HospitalInspections.org

Based on interview and record review, the facility (facility 2) failed to report the transfer of one patient (Patient 1) with an emergency medical condition that had not been stabilized, within 72 hours of receiving the patient. The patient was transferred to the facility without stabilizing medical treatment on August 30, 2019, and the facility reported the transfer on September 13, 2019 (13 days after the patient was transferred, and 10 days after they were required to report it).

This failed practice resulted in a delay in the investigation, and the potential for other inappropriate transfers to be accepted that could result in harm.

Findings:

On September 12, 2019, at 10 a.m., Patient 1's record was reviewed at facility 1. Patient 1's record indicated on August 30, 2019, the following occurred:

- The "Triage Report," dated August 30, 2019, at 10:58 a.m.,indicated Patient 1 arrived at the facility 1 Emergency Department (ED) in a privately owned vehicle, stating she "fell out of a truck, her left foot was run over,caught and she was dragged. ERMD immediately at bedside";

- The report indicated Patient 1 was triaged as an acuity 2 (emergent) due to her foot injury. She denied losing consciousness, and did not hit her head;

- The document titled "Procedures in the Emergency Department" indicated the patient was given two different pain medications intravenously (IV - directly into a vein), a tetanus shot, and IV antibiotics;

- At 12:53 p.m., an x-ray of the left foot indicated a minimally displaced fracture of the second metatarsal (toe) and a minimally displaced fracture of the distal left fourth toe;

The record entry titled, "ED Course/Medical Decision Making," authored by the ED physician (ED MD) indicated the following:

"ED Course: patient immediately brought back to acute care bed. patient was placed on IV, O2, and cardiac monitor. Patient was immediately assessed by myself. Orders placed as noted above. Administered Fentanyl 50 mcg. IV, IVNS, Tetanus, 4 mg. Morphine IV, and Ancef 1 g IV.

11:26 a.m.:Upon recheck, patient's pain is not improved. Still unable to fully assess patient's left foot due to pain.

12:50 p.m.: CR (xray) left elbow and CR left ankle both unremarkable.

12:53: CR Foot Complete showed minimally displaced fracture second metatarsal. Minimally displaced fracture distal tult left forth toe.

13:11 p.m.: Phone consult with Dr. (name) internal medicine (IMMD), discuss patient's case at length including work up, results, and patient's current condition. Dr. (IMMD) advises to speak with Dr. (name), podiatry (PMD), prior to discussing further plan of care.

13:15 p.m.: Phone consult with Dr.(PMD) podiatry, discuss patient's case at length including work up, results, and patient's current condition. Dr. (PMD) recommends NPO. Advises to contact OR and states that she will come in at 17:00 to wash out wound.

14:17 p.m.- Phone consult with Dr. (IMMD), discuss patient's case at length including work up, results, and patient's current condition. Dr. (IMMD) would like Dr. (PMD) to accept patient under her service.

15:30 p.m.: Dr. (PMD) is unable to be reached to discuss placing patient under her service.

18:18 p.m.: OR Staff states patient needs to be medically cleared by admitting doctor and are unable to reach Dr. (IMMD). request for Dr. (IMMD) to consult. Phone consult with Dr. (IMMD) discuss patient's case at length including work up, results, and patient's current condition. Dr. (IMMD) agrees to consult but not to admit.

18:33 p.m.: Phone consult with Dr. (IMMD) discuss patient's case at length including work up, results, and patient's current condition. Dr. (IMMD) recommends transfer to different facility as Dr. (PMD) cannot perform surgery due to patient's recent cocaine use.

18:40 p.m.: Consult with Dr. (PMD), who states she is not a primary doctor and cannot assume extensive post-operative medical care of patient outside of the 23 hour observation period if Dr. (IMMD) cannot be the primary admitting physician. Agrees with plans to transfer patient to a different facility. Patient brought back to ED. Admit orders are canceled and I have assumed care of the patients once more. Pending transfer.

18:48 p.m.: Phone consult with Dr. (another hospital physician) discuss patient's case at length including work up, results, and patient's current condition. Dr. (name) states (hospital name) ED is at capacity and is unable to take transfers. Will call (receiving hospital's name).

18:52 p.m.: Phone consult with Dr. (name of ED physician at receiving hospital), discuss patient's case at length including work up, results, and patient's current condition. Dr. (name) will call back after consulting with (name of receiving hospital) orthopedist.

19:01 p.m.: Phone consult with Dr. (ED physician at receiving hospital), discuss patient's case at length including work up, results, and patient's current condition. Dr. (name) agrees to accept patient under her care. Requests that wound is irrigated, loosely closed, and splinted. RN is aware. patient will be transferred to (name of receiving hospital). Patient was made aware of the decision to transfer. Patient understands and agrees. No further recommendations.

Disposition: stable."

The, "INTERFACILITY TRANSFER FORM," dated August 30, 2019, indicated Patient 1 was being transferred for, "higher level of care."

The ED Physician Addendum dated August 30, 2019, at 7:55 p.m., indicated, "Patient with open fracture of left foot after being run over accidentally by a truck... (name of podiatry physician-PMD) podiatry who agreed she would book the patient for the OR (operating room) at 5 p.m...I attempted several times to call via our unit secretary to (name of PMD) with several pages over 3-4 hours as documented on my note but was unable to reach her to inform her that I would need to admit to her services as (name of internal medicine physician - IMMD) was refusing admission to his service...(name of IMMD) called down and informed me that given the patient's recent cocaine use, (name of PMD) would not be doing surgery on the patient and he would not be admitting the patient, we need to transfer patient to a trauma center...I wanted to provide the best patient care for this patient by utilizing our podiatrist on call and the internal medicine physician but there was no willing and capable team to admit this patient..."

On September 12, 2019, at 12:27 p.m., the survey team conducted a telephone interview with the emergency department physician (EDMD) who attended and transferred Patient 1 on August 30, 2019. The EDMD stated she tried first to admit Patient 1 in the hospital, "The whole OR team was here." The EDMD stated the transfer was "Due to cocaine use...what (internal medicine MD- IMMD name) said." The EDMD stated she did not call the orthopedic on call, "I only called podiatry...I don't know if we have orthopedic on call." The EDMD stated she transferred Patient 1 because she did not have a place to admit Patient 1 in the facility, "I didn't have a choice." The EDMD stated she was not the one who made the call to transfer Patient 1, "The two other doctors decided (regarding the transfer)." The EDMD further stated "My only option was to transfer her."

On September 12, 2019, at 1:05 p.m., the survey team conducted a telephone interview with the Certified Registered Nurse Anesthetist (CRNA) who was called in to administer anesthesia for the surgical procedure. The CRNA stated he was called in for the scheduled 5 p.m. procedure for Patient 1 on August 30, 2019. The CRNA stated he met Patient 1 at her bedside but did conduct an assessment at that time. The CRNA stated the podiatrist informed him Patient 1 was sent to the OR without anyone to admit her. The CRNA stated the podiatrist told him Patient 1 was going to be transferred. The CRNA stated even with cocaine use he would not have canceled the case, he would have been able to do the procedure using general anesthesia with rapid sequence intubation.

On September 12, 2019, at 1:30 p.m., the survey team conducted an interview with the podiatrist (PMD). The PMD stated she received a call from the EDMD and was informed Patient 1 had an open foot metatarsal fracture. The PMD stated she gave instructions to start antibiotics, call the on call team, and schedule a surgical procedure for 5 p.m., on August 30, 2019, for Patient 1. The PMD stated she looked at Patient 1's injury, and from a surgical standpoint she could have done the procedure, "It was not a complex procedure." The PMD stated the whole on call team was in the facility for the procedure. The PMD stated she was not on the ER on call log, but she still answered the call. The PMD stated "Ortho (orthopedic) was on call." The PMD stated, "I was not on call...It is not true that I was not answering for 3-4 hours...in fact I texted the rep at 1:17 p.m., and asked to get things set up."

On September 12, 2019, at 2:20 p.m., the survey team conducted a telephone interview with the IMMD who consulted with the EDMD and the PMD on August 30, 2019. The IMMD stated Patient 1 had an open foot fracture. The IMMD stated the podiatrist said she could not do the procedure and anesthesia would not do the case. The IMMD stated anesthesia was not comfortable and thought Patient 1 was a high risk. The IMMD stated Patient 1 was transferred to a higher level of care because of the open fracture. The IMMD stated, "No, I did not refuse to admit this patient...I went to the patient in the pre-op area." The IMMD further stated "I could have managed this patient after the procedure medically."

A review of the facility "Emergency Room Specialty Roster" from March 2019 thru August 2019 indicated orthopedic physicians were scheduled on call, and could have admitted the patient.

A review of the facility policy and procedure titled, "EMTALA," last reviewed January 2019, indicated, "...If it is determined that the individual has an EMC (emergency medical condition), (facility name) will provide for further medical examination and treatment as required to stabilize the medical condition, within the capabilities of the staff and facilities available at the hospital..."


The record for Patient 1 at the receiving facility was reviewed. The record indicated the following:

- Patient 1, "was not symptomatic for cocaine toxidrome (evidence of cocaine use);"

- She had talked with anesthesia at the first hospital and was ready to have surgery, but it was canceled; and,

- The patient was taken from the OR back to the ED at the first hospital because no physician was willing to admit her.

During an interview with the orthopedic surgeon (OS) at the receiving facility on September 16, 2019, at 12 p.m., the OS stated Patient 1 was transferred 12 hours after the injury, so the wound was cleaned out and left open. The OS stated due to the swelling caused by the delay, the wound would have been too hard to close.

Record reviews and interviews indicated facility 1, to include the CRNA, the IMMD, and the PMD were capable of providing stabilizing treatment for Patient 1, but failed to do so.

On September 13, 2019 (13 days after the patient was transferred), facility 2 reported a possible EMTALA violation to the Department.