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Based on interview and document reviews it was determined that the facility failed to ensure compliance with the responsibility to accept patients for specialized care that was within the facility's capability for one (#21) of twenty one sampled patients. This practice may cause a delay in emergency treatment that may lead to adverse outcomes.

Findings include:


1. Patient #21 presented to the transferring facility on 6/17/10 at 7:15 p.m. with a chief complaint of a cut to the right hand with a Chainsaw with an exposed tendon. Review of patient information revealed no payor source. Review of the Emergency Department (ED) physician documentation revealed the extensor tendon was completely visible and the patient had limited extension of the right 2nd digit. The documentation noted the wound was 8 centimeters in length, was heavily contaminated, and the extensor tendon was completely avulsed. The ED physician attempted to debride the wound but was unsuccessful.

The documentation showed at 8:30 p.m. the ED physician spoke to an on-call hand surgeon at receiving facility #1. The on call hand surgeon was informed the laceration was dirty with an extensor tendon laceration and would benefit from a surgical wash out and intra-operative repair. The hand surgeon refused the case.

Review of receiving hospital #2's operative note dated 6/18/10, the same day of transfer, revealed an exploration of wound, repair of right extensor indicis proprius and extensor digitorum communis of the index finger, extensor tendons, and repair of the right extensor carpi radialis longus tendon was performed.

A review of receiving facility #1's Emergency Department Incoming Transfer Log revealed the facility received a call from the transferring facility on 6/17/10 at 8:10 p.m., for a patient with a right hand laceration and right index extensor tendon damage. The disposition box stated Non Emergent with specific medical requirements for hand surgery. The log noted the reason the specialist on call did not come in was "not necessary".

Based on policy, on call logs, and clinical record review and interview it was determined that the facility failed to accept a transfer of one (#21) of twenty one sampled patients for whom it had the capacity and capability to provide specialized surgical care that was not available at the requesting facility. This practice may lead to a delay in patients receiving necessary specialized services for emergency medical conditions.

Findings include:

1. Patient #21 presented to the transferring facility on 6/17/10 at 7:15 p.m. with a chief complaint of a cut to the right hand with a Chainsaw with an exposed tendon. Review of patient information revealed no payor source. Review of the Emergency Department (ED) physician documentation revealed the extensor tendon was completely visible and the patient had limited extension of the right 2nd digit. The documentation noted the wound was 8 centimeters in length, was heavily contaminated, and the extensor tendon was completely avulsed. The ED physician attempted to debride the wound but was unsuccessful. The transferring ED physician noted the on call orthopedic physician at the transferring facility did not provide hand care and the patient would need to be transferred.

The documentation showed at 8:30 p.m. the ED physician spoke to an on-call hand surgeon at receiving facility #1. The on call hand surgeon was informed the laceration was dirty with an extensor tendon laceration and would benefit from a surgical wash out and intra-operative repair. The hand surgeon refused the case and advised the transferring ED physician to transfer the patient to another facility that the hand surgeon recommended and the hand surgeon would see the patient in the office. Transferring ED physician documentation at 10:20 p.m. revealed the patient was accepted by a hand surgeon in another county at receiving hospital #2.

Review of receiving hospital #2's triage record revealed the patient presented via ambulance on 6/18/10 at 12:22 a.m. Review of the hand surgeon's consult dated 6/18/10 revealed the patient was right hand dominant and suffered a laceration to the dorsum of the right hand with tendon injury. The plan was to take the patient to surgery for irrigation and debridement, wound exploration, and extensor tendon repair. Review of the Operative note dated 6/18/10, the same day of transfer, revealed an exploration of wound, repair of right extensor indicis proprius and extensor digitorum communis of the index finger, extensor tendons, and repair of the right extensor carpi radialis longus tendon was performed.

Review of the hand surgery on-call schedule from receiving facility #1 for June 2010 revealed a hand surgeon was on call the evening the transferring facility requested the transfer.

A review of receiving facility #1's Emergency Department Incoming Transfer Log revealed the facility received a call from the transferring facility on 6/17/10 at 8:10 p.m., for a patient with a right hand laceration and right index extensor tendon damage. The disposition box stated Non Emergent with specific medical requirements for hand surgery. The log noted the reason the specialist on call did not come in was "not necessary".

Interview with the ED Medical Director on 7/7/10 from receiving hospital #1 revealed if s/he was presented with a similar situation, a debridement of the wound, simple sutures and a referral to a hand surgeon would be conducted. The Medical Director indicated if the patient had an avulsed extensor tendon, that although it is a serious injury, extensor tendons can be repaired weeks after the injury with full recovery. The Director also explained that if there was an inability to debride the wound fully, the patient would be admitted to the medical services with intravenous antibiotics with a referral to the hand surgeon.

Review of receiving facility #1's Policy for Transfer Acceptance of Patient to the Emergency Department and Incoming Transfer Activity, policy # ED 143, reviewed on 5/10, revealed the facility shall not refuse to accept any medically necessary individual from another hospital. Under definitions listed in the policy an Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity, which may in the absence of immediate medical attention could reasonably be expected to result in serious impairment to bodily functions.