attempted to get hold of [ Medical Doctor #1's name] and he did not answer. I did not, I sent a text message. There is a process that physicians follow, [ MD #2's name] could have admitted the patient to medicine, the hospitalist and consulted cardiovascular surgery. That is what she should have done. I did not receive a call from the transfer center and did not authorize the patients transfer. I know that this was being evaluated and that had been placed on the back burner when hurricane Ian became a threat, and we were busy with those preparations for the storm. We do have measures that would prevent this from occurring, they just were not followed."

During an interview conducted on 10/4/2022 at 10:33 AM Staff C, RN Nursing Supervisor stated, "I was notified that [MD #1's name] had refused to admit the patient and that [ MD #2's name] wanted to transfer the patient. I think to [Hospital name]. I did contact the AOC that night and he dealt with this with the physician. That is the last I knew anything until the patient was actually transferred. "


Review of the Policy and Procedure titled "Florida EMTALA- transfer policy "Policy number LL. EM.001.02 last approval date 6/2022 reads, "Scope: This policy reflects guidance under the Emergency Medical treatment and labor Act (EMTALA) and associated state laws only. Purpose: To establish guidelines for either accepting appropriate transfer from another facility or providing an appropriate transfer to another facility of an individual with an emergency medical condition ( " EMC"), who requests or requires transfer for further medical care and follow-up to a receiving facility as required by EMTALA, 42 , U.S.C.§1395dd, and all Federal regulations and interpretive guidelines promulgated thereunder as well as section 395.1041, Florida Statutes, and all related administrative rules. 2. Additional Transfer-related situations: f. Lateral Transfers: Transfers between hospitals of comparable resources and capabilities are not permitted unless the receiving facility would offer enhanced care benefits to the patient that would outweigh the risks of the transfer. Examples of such situations include a mechanical failure of equipment or no ICU (intensive care unit) beds available."

Review of the "Physician Bylaws, Emergency Room Services" reads, "4. A physician of the medical staff shall be assigned Emergency Department on-call responsibility for an assigned 24-hour period. The assigned on-call physician shall be available to provide care for a patient seen in the ED who requires stabilization of their medical condition as deemed necessary by the ED physician. When a patient presents to the ED for treatment, the appropriate on-call physician (as deemed by the ED physician) shall be responsible to evaluate & treat the patients' unstable medical condition. The on -call physician is responsible to stabilize the patient for either transfer from one facility to another, stabilization for discharge or stabilization for admission to the hospital. All managed care patients will be referred to their primary care physician for follow up. On-call responsibility is only for care required in the ED to stabilize a medical condition. The on-call physician is only responsible to provide care to ED patients as requested by the Ed physician. The scope of on-call responsibility does not include care of a patient already admitted to another physician service. Admitting physicians are responsible to obtain their own consultants for admitted patients. 5. A patient from the ED who requires admission will be asked to identify their physician provider or preferred physician for admission. 1. If the patient does not identify a physician, the Ed physician shall: a. Determine if the patient was discharged within the last 30 days from the facility and evaluate if the discharging physician is appropriate to manage the existing condition, If so, the discharging physician is contacted for admission. b. If a surgeon is required, the appropriate surgical specialist, as published on the ED roster, is contacted for the admission. If this surgical patient does not have associated complicated or multiple medical problems, the surgical specialist shall admit the patient."

The facility failed to provide medical treatment within its capability and capacity and minimize the risks to the individual's health as evidenced by failing to ensure that the On-call Physician who was on-call on 9/19/22, when Patient #1 presented to the ED failed to come to the ED and provide further evaluation and treatment. As this facility had comparable resources and capability to treat, stabilize and admit Patient #1 on 9/19/22. As this resulted in an inappropriate transfer for patient on 9/19/2022.