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Based on observation, interview, and record review, the facility failed to ensure that medications ordered were administered on time, in accordance with the facility policy for one (1) of five (5) patient's reviewed for medication administration resulting in a delay in treatment and the potential for less than optimal outcomes. Findings include:

On 03/13/2023 at 1435 while on tour in the Stroke and Rehab unit, Registered Nurse Staff SS was observed doing patient care rounds and medication administrations.
Upon entering, room 102, Patient #47 (64 year old male, admitted 02/27/2023 with cerebral vascular accident) was observed to have his eyes closed (appeared to be sleeping). Staff SS had a syringe
and vial of medication in her hand as she called the patient's name and said she was there to "give him a shot in his tummy." Patient #47 opened his eyes to the sound of Staff SS's voice, Staff SS went on to say I have your heparin (anticoagulant) shot, can I give it to you now? The patient responded "yes" while Staff SS preceded to document in the mobile computer. Staff SS then opened a compartment on the computer stand and placed the syringe and vial inside. After locking the compartment, Staff SS left the room with the mobile computer. Staff SS was queried as to why she had not given the medication to the patient, Staff SS stated, "he was sleeping and didn't want it right now, I will give it later."

On 03/13/2023 at 1530 during an interview with the Stroke and Rehab unit Registered Nurse Manager Staff JJ, she reiterated the importance of giving stroke patients their anticoagulants on schedule, and that the policy "gives a leeway" but this was not according to policy.
At the time of interview, the policy for Medication administration (Heparin) was requested.
On 03/13/2023 at 1533 the nurse manager opened Patient #47's chart to find that the anticoagulant order of 5000 units subcutaneous (SQ) was scheduled to be given every eight (8) hours (1300) and had not been documented as given at the time of record review (1533).

Further review of patient #47's record on 03/14/2023 revealed the 03/13/2023 1300 ordered heparin was not documented as administered. The next heparin administration documentation occurred on 03/14/2023 at 0009. Second request for the medication administration policy was made on 03/14/2023.

On 03/15/2023 at the time of exit no medication administration policy had been received.

Based on interview and record review, the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to provide an appropriate transfer to another facility resulting in the potential for less than optimal outcomes for all patients requiring emergency transfer to another facility.

See Specific Tag:

A-2409 Failure to provide an appropriate transfer

Based on interview and record review, the facility failed to advise 3 (#15, 19, 20) of 4 patients, who were transferred to another facility for emergency care, of the details of their transfer, resulting in the potential for all patients who require emergency transfer to make uninformed decisions and to have undesirable outcomes affecting their health. Findings include:

Review of the medical record for Patient #15 on 3/16/2023 at 1000 revealed he was a 3-year-old male that presented to the Emergency Department (ED) on 12/31/2022 at 1750 with difficulty in breathing. Upon obtaining labs and x-rays, Patient #15 was diagnosed with "Acute asthma exacerbation, Acute RSV (respiratory syncytial virus) pneumonia, and Acute viral syndrome." The decision was made to transfer him to the local children's hospital via private car.

At the time of record review, the EMTALA transfer form was requested; however, it was discovered there was no transfer form in the medical record that would indicate what type of ambulance services were required, the risks and/or benefits of the transfer, why the transfer was indicated, who had accepted the transfer, and that the patient/representative had agreed to the transfer.

Review of the medical record for Patient #19 revealed he was a 46-year-old male that presented to the emergency department (ED) on 9/2/2022 at 2036 with anxiety. After obtaining labs and a psychiatric consult, Patient #19 was diagnosed with "Acute delusions likely decompensated schizophrenia." The decision was made to transfer Patient #19 to a local acute psychiatric hospital.

At the time of record review, the EMTALA transfer form was requested; however, it was discovered there was no transfer form in the medical record that would indicate what type of ambulance services were required, the risks and/or benefits of the transfer, why the transfer was indicated, who had accepted the transfer, and that the patient/representative had agreed to the transfer.

Review of the medical record for Patient #20 revealed she was a 9-month-old female who presented to the ED on 4/8/2022 at 0328 unresponsive. Mom stated the patient was watching TV in the living room when she left to fix her a bottle. Upon her return, the patient was sleepy and was difficult to rouse before becoming unresponsive. A narcotic prescription bottle was found in the living room. Patient #20 went into respiratory arrest and was intubated. Following labs and x-rays, the patient was diagnosed with hypoxic respiratory failure requiring mechanical ventilation; acute respiratory arrest; suspected opiate overdose. The decision was made to transfer her to the local children's hospital via ambulance.

At the time of record review, the EMTALA transfer form was requested and found to be partially completed. The form did not indicate what type of equipment would need to be used during transfer, the reason for transfer, and the signatures were dated but not timed. A parent did sign that they were informed of the risks and benefits of transfer; however, the risks and benefits of transfer were not found to be documented on the transfer form or in the medical record.

ED Director Staff E stated on 3/15/2023 at 1135 that the transfer form was very "physician driven." She provided a blank copy of the EMTALA transfer form that was titled by the facility as "Physician Authorization for Ambulance Transfer" and questioned whether it was not completed for patient #15 because the patient was transferred via private vehicle.

The ED Medical Director, Staff I, agreed in an interview on 3/16/2023 at 1150, that the EMTALA transfer forms should be filled out completely.

Facility document #2 ED 156 (COMP-RCC 5.16) titled "EMTALA - Emergency Medical Treatment and Labor Act" effective 7/15/2022 states, "With certification. The individual may be transferred if a physician or, should a physician not physically be present at the time of the transfer, another qualified medical person in consultation with a physician, has certified that the medical benefits expected from transfer outweigh the risks. The date and time of the certification should be close in time to the actual transfer. A certification that is signed by a non-physician qualified medical person shall be countersigned by the responsible physician within twenty-four (24) hours. Individual states have additional requirements for the content of the certification or memorandum of transfer. 2. When the Hospital transfers an individual with an unstabilized emergency medical condition to another facility, the transfer shall be carried out in accordance with the following procedures. a) The Hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual's health and, in the case of a woman who is having contractions, the health of the unborn child... c) The Hospital must send to the receiving facility copies of all pertinent medical records available at the time of transfer, including: (1) history; (2) records related to the individual's emergency medical condition; (3) observations of signs and symptoms; (4) preliminary diagnoses; (5) results of diagnostic studies or telephone reports of the studies; (6) treatment provided; (7) results of any tests; (8) the written patient consent or physician certification to transfer... d) The transfer must be affected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer.