HospitalInspections.org

Based on review of the facility policies and procedure, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review ,transferring hospital (Hospital B and Hospital C) Medical Record (MR), receiving hospital (Hospital D) MR, ambulance run report(s), facility Transfer Line Log, Transfer Services Record/Case Summary, facility Transfer Line audio files, facility Vascular Surgery Call Schedule, facility Spine and Neuro (Neurological) Center Call Schedule, facility STICU (Surgical Trauma Intensive Care Unit), 8 MST Unit (Neurosurgical unit) and 8 NE Unit (Neurological Intensive Care Unit) bed census documentation, and interviews, it was determined Huntsville Hospital (HH), Hospital A, 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.

2. Ensure the staff implemented steps to prevent a patient with Suicidal Ideation (SI) from leaving prior to receiving stabilizing treatment, including placement of the patient in a safe environment area with safe attire, placement of a blue suicide precaution armband and the initiation of 1:1 observation and/or constant observation with documentation of the patient's behavior per the facility policy, including PI # 8.

3. Inform patients who refused to consent to a MSE of the risks and benefits to the individual of the examination, including Patient Identifier (PI) # 16 and PI # 15.

4. Accept appropriate transfers from referring hospitals (Hospital B and Hospital C), of:

a. PI # 22, who was experiencing a Right Lower Occlusion of the Popliteal Femur Area with no pulse to the extremity, and required HH 's specialized capabilities. HH had the capability and capacity to treat PI # 22, when contacted by the transferring hospital (Hospital B) which did not have the capability of treating PI # 22.

b. PI # 23, who had a Brain Mass with new onset of Seizures, and required HH's specialized capabilities. HH 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.

Findings Include:

Refer to A 2406, A 2407 and A 2411 for findings.

Based on review of the facility policy, Medical Staff Bylaws and Rules and Regulations, Medical Record (MR) review and interviews with staff it was determined the facility failed to 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 had the potential to affect all patients served by the facility ED.

Findings include:

Facility Policy: Medical Screening Guidelines
Revised Date: 7/20

I. Guideline

1. Every patient who presents for treatment receives a MSE. ED Physician, ED Nurse Practitioners (CRNP), ED Physician Assistants (PA) and Private Physicians on the Medical Staff may perform screening exams....

The facility bylaws and rules and regulations were received from Employee Identifier (EI) # 3, Coordinator of Regulatory Affairs and Accreditation, on 8/10/21.

Review of the facility bylaws and rules and regulations on 8/10/21 revealed no documentation to identify and approve the individual(s) qualified to perform the MSE in the ED.

An interview was conducted with EI # 2, Executive Director of Quality, on 8/12/21 at 11:35 AM who confirmed there was no documentation to identify and approve the individual(s) qualified to perform the MSE in the facility Medical Staff Bylaws and Rules and Regulations.

Based on review of facility policies and procedures, medical records (MR), and interview with staff, it was determined the facility failed to:

1. Ensure the staff implemented steps to prevent a patient with Suicidal Ideation (SI) from leaving prior to receiving stabilizing treatment, including placement of the patient in a safe environment area with safe attire, placement of a blue suicide precaution armband and the initiation of 1:1 observation and/or constant observation with documentation of the patient's behavior per the facility policy.

2. Inform patients who refused to consent to a MSE of the risks and benefits of the examination.

This deficient practice affected 1 of 2 MR's reviewed with SI, including Patient Identifier (PI) # 8 and 2 of 3 MR's reviewed who left the ED without being seen, including PI # 16 and PI # 15 and had the potential to affect all patients served by the facility Emergency Department (ED).

Findings include:

Facility Policy: Preventing Suicide
Revised Date: 1/16/2020

I. Purpose

A. The purpose of this policy is to identify patients at risk for suicide through screening and assessment. If results are positive for suicide ideation (low, moderate, high) implement processes to help prevent patients from harming themselves...

...IV Procedure:

...K. Implementing Suicide Precautions

...2. Immediately provide safety for the patient by evaluating...their room...

...d. Utilize the Non Dedicated Patient Room Item Removal Checklist as a guide to identify possible risk in the patient room....

...4. Place a blue "suicide precaution" armband on patient.

...VI. Sitter for 1:1 (1 to 1) Continuous Observation

...E. Both nurse and sitter perform observation and search of room for safety hazard items each shift and as needed.

1. Hazardous items are removed from patient's room - refer to "Non Dedicated Patient Room Item Removal Checklist"...

F. Both nurse and sitter verify blue armband for suicide precautions is on patient and patient is dressed in safe attire.

1. Adults: hospital issued attire...

...N. Sitter is to document on the observation form at a minimum at the beginning of each shift, the end of each shift, with any significant events, and any transports to other areas. Record observations of the patient's behaviors, actions and/or their comments/speech as indicated...

...VII. Patient Educations and Discharge

A. For patients placed on suicide precautions during hospitalization, reassess patient for suicide risk prior to discharge...

...VIII. Documentation

...B. Implementation of suicide precautions and 1:1 observation.

C. 1:1 observation on the observation form.

D. The presence of a safety attendant/sitter for patients on suicide precautions (initiated, continued or discontinued).

E. Self-harm items removed per checklist.

...G. The presence of the suicide precaution blue armband is placed/present on patient.

Facility Policy: Sitter for Continuous Observation
Revised Date: 12/10/19

I. Purpose/Guideline:

A. To prevent self-harm by providing continuous 1:1 observation for patients who have been identified as a safety risk.

B. This includes patients who may be at high risk for suicide, fall or elopement...

II. Procedure

A. For all patients: once patient has been identified at risk or when an order is received for a sitter from a provider: ... At Huntsville Hospital Main...: notify charge nurse and staffing office of need for sitter....

Facility Policy: Patient Redirection
Revised Date: 7/20

I. Guideline/Purpose:

...2. The hospital provides an appropriate, uniform medical screening for every patient who comes to the hospital, to determine whether the patient exhibits and emergency medical condition (EMC) as defined by EMTALA (Emergency Medical Treatment and Labor Act).

3. According to the policy developed by the Hospital Medical Staff and approved by the Health Care Authority...a Physician, ED Mid Level Practitioner...performs the initial medical screening for all patients who present to the ED...following priority codes as guidelines for such redirection...Priority 2 Emergent...

Facility Policy: Divert/Transfer
Revised Date: 7/8/19

I. Policy: The following is the policy...related to: the medical screening examination...of emergency patients.

A. EMTALA...All persons presenting for emergency care at Huntsville Hospital....will be considered to have "come to the Hospital" if a request is made by the individual or on the individual's behalf for emergency medical care and shall receive a MSE within the capabilities of the Hospital and the ancillary services routinely available at the Hospital, including examination...

1. PI # 8 presented to the facility ED via ambulance on 4/25/21 at 9:24 PM with a chief complaint of "dog bite...3 wks (weeks) ago from police dog. pt (patient) also state (he/she) is having suicidal thoughts and wants to be checked out."

Review of the ED Triage dated 4/25/21 at 9:30 PM revealed documentation revealed the following Columbia-Suicide Severity Rating Scale (CSSRS) scale:

"1. CSSRS Wish to be Dead: Lifetime, yes

2. In past month, have you actually had thoughts about killing yourself?...: Yes

3. In past month, have you been thinking about how you might kill yourself?...: Yes

4. In past month, have you had these thoughts and had some intention of acting on them?...: Yes

5. In past month, have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?...: Yes

6.. Have you ever done anything, started to do anything, or prepared to do anything to end your life?...: Yes In past 3 Months, have you done anything, started to do anything, or prepared to do anything to end your life? : No

CSSRS Suicide Risk Level: Moderate"

Review of the ED Certified Registered Nurse Practitioner (CRNP) Note dated 4/25/21 at 9:25 PM revealed documentation of "...PMHx (Prior Medical History) of Depression, Anxiety, Asthma and Substance Abuse who presents to the ER (Emergency Room) with...concern for infected dog bite and suicidal thoughts...states that (he/she) needs mental help...states that (he/she) needs help for (his/her) depression and needs to be 'placed in a facility somewhere like (Hospital Identified). When questioned further (he/she) states that (he/she) needs this because (his/her) depression is going to make (him/her) end (his/her) life or someone else's especially if (he/she) can't get to food or water...Mental Status: Speech clear, oriented x 4, flat affect, responds appropriately...Diagnoses this visit: Depression...Psychiatric Problem..."

Review of the Patient Care Order dated 4/25/21 at 9:36 PM revealed documentation of an order for 1:1 Observation and Suicide Precautions due to the patient answering yes to "...have you had these thought and had some intention of acting on them?" There was no documentation the patient was placed on 1:1 observation, the patient's room was evaluated for safety, of a Non Dedicated Patient Room Item Removal Checklist, a blue "suicide precaution" armband was placed on the patient and patient safety checks were completed per the order.

Review of the Suicide Risk Assessment dated 4/25/21 at 9:43 PM revealed intensity of ideation documentation as "1. How many times have you had these thoughts? : Two to five times a week. 2. When you have the thoughts how long do they last? : More than eight hours, persistent or continuous. 3. Could/can you stop thinking about killing yourself or wanting to die if you want to? : Can control thoughts with a lot of difficulty. 4. Are there things, anyone or anything...that stopped you from wanting to die or acting on thoughts of committing suicide? : Deterrents definitely stopped you from attempting suicide. 5. What sort of reason did you have for thinking about wanting to die or killing yourself? ....: Mostly to end pain, can't go on living with pain or feelings...Lifetime Intensity of Ideation Subscale...: 17. CSSRS Suicide Risk Level: Moderate"

Review of the ED Physician Note dated 4/26/21 at 1:29 AM revealed documentation of "...history of depression, presents (to) ED with...worsening depression/SI...does endorse SI...denies a specific plan to me. On my initial evaluation (he/she) is disheveled appearing..."

Review of the Psychosocial Intake Assessment dated 4/26/21 at 5:10 AM revealed documentation of "...presents to the ED with Depression...Pt has depression that is ongoing as well as SI. Pt denied SI currently but indicated having SI frequently (2 - 5 x's) during the week. Pt stated to...ED physician that (he/she) needed admission to a mental facility for (his/her) depression and if he could (couldn't) get in that it would cause him to end his life or someone elses....Pt was void of psychosis...currently unmedicated and void of mental health services...void of AVH (Auditory and Visual Hallucinations) and denied SI or HI (Homicidal Ideation). Pt continues to desire psych (psychiatric) admission...Pt denied SI at time of screening but states that (he/she) is having SI frequently during the week... Speech: Appropriate...Judgement: Fair...Patient Behavior: Cooperative, Suicidal Statements...Pt was meically (medically) cleared and recommended for admission per (Psychiatrist Identified) voluntarily..."

Review of the Patient Care Orders dated 4/26/21 at 6:30 AM revealed an order for Suicide Precautions order by the Psychiatrist, a blue armband to be placed on the patient due to the order of Suicide Precautions, patient safety checks to be completed due to the order of Suicide Precautions. There was no documentation the patient's room was evaluated for safety, of a Non Dedicated Patient Room Item Removal Checklist, a blue "suicide precaution" armband was placed on the patient and patient safety checks were completed per the order.

Review of the ED Nursing Note dated 4/26/21 at 6:34 PM revealed documentation of "pt (patient) eloped and seen walking out of ED at 1808 (6:08 PM) with steady gait...had been verbalizing to staff multiple times throughout the day that (he/she) wished to leave after waiting...for a Behavior Health Unit admission bed. (Physician Identified) had been aware of the patient stating these thoughts throughout the day. (Physician Identified) was seen at bedside at 1411 (2:11 PM) discussing the stay with patient. Attempted to call MD (Medical Doctor)...unable to reach the MD to make...aware of the patient elopement. Security made aware of patient just in case patient had stepped outside but has not been able to locate patient...." There was no documentation of the "multiple times throughout the day..." the patient had expressed a wish to leave the ED and the physician was notified of the patient's desire to leave the ED.

Review of the ED Disposition Documentation dated 4/26/21 at 6:43 PM revealed documentation the patient eloped.

Review of the Psychiatrist History and Physical signed 4/26/21 at 6:49 PM revealed documentation of "...Patient seen and evaluated this afternoon in the ED....reported of suicidal thoughts and severe depression...denies any auditory or visual hallucinations...reports poor sleep, nightmares, intrusive memories and flashbacks of prior trauma in (his/her) childhood...Mental Status Examination: ...Eye contact: decreased...Mood: Depressed, at times anxious Affect: Depressed Thought Process: Linear and goal-directed Thought Content: Depressive cognitions...SI without a plan...Insight/Judgment: fair...Assessment/Plan 1. Major depression, recurrent...start Lexapro for depression. Start Seroquel for mood stabilization and augmentation in the treatment of Depression....Follow agitation protocol as needed. 2. PTSD (Post-Traumatic Stress Disorder) 3. Cannabis Use Disorder, Severe, Dependence. 4. Methamphetamine Abuse..."

Review of the Psychiatrist Discharge Documentation dated 4/27/21 at 2:59 PM revealed documentation of "...During the assessment in the ED patient stated that (he/she) does not have suicidal intent. Prior to this admission (he/she) however had reported that (he/she) was having some vague SI. I have reassured (him/her) that (he/she) would be admitted in the inpatient unit once a bed is open...I was later informed by the ED nursing staff that patient had eloped. Security has been made aware. They have not been able to locate the patient. Per nursing staff patient had asked to leave the hospital multiple times as (he/she) has been waiting here for a long time...Patient had eloped... Discharge Condition...Patient had refused care and had left the ED...Patient was not seen at the time of discharge. Patient had eloped. "

The facility staff failed to implemented ordered Suicide Precautions to include 1:1 observation, ensuring the patient's room was safe per the use of the Non Dedicated Patient Room Item Removal Checklist, a blue armband was placed on the patient and safety checks were completed, which allowed the patient with expressed SI to elope from the ED.

An interview was conducted on 8/11/21 at 4:27 PM with Employee Identifier (EI) # 1, ED Director, who confirmed there was no documentation the patient was placed on Suicide Precautions, 1:1 observation and patient safety checks were performed. EI # 1 also verbalized the patient was in a regular ED room and not the rooms designed for a psychiatric patient to be safe rooms.

2. PI # 16 presented to the facility ED on 6/23/21 at 10:41 PM with a chief compliant of "heart racing and syncopal episode x (times) 2 hours ago, denies cardiac history, extreme alcoholic tried not to drink a couple of days and then started again today and got extreme nausea and passed out, states (she/he) has had at least 12 glasses of wine pta (prior to arrival)"

Review of the ED triage dated 6/23/21 at 10:52 PM revealed a Tracking acuity of 2.

Review of the Disposition Documentation dated 6/23/21 at 11:45 PM revealed nursing documentation of "pt (patient) reporting that (she/he) wanted to go to another hospital. Ambulatory to the car w/(with) an even gait and no acute distress noted at time of leaving. Even and equal respirations while at the ER (Emergency Room) lobby desk."

There was no documentation PI # 16 who refused to consent to a MSE was informed of the risks and benefits to the individual of the examination.

An interview was conducted with EI # 6, Registered Nurse, on 8/12/21 at 8:54 AM. EI # 6 was asked can you tell me the facility policy/procedure for when a patient and/or caregiver reports to you and/or staff they want to leave without being seen and go to another hospital? EI # 6 stated, "...we encourage them to stay, if they refuse we document what they say and let them leave. EI # 6 was asked do you ever explain risk/benefits of staying for MSE? EI # 6 stated, "no, not as nursing staff. That would be the CRNP (Certified Registered Nurse Practitioner)." EI # 6 was asked if he/she recalled PI # 16? EI # 16 stated, "I do. (She/He) came in and said (she/he) had 2 syncopal episodes after drinking. (She/He) did come to the desk and said (she/he) was going to another hospital. I didn't notice anything acute, so (she/he) walked out to an exit door and that was it. (She/He) walked outside to (her/his) ride."

An interview was conducted with EI # 1, ED Director, on 8/11/21 at 4:15 PM who confirmed there was no documentation PI # 16 was informed of the risks and benefits of leaving prior to the completion of the MSE by the ED staff who observed the patient leave.

3. PI # 15 presented to the facility ED on 6/23/21 at 6:16 PM with a chief complaint of "...having chest pain and tightness..."

Review of the ED triage dated 6/23/21 at 6:31 PM revealed a Tracking acuity of 2.

Review of the Disposition Documentation dated 6/23/21 at 7:59 PM revealed nursing documentation of "...left without being seen...ED reason for leaving: wait too long...pt to f/u (follow up) with PMD (Primary Medical Doctor) tomorrow."

There was no documentation PI # 15 who refused to consent to a MSE was informed of the risks and benefits of the examination.

An interview was conducted with EI # 1 on 8/12/21 at 8:15 AM who confirmed the above documentation did indicate the ED staff were aware of PI # 15 plan to leave the ED without the MSE completion and there was no documentation PI # 15 was informed of the risks and benefits of leaving prior to the completion of the MSE by the ED staff who observed the patient leave.

Based on review of the transferring hospital (Hospital B and Hospital C) Medical Record (MR), receiving hospital (Hospital D) MR, ambulance run report(s), facility Transfer Line Log, Transfer Services Record/Case Summary, facility Transfer Line audio files, facility Vascular Surgery Call Schedule, facility Spine and Neuro (Neurological) Center Call Schedule, facility STICU (Surgical Trauma Intensive Care Unit), 8 MST Unit (Neurosurgical unit) and 8 NE Unit (Neurological Intensive Care Unit) bed census documentation, and interviews, it was determined Huntsville Hospital (HH), Hospital A, refused to accept from referring hospitals (Hospital B and Hospital C) an appropriate transfer, of:

1. Patient Identifier (PI) # 22, who was experiencing a Right Lower Occlusion of the Popliteal Femur Area with no pulse to the extremity, and required HH 's specialized capabilities. HH had the capability and capacity to treat PI # 22, when contacted by the transferring hospital (Hospital B) which did not have the capability of treating PI # 22.

2. PI # 23, who had a Brain Mass with new onset of Seizures, and required HH's specialized capabilities. HH 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.

This deficient practice affected 2 of 2 emergency transfer requests reviewed, who were appropriate for transfer to the facility and, which HH had the capability and capacity to treat. This did affect PI # 22 and PI # 23, and had the potential to affect all patients with a request for transfer to HH.

Findings include:

1. Hospital B (transferring hospital) documentation:

PI # 22 presented to Hospital B's emergency department (ED) on 5/29/21 at 2:27 PM with a chief complaint of "my left kidney is hurting and I am weak..."

Review of the Triage note dated 5/29/21 at 2:43 PM revealed documentation of "...patient states: my left kidney is hurting and I am weak. I went to (the) doctor last week and they told me I was dehydrated and had kidney infection. I have been drinking Gatorade and sometimes I keep it down and sometimes I vomit. They gave me (a) stomach pill and antibiotic but I am not getting better...General: Appears uncomfortable, Behavior is anxious. Pain: Complains of pain in back. Pain began 1 week ago. Noted to be grimacing, guarding, moaning, restless..."

Review of the nursing assessment dated 5/29/21 at 3:09 PM revealed documentation of "...pt (patient) received 2nd dose of Moderna COVID vaccine on May 5, 2021. Reports (she/he) has been sick since that time."

Review of the nursing assessment dated 5/29/21 at 3:10 PM revealed documentation of "...appears uncomfortable, behavior is restless. Pain: complains of pain in right leg and back..."

Review of the laboratory (lab) testing dated 5/29/21 at 3:22 PM revealed the following abnormal values: Blood Urea Nitrogen 31 (normal 7 - 18), Creatinine 1.6 (normal 0.6 - 1.3), Calcium 11.9 (normal 8.5 - 10.1), White Blood Cells 13.7 (normal 4.6 - 10.2), Hemoglobin 14.6 (normal 12.0 - 14.1), Platelets 473 (normal 142 - 424), Neutrophil 10.90 (normal 1.96 - 4.95), Monocytes 1.02 (normal 0.25 - 0.71) and Eosinophils 0.00 (normal 0.05 - 0.35).

Review of the Urinalysis lab testing dated 5/29/21 at 3:38 PM revealed the following abnormal values: Clarity Slight Hazy (normal clear), Leukocytes 1 + (normal negative), Protein 2 + (normal negative), Bilirubin 1 + (normal negative), White Blood Cells 5 - 10 (normal 0), Squamous Epithelial Cells 10 - 20 (normal negative) and Bacteria Moderate (normal negative).

Review of the Electrocardiogram (EKG) dated 5/29/21 at 3:51 PM revealed documentation of "Atrial Fibrillation (A. Fib) with Rapid Ventricular response (RVR) with premature Ventricular or aberrantly conducted complexes..."

Review of the Physician note dated 5/29/21 at 4:13 PM revealed documentation of "...presents to ER...with complaints of general weakness, possible Dehydration/Body Aches...muscle aches, malaise and mild cough...reports symptom began 4-5 days (ago)...recently being treated for UTI and finished Macrobid...Fully vaccinated for COVID on May 05. 2021..."

Review of the Physician note dated 5/29/21 at 8:11 PM revealed documentation of "...HH called and declined transfer at 1824 (6:24 PM). Pt accepted at (Hospital D, Receiving Hospital Identified)...at 2005 (8:05 PM)...spoke with Vascular Surgery and they agree pt can come to (Hospital D Identified). Heparin was initiated in ER (Emergency Room)."

Review of the Physician note dated 5/29/21 at 8:15 PM revealed documentation at approximately 7:00 PM the patient began complaining of right lower leg pain and upon physician assessment the right lower leg was "...discolored and pale. I felt no pedal or popliteal pulse. Right femoral pulse is faint..."

Review of the Disposition Summary dated 5/29/21 at 8:11 PM revealed PI # 22 was transferred to Hospital D with diagnoses including Stricture of Artery and Unspecified A. Fib.

Hospital A, Huntsville Hospital (HH) documentation:

Review of the facility Transfer Log documentation revealed documentation of a transfer request from Hospital B on 5/29/21 at 7:14 PM, which was denied by Vascular Surgery due to "...referred to local resource..."

Review of the Vascular Surgery Call Schedule dated 5/29/21 revealed documentation Employee Identifier (EI) # 4 was the on-call Vascular Surgeon for the facility.

Review of the Transfer Services Record/Case Summary documentation revealed documentation the facility received a call from Hospital B on 5/29/21 at 7:14 PM for PI # 22, who had a "...Right Lower Occlusion in the Popliteal (Pop) - Femur area...no pulse to extremity. Patient presented with generalized weakness and found to have Af with RVR (Atrial Fibrillation with Rapid Ventricular Response). Pt (patient) was going to be admit (admitted) locally unitl (until) pt started complaining or (of) leg pain...pt treatment heparin drip..."

Further review of the Transfer Services Record/Case Summary documentation dated 5/29/21 at 7:14 PM revealed documentation EI # 4 "...declined stating there are closer facilities with vascular surgery. I did (do) not wish to speak with referring facility but will if they push back..." and PI # 22 was declined for "...referred to local resource..."

Review of the Transfer Line audio file and transcript for the called dated 5/29/21 at 7:14 PM revealed the following information:

EI # 4 was called by the facility Transfer Line staff and told the facility received a transfer request call from Hospital B on "...a patient over in (Hospital B Identified). Evidently they do not have Vascular Surgery available... patient came in with general weakness, they were found to have Atrial Fib (Fibrillation) with RVR and they were going to admit them for that locally. Then the patient started complaining of lower leg pain. They believe the patient has a right lower occlusion somewhere around the pop-femur area. The patient does not have a pulse in the extremity. This is by clinical exam. I think (he/she) told me that this was by ultrasound but they did not do a CTA (Computed Tomography Angiography). "

EI # 4 replied, "that's not part of our catchment area...you know, there are other places closer than here...We drag stuff in from all over the place that's in our system, and I take it. It isn't part of our system...So, there are other vascular surgeons between here and there that can take it..." EI # 4 then asked the Transfer Line staff if the facility had ICU (Intensive Care Unit) beds available, to which the Transfer Line staff replied, "I do have some SICU (Surgical ICU) beds....I have...two..."

EI # 4 then replied, "no, I mean, it's not part of our catchment area..." and identified other facilities Hospital B could try and transfer the patient too. EI # 4 then stated, "I mean, that's it. If there's an issue the hospital can talk to me about it..."

The facility Transfer Line staff then called Hospital B to notify Hospital B of the declined transfer request and inform Hospital B staff of the other facilities to try and transfer too named by EI # 4.

Review of the STICU (SICU Unit name) bed census for 5/29/21 at 7:14 PM revealed documentation the unit had 1 bed available.

Interviews:

An interview was conducted on 8/11/21 at 3:24 PM with EI # 3, Coordinator of Regulatory Affairs and Accreditation, who verbalized, PI # 22 would have been placed in the SICU (STICU) if the transfer request would have been accepted.

An interview was conducted on 8/12/21 at 9:25 AM with EI # 4, HH, On Call Vascular Surgeon, who was asked reasons you might decline a transfer request? EI # 4 stated, "If we don't have the capacity to handle what's wanting to be transferred, especially with Covid. It's only me on call, if I can't get to that call in an expeditious/timely manner, that would be another reason to decline." EI # 4 was asked about the transfer request call on 5/29/21 for PI# 22. EI # 4 verbalized he/she had scheduled cases that day and had "...just gotten caught up..." so he/she asked where the transferring facility could normally transfer patients. After being told where the transferring facility would normally transfer a patient, EI # 4 verbalized the transferring facility had not called the other facility to see if they were on diversion or had availability and to call back if not an option.

An interview was conducted via email on 8/16/21 at 3:07 PM with EI # 3, who confirmed per the Chief Nurse the facility STICU did have adequate staffing on 5/29/21 at 7:14 PM.

A second interview was conducted via email on 8/18/21 at 11:03 AM with EI # 3 who confirmed per the Unit Director, STICU did have 1 bed available on 5/29/21 at 7:14 PM.

Ambulance Run Report:

Review of the Ambulance Run Report dated 5/29/21 revealed:

The ambulance was dispatched to Hospital B, transferring hospital at 8:20 PM.

At 8:26 PM, the ambulance left Hospital B enroute to Hospital D, Receiving Hospital.

Review of the narrative section revealed documentation of "...pt (patient) came in today not feeling well... Pt skin pink W&D (warm and dry) except for right leg and it was cool and pale...pt had a new onset of A-Fib (Atrial Fibrillation) when (she/he) got the ER (Emergency Room). After being in ER for awhile pt began having pain to right leg. Pt right leg was cool pale and pulseless... Pt in lots of pain, from right leg. Pt right leg was cold white and had no pulse in it. Pt sill in A-Fib...."

PI #22 arrived at 9:51 PM (10:51 PM for Hospital D due to time zone) to Hospital D.

Hospital D, Receiving Hospital:

PI # 22 arrived at Hospital D via ambulance on 5/29/21 with a chief complaint of "...right leg pain since this am. Right lower leg pale, cool and no pulse. Heparin and Cardizem drips infusing on arrival...."

Review of the Triage assessment dated 5/29/21 at 10:54 PM revealed documentation of pain in the right upper leg at a 10 on a 1-10 scale. Patient was assigned an Acuity code of "...1 - Resuscitation".

Review of the nursing assessment dated 5/29/21 at 10:56 PM revealed documentation of "...Dorsalis Pedis Pulse, Right: 0 Absent...Right Posterior Tibial: 0 Absent..."

Review of the ED Physician note dated 5/29/21 at 11:00 PM revealed documentation of "...presents for evaluation as a transfer from (Hospital B identified) for Atrial Fibrillation and right lower extremity Acute Arterial Thrombosis... medications Cardizem IV (intravenous) 100 mg (milligrams) + (plus) Sodium Chloride 0.9 % IV solution 100 ml (milliters): 5 ml/hr (milliters per hour)...Heparin IV 25,000 Units...250 ml...Cardiovascular: Regular rate and rhythm,...right leg is pale, cold, right leg from the knee to the foot is cold, pale, with diminished sensation, Arterial pulse: Right, popliteal, posterior tibial, dorsalis pedis, absent...Telemetry shows fibrillation in the 150s... Vascular Surgeon (Physician identified) present on patient's arrival to the ED, and agreed with previous assessment that (she/he) likely has an Arterial Thrombus in the right lower extremity. (She/He) is pale and cold from the knee down to the foot, decreased sensation in the foot. (She/He) will be restarted on Heparin and Cardizem drips, and admitted to the ICU (Intensive Care Unit) to the Hospitalist...Critical Care Note...treatment response: Improved with interventions, but still critical...Diagnosis...Atrial Fibrillation (A. Fib) with RVR, right lower extremity Arterial Thrombus..."

Review of the ED nursing note dated 5/29/21 at 11:18 PM revealed documentation of "...2305 (11:05 PM) pt to surgery..."

Review of the History and Physical dated 5/30/21 at 3:59 AM revealed documentation of "patient is...s/p (status post) R (right) Fem (Femoral) Embolectomy and Fasciotomy...transferred here for vascular surgery evaluation and has undergone emergent surgery...Condition: Guarded...Impression and Plan...New onset A. Fib with RVR...Ischemic RLE (Right Lower Extremity) s/p R Fem Embolectomy and Fasciotomy...Lactic Acidosis sec (secondary) to Limb Ischemia...Leukocytosis likely reactionary..."

Review of the Discharge Summary revealed the patient was discharged on 6/7/21.

2. Hospital C (transferring hospital) documentation:

PI # 23 presented to the ED via ambulance on 7/14/21 at 7:58 AM with a chief complaint of Seizure.

Review of the Triage note dated 7/14/21 at 7:58 AM revealed documentation of "pt in...for eval (evaluation) of Sz (Seizure) like activity that happened this AM (morning)...pt was diagnosed with a tumor to Right Frontoparietal region of the brain. Pt experiencing L (left) sided weakness that has gotten worse this weekend which is why pt had MRI of brain done. Pt also has Sarcoma under belly button that (she/he) had radiation x (times) 33 txs (treatments) last May..."

Review of the ED Physician note dated 7/14/21 at 8:18 AM revealed documentation of "...presents with a history of having a seizure this morning...has had left-sided weakness for about 2 days...went (to) a local urgent care clinic yesterday and they scheduled an outpatient MRI (Magnetic Resonance Imaging) that showed a brain mass....came in today because of the seizure....said that they were trying to get her into see one of the neurosurgeons in town. The MRI report revealed a large right-sided brain mass with cerebral edema and mild shift...does have a history of Fibrosarcoma...treated here with radiation operation for this Fibrosarcoma that was diagnosed last year. It was on the abdominal wall...Grand mal seizure that initially began as a focal seizure involving (her/his) left arm and leg...Neuro: Cranial nerves grossly intact, motor and sensory grossly normal except: mild to moderate left-sided weakness....could lift (her/his) arm and leg up off the bed but it was weaker than the right side...decreased sensation involving...left upper and lower extremity..."

Further review of the ED Physician note dated 7/14/21 at 8:18 AM revealed documentation of "patient was given Keppra and Decadron. Reviewed the MRI. Patient has a 5 cm (centimeter) Right Frontoparietal mass that is heterogeneous. It appears the (to) have some vasogenic edema and there is a slight shift noted. It appears to be extra-axial...labs are unremarkable. I spoke with...neurosurgeon. (He/She) reviewed the MRI and recommended the patient be transferred to (Hospital E, Recommended Receiving Hospital Identified). Over the next several hours I attempted to get the patient transferred to another facility. I spoke with the surgeon...at (Hospital E Identified)....They did not have any beds...recommended admission to a facility that could care for the patient appropriately in case (she/he) worsens in any way. Patient did not want to leave the state...neurosurgeon at Huntsville recommended (she/he) stay here and then go to (Hospital E Identified) with no beds available. That is what we are going to do. I redosed (her/him) with Decadron while here. (She/He)...felt like...left side was getting weaker...I contacted (Facility Neurosurgeon Identified)...consult on patient. Also spoke with (facility Hospitalist identified) multiple times and case management will be consulted to help with transfer of the patient when it becomes available at Hospital E...The patient was admitted, I was contacted by (Hospital E, Neurosurgeon Identified) and (he/she) felt like the patient could follow up outpatient with (him/her) in...office preferably tomorrow..."

Review of the History and Physical dated 7/14/21 at 2:12 PM revealed documentation of "...prior high-grade Fibrosarcomatous Dermatofibrosarcoma Protuberans excised as a mass from abdominal wall in 2020 (7.5 cm in size) who presented to the ED after a seizure this morning....been having worsening 'migraine' headaches for the last few months, culminating in an odd progressive left-sided weakness for about 2 days...went to a local urgent care clinic yesterday and they scheduled an outpatient MRI that showed a large right-sided brain mass with cerebral edema and mild shift...says they were trying to get (her/him) in to see Neurosurgery...began having tremorous spells of...right hand that would resolve on it's own, but ultimately progressed into a full blow (blown) seizure. (Spouse) reports (he/she) just went back to get something & (and) found (her/him) on the ground. I guess seizing. ED physician has called (Hospital E, Recommended Receiving Hospital Identified)...and Huntsville attempting transfer. Waiting on possible bed at (Hospital E Identified) with Neurosurgery...Neurosurgery here is following as well...await bed...CM (Case Management) consult to help facilitate with urgent transfer. Ultimately after admission I received word back from (ED Physician Identified) that (Hospital E, Neurosurgeon Identified) would prefer (PI # 23) follow up with (him/her) in (his/her) office tomorrow...if possible...Plan: steroids...Keppra...Seizure Precuations (Precautions) and Neuro checks...if seems fesable (feasible)/safe could tentatively plan to see if we can DC (discharge)...in the am to be driven to appt (appointment) with (Hospital E, Neurosurgeon Identified). I personally feel this should work well. If no seizures overnight and if able to make the trip, then will...plan on an early am DC..."

Review of the ED notes dated 7/14/21 at 3:00 PM revealed documentation the patient was admitted to the facility ICU with diagnoses including, Left-Sided weakness, Brain Mass, Seizure and Cerebral Edema.

PI # 23 was discharged from the facility on 7/15/21 with a same day follow up appointment with a Neurosurgeon at Hospital E.

Hospital A, Huntsville Hospital (HH) documentation:

Review of the facility Transfer Log documentation revealed documentation of a transfer request from Hospital C, Transferring Hospital, on 7/14/21 at 1:16 PM, which was denied by Neurosurgery due to "...requires resource closer to referring..."

Review of the Vascular Surgery Call Schedule dated 7/14/21 revealed documentation Employee Identifier (EI) # 5 was the on-call Neurosurgeon for the facility.

Review of the Transfer Services Record/Case Summary documentation revealed documentation the facility received a call from Hospital C on 7/14/21 at 1:16 PM for PI # 23, "...pt has been having left sided weakness for a few days, came to ER today with seizures, pt had outpatient MRI yesterday which shows brain mass, no hx (history) of seizures. pt had Fibro Carcinoma removed from abd (abdominal) wall less than 1 year ago. Radiologist called mass a meninioma. (Referring MD Identified) spoke with NS (Neurosurgeon) at (Hospital E, Recommended Receiving Hospital Identified), and NS at (Hospital C Identified) and they are concerned that this mass could be a result of the carcinoma. Pt has shift and edema. 6 cm extra axial appearing Right Parietal heterogeneous contrast enhancing mass..."

Further review of the Transfer Services Record/Case Summary documentation dated 7/14/21 at 1:16 PM revealed documentation EI # 5 discussed the case with Hospital C Physician and reviewed imaging results performed at Hospital C then verbalized "...would prefer for patient to be put on steroid and sent to Hospital E tomorrow...let oncology follow up with patient and call Hospital E tomorrow and see if they have any available beds..." and PI # 23 was declined for "...requires resource closer to referring..."

Review of the Transfer Line audio file and transcript for the called dated 7/14/21 at 1:16 PM revealed the following information:

EI # 5 spoke with the ED physician at Hospital C and was provided the following information on PI # 23 "...got a brain mass with a little shift and edema...some mild left-sided weakness. (She/He, PI # 23) had a Fibrosarcoma of...abdominal wall resected about a year ago, and went through radiation and has been fine and then about 2 or 3 days ago (she/he, PI # 23) started noticing...left arm and leg were weak. Went to an Urgent Care yesterday and they ordered the MRI and it showed this mass and (she/he, PI # 23) came here today because (she/he, PI # 23) had a seizure... It's a 6 cm extra-axial appearing Right Parietal heterogeneously contrast-enhancing mass producing mass effect upon the Right Frontoparietal Region as well as some associated Vasogenic edema and most likely represents a Meningioma. I talked to...our Neurosurgeon here, and (he/she, Hospital C, Neurosurgeon) told me to send (her/him, PI # 23) to (Hospital E Identified), and I talked with (Neurosurgeon at Hospital E Identified)...and they don't have any beds and (he/she, Hospital E, Neurosurgeon) said I might could get one tomorrow, but (he/she, Hospital E, Neurosurgeon) was concerned because of (her/his, PI # 23) history of the Fibrosarcoma that it could be that instead and (he/she, Hospital E, Neurosurgeon) said these things can change rapidly..."

EI # 5 asked who PI # 23's Oncologist was. The ED physician replied with "...I don't think (she/he, PI # 23) ever got chemo (chemotherapy)...just got radiation...they did a work up there at (Hospital E Identified) and after the work up they cleared (her/him, PI # 23) and told (her/him, PI # 23) just to have...radiation done here." EI # 5 then stated, "...I don't know if they did scans on (her/his, PI # 23) brain? We do, they do a full body work up with Sarcomas here, looking everywhere...to see whether this is a Meningioma that has been there for a long time, or whether it is something that just grew." The ED physician replied with, "I don't know...(He/She, Hospital E, Neurosurgeon) said (he/she) pulled up...records, and you know...looked at...MRI."

EI # 5 stated, "...I bet they did. I would be glad to take (her/him, PI # 23) but, goodness, I mean, I would prefer...(she/he, PI #23) doesn't need an ICU bed, it doesn't sound like...Why don't you put (her/him, PI # 23) in...on steroids and send...to (Hospital E Identified) tomorrow? They have...records..." The ED physician then stated, "...since (Hospital E, Neurosurgeon Identified) wanted to try...I would call around and see..." EI # 5 stated, "...best bet is just to put (her/him, PI #23) in your hospital, hit...with some seizure medicines and steroids and let the Oncologists that are familiar...take care of (her/him, PI # 23)..."

Review of the bed census for 8 MST Unit (Neurological floor) and 8 NE Unit (Neurological Intensive Care Unit) dated 7/14/21 at 1:16 PM revealed documentation the 8 MST Unit had 1 bed available and the 8 NE Unit had 2 bed available.

Interviews:

An interview was conducted on 8/11/21 at 3:25 PM with EI # 3, Coordinator of Regulatory Affairs and Accreditation, who verbalized, PI # 23 would have been placed in the Neuro ICU (8 NE) or 8 MST Unit (Neurological Floor) if the transfer request would have been accepted.

An interview was conducted on 8/12/21 at 9:25 AM with EI # 5, HH, On Call Neurosurgeon, who was asked reasons you might decline a transfer request? EI # 4 stated, "main reason would be if the person could receive the same care from where they are. We accept everyone in the 10 county area. Most of the time it's the physician just wanting to consult. If it's outside of our area, then we get a call. Sometimes it's better for the patient to come, sometimes it's not.." EI # 4 was asked about the transfer request call on 7/14/21 for PI# 23. EI # 4 verbalized PI # 23 had "...known cancer, actually being treated by (Hospital E Identified). New onset of seizures, which was probably a metastasis from the cancer. They had called Hospital E, most likely would have a bed the next day. They had spoke with neurosurgeon there and for some reason they didn't want to just bed (her/him) down and transfer...then. So, they called for a transfer and I told them to put (her/him) on steroids and bed...down until the next day."

An interview was conducted via email on 8/16/21 at 3:07 PM with EI # 3, who confirmed per the Chief Nurse the facility 8 MST and 8 NE Units did have adequate staffing on 7/14/21 at 1:16 PM.

A second interview was conducted via email on 8/17/21 at 8:03 AM with EI # 3 who confirmed per the Unit Director, the facility 8 MST Unit had 1 bed available and 8 NE Unit had 2 beds available on 7/14/21 at 1:16 PM.