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Based on reviews of medical records and policies and procedures the facility failed to stabilize a medical condition as required that was within the capability of the staff and facility available for 1 of 20 sampled patients. (#1). Refer to finding at Tag A- 2407.

Based on record review, review of specialty on call schedules and staff interview, it was determined that the facility transferred (#8) of 20 sampled patients to another acute care hospital for specialty care that was available at the facility. This practice does not comply with federal regulations and results in delay in treatment for the patients. Refer to finding at Tag A-2409.

Based on reviews of medical records and policies and procedures the facility failed to stabilize a medical condition as required that was within the capability of the staff and facility available for 1 of 20 sampled patients. (#1).

Findings:
The facility's policy titled "Emergency Department- Subject: Medical Screening revised 10/09 was reviewed. The policy indicated in part, 4." MEDICAL SCREENING EXAMINATION-When the individual is taken into the treatment area, a physician, physician assistant, or ARNP (Advanced Registered Nurse Practitioner ) will provide appropriate medical screening examination to determine whether or not an emergency medical condition exists. ...All individual on-duty Emergency Department Physician, physician assistant, or ARNP determines to have an emergency medical condition will receive medical treatment and will be stabilized. "

Patient #1's medical record from Winter Haven Hospital was reviewed. The medical record indicated that patient #1 presented to the ED on October 2, 2010 and triaged at 10:14 a.m. Review of the HPI (History of Present illness) the Emergency Physician documented the patients Chief complaint was "Ear and neck pain and tongue swelling " Further review indicated the patient was 62 years old had a history of neck cancer with complaint of increased pain to his/her neck and ear and increased tongue swelling. The patient ' s quality of pain was listed as throbbing, and the patient ' s severity was listed as "Currently symptoms are severe. " The section of the HPI "Medical History" indicated that patient #1 had a history of Hypertension, and had undergone chemotherapy and radiation treatments. Additionally, the patient had surgery for a neck dissection (a surgical procedure for control of neck metastasis from cancer cells of the head and neck) and the insertion of a PEG (percutaneous endoscopic gastrostomy) tube. (An effective way to provide food, liquids, and medications (when appropriate), directly into the stomach through a tube placed in the abdomen. The procedure is done for people who are having difficulty swallowing and can't consume enough food or liquids by mouth to maintain adequate nutrition). The ED physician documented that the patient's condition was considered an Emergency due to: severe pain/Acute onset of symptoms ... Tachycardic, Patient is ill appearing, drooling present, tongue elevated unable to visualize ...Patient has no stridor but very mumble voice. I cannot see the oropharynx (section of the throat, located at the back of the mouth. When the mouth is opened wide, the posterior oropharynx can usually be seen directly), nor vulva due to tongue swelling. Tongue swelling had improved but still not able to see oropharynx. " Review of the physician's orders indicated in part, " Difficulty airway (airway equipment used to secure both pediatric and adult difficult airways.) at bedside. There was no documented evidence in the medical record the difficulty airway equipment was used in an attempt to secure the patient's compromised airway prior to transfer. Documentation by the ED physician also indicated that patient (Patient #1) ....Rad (radiology) Interpretation Neck CT: (Computed tomography (CT) is a diagnostic procedure that uses special x-ray equipment to obtain cross-sectional pictures of the body) Increased in size neck tissue mass with involving base of tongue. Extensive tongue swelling. Mild distortion of oropharynx but patent. .. Final diagnosis was listed as " Neck Cancer; Tongue swelling/Edema.. . " The patient received laboratory blood work , Electrocardiogram and CT of the neck and sinuses at Winter Haven Hospital. Further documentation by the ED physician indicated that the patient required transfer due to availability of specialty care. The facility failed to provide stabilizing treatment that was within the capability of the hospital and staff for patient #1 as evidenced by not securing the patient's compromised airway prior to transferring the patient to another acute care facility.

Patient #1's Medical record from the receiving hospital was reviewed. Review of the history and physical examination specified in part, "Transferred from Winter Haven Hospital. The patient was an ER (Emergency Room) to ER transfer. The patient was transferred in airway distress and on arrival was noted to have symptoms of air hunger difficulty with breathing. He/She was noted to have drooling. He/She was noted to have tongue swelling and has a history apparently of a large tongue mass. .. the patient presented to the emergency room with the above findings ... In the emergency room, attempts were made by ER service to intubate the patient .... bleeding was encountered and several esophageal intubations occurred. Anesthesiology was stat paged. Dr. ---from Anesthesia came down a guide. Laryngoscope was used; however, the visualization was very poor. There were significant amounts of swelling bleeding and edema. .. stat consulted for emergency tracheostomy and securing of the airway. The patient was emergently sent up to the operating room. Review of the operative report dated 10/02/2010 indicated that patient #1's pre-operative diagnosis was "Acute airway emergency." The procedure in the operative report was listed as an "emergency tracheostomy." Patient #1 was admitted to the Intensive care unit on a mechanical ventilator.

Based on record review, review of specialty on call schedules and staff interview, it was determined that the facility transferred (#8) of 20 sampled patients to another acute care hospital for specialty care that was available at the facility. This practice does not comply with federal regulations and results in delay in treatment for the patients.



Findings include:


1. Patient # 8 was admitted to the facility on 10/21/10 with the chief complaint of flank pain and fever. The patient received a medical screening examination by the ED physician who diagnosed fever, flank pain, renal stone and bactiuria. The physician documented the patient was transferred to another facility. He certified the medical need for the transfer for urology specialty care. Review of the on call schedule revealed that an urologist was on call on 10/21/10. There was no documentation that the physician had contacted the on call physician. The Director of Regulatory compliance was interviewed on 11/17/10 at approximately 3:30 p.m. She confirmed that there was urology coverage and the urologist on call should have been consulted.


12/17/10