HospitalInspections.org

Based on medical record (MR) review, document review and interview the hospital did not comply with the requirements at 489.24 and 489.20.

Three of 3 (Patient #2, Patient #3 and Patient #4) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the risks of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks related the transfer and untoward patient outcomes. Please reference specific findings within Tag 2409.

Based on medical record review, document review and interview, in 3 of 3 (Patient #2, Patient #3 and Patient #4) medical records reviewed of patients who were transferred to a higher level of care, each lacked documentation of the risks of transfer specific to the patient's medical condition. This could lead to patients not being informed of potential risks related the transfer.

Findings include:

-- Per review of Patient #2's medical record, she was a 2-year-old who presented to the emergency department on 12/31/2023 at 10:38 pm via ambulance after having seizures and vomiting at home. Patient arrived with continued seizure activity and reduced responsiveness. An intravenous line was started and Ativan (treat seizures) was given on 12/31/2023 at 10:53 pm and repeated on 1/1/2024 at 12:10 am to treat the seizure activity. On 1/1/2024 at 1:20 am the patient received Keppra (anti-seizure medication) 800 milligrams intravenously as additional treatment for the seizures. Physician documentation indicated that the patient appeared to be in moderate distress, was somewhat obtunded, and noted crying and abnormal consolability. The physician documented "Patient has now had five seizures with very little to no post-ictal (post seizure when patient returns to baseline) period. Will give bolus of intravenous Keppra and transfer for more inpatient care."

-- Per review of the form labeled "Physician Assessment and Certification- Patient Transfer Request," which was signed by the physician on 1/1/2024 at 12:41 am, there is a preprinted statement: "All transfers have the inherent risk of traffic delays, accidents during transport, inclement weather, rough terrain, or turbulence, and the limitations of equipment and personnel present in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient." Under the section titled "risks" Motor Vehicle Accident, Death, and Disability were indicated. There was no reference made to risks that were specific to this patient's condition.

-- Per review of Patient #3's medical record, she was a 20-year-old who presented to the emergency department on 3/10/2024 at 11:47 am. The patient reported that one month ago she was assaulted and sustained a blow to the face. Over the past week the patient has had chills, noticed a red bump under her chin, and then had purulent drainage come out near her teeth. One of these teeth was loose. Imaging was done and revealed a fractured mandible (jaw) in the vicinity of two lower teeth and a presumed abscess adjacent to the fracture.

-- Per review of the form labeled "Physician Assessment and Certification- Patient Transfer Request," which was signed by the physician on 3/9/2024 at 2:30 pm, there is a preprinted statement: All transfers have the inherent risk of traffic delays, accidents during transport, inclement weather, rough terrain, or turbulence, and the limitations of equipment and personnel present in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient." Under the section titled "risks" Motor Vehicle Accident, Death, and Disability were indicated. There was no reference made to risks that were specific to this patient's condition.

-- Per review of Patient #4's medical record, she was a 21-year-old who presented to the emergency department reporting a two day history of jaw pain and swelling. The patient reported she had teeth pulled the prior week and noticed two days ago that her face was starting to swell, today it has moved to her neck and she reported she is having a hard time swallowing. The physician documented swelling to the submental space (area under chin). A computed tomography was ordered and did not reveal any focal collection. It did show the patient had multiple dental caries which needed to be addressed through a dental consult. Treatment was started with intravenous Clindamycin (antibiotic). Patient complained of a headache and was given Tylenol with improvement noted. At 7:47 pm the patient reported tongue swelling, the doctor was notified, and she received Decadron (steroid), Benadryl (antihistamine), and famotidine (decreases stomach acid) intravenously. On 2/1/2024 at 12:17 am Racemic Epinephrine (for relief of symptoms associated with bronchial asthma and shortness of breath) was given via nebulizer and at 12:33 am the nurse gave a second dose of Decadron intravenously. The transfer orders indicated the diagnosis of Ludwig's Angina (life-threatening cellulitis of the soft tissue involving the floor of the mouth and neck).

-- Per review of the form labeled "Physician Assessment and Certification- Patient Transfer Request," which was signed by the physician on 2/1/2024. No time was indicated. The form includes a preprinted statement: "All transfers have the inherent risk of traffic delays, accidents during transport, inclement weather, rough terrain, or turbulence, and the limitations of equipment and personnel present in the vehicle, all of which are potentially a threat to the health, medical safety, and possible survival of the patient." Under the section titled "risks" Motor Vehicle Accident, Death, and Disability were indicated. There was no reference made to risks that were specific to this patient's condition.

-- Per review of facility's policy and procedure, "Transfer of Patient to Another Facility," last reviewed 12/2023, "The physician certifies in writing on Form Physician Assessment and Certification - Patient Transfer Request, a summary of the risks and benefits upon which the certification is based."

-- During interview of Staff D, Emergency Department Director, on 3/12/2024 at 3:30 pm, he/she/they acknowledged the above findings.