HospitalInspections.org

Based on review of hospital policies/procedures, medical records, and staff/physician interviews, it was determined that the hospital's Emergency Department(s) failed to ensure that non-emergent patient transfers to other hospitals were conducted at patients' requests, and/or according to the hospital's capability or capacity to admit. This failure presents the potential for delay in care of services when the patient is transfered to another hospital for inpatient care/treatment, and affects patient rights violations when patients are not included in the decision to transfer to a specific hospital, as demonstrated by:

1. Two (2) of eleven (11) Chandler ED patients were transferred to neighboring acute care hospitals for "higher level of care" rather than to the hospital proper in Laveen that had the capability and capacity to admit/treat. (Patient #'s 4 and 7), and

2. Two (2) of eleven (11) Chandler ED patients were transferred to neighboring acute care hospitals for admission/treatment rather than to the hospital proper in Laveen, with no confirmation of patients' requests for transfers (Patient #'s 4 and 7).

Findings include:

This acute care general hospital opened for business in Laveen, on 12/02/14. The hospital proper includes sixteen (16) inpatient beds, laboratory, surgical services, radiology, and Emergency Department (ED). The hospital does not provide pediatrics, obstetrics, or psychiatric inpatient beds. In addition, the hospital's freestanding provider-based ED located in Chandler opened for business on 04/29/15, and treated it's first patients on 05/02/15. The hospital's average daily inpatient census is 1.6 patients, according to hospital sources.

The hospital policy titled MSE (medical screening examination) and Transfer Procedures for Patients Seeking Emergency Treatment #PC-3009, requires: "...A patient considered appropriate for transfer will...request the transfer or when the hospital does not have...the capability or capacity to admit the individual...."

The hospital policy titled Assessment and Reassessment of Patients Presenting for Emergency/Urgent Treatment #PC-3002, requires: "...Patients requiring...care beyond the scope of services...will be transferred once stabilized...."

The hospital policy titled Admission Policy #PR-1000, requires: "...It is the policy of (the hospital) to admit all types of patients on a routine general care basis...Patients with medical conditions and/or complexities appropriate for treatment and surgical operation...."

1. Documentation failed to confirm that the patient(s) requested transfers from Arizona General Hospital (AGH) ED in Chandler AZ, to other acute care hospitals for inpatient treatment that was available at AGH in Laveen, as follows:

Patient #4: DOS 05/07/15. Diagnosed with diverticulitis (non-obstructive). Transferred to an acute care hospital in Chandler for inpatient treatment, and intravenous antibiotics.

Patient #7: DOS: 05/06/15. Diagnosed with deep vein thrombosis and bilateral pulmonary embolisms. Transferred to an acute care hospital in Chandler.

Chandler ED RN # 5, indicated during an interview conducted on 05/15/15, "if a patient needs to be transferred to an inpatient unit, we call the Dignity Transfer Center or Banner Transfer Center - they (the centers) set up the transfer to whichever hospital the patient is going to...they determine which hospital has opening and they arrange the transfer...the Transfer Center determines where the patient goes."

The ED transfers patients to other acute care hospitals for inpatient treatment when the hospital proper has the capability and capacity to admit and treat.

2. Documentation revealed that the Chandler ED location transferred the above listed patients to neighboring acute care hospitals instead of the AGH Laveen location, without a specific request from the patient/patient's representative to transfer them to locations other than the hospital proper.

Chandler ED RN #10, indicated during an interview conducted on 05/15/15, that when the ED has a possible inpatient admission "the nurse or doctor will say (to the patient) - 'looks like you'll need to be admitted - where (what hospital) would you like to go?'...if the patient has no preference, we'd offer them AGH in Laveen, but we generally suggest a nearby hospital instead." ED RN #10 confirmed that the Chandler location has not transfered any patients to the Laveen inpatient unit.

The hospital transfers patients to other acute care hospitals without the patients' specific request(s).

Based on review of hospital policies/procedures, Medical Staff Rules and Regulations, and staff/physician interviews, it was determined that the hospital failed to require the Emergency Department(s) maintained a list of individually identified on-call physician specialists, which presented the potential for patients with emergency medical conditions to be delayed or not receive further evaluation or stabilizing treatment in the event the ED physician or staff were unclear as to which physician to contact, as demonstrated by:

1. The Laveen location Emergency Department (ED) May 2015 physician on-call list(s) for Cardiology and Orthopedic Surgery did not identify specialists by individual name;

2. The Chandler location ED did not maintain a list of physician on-call specialists but instead referred to FIRST CALL "transfer center" resource phone number, and

3. The Laveen location ED May 2015 Orthopedic physician specialist (the only physician on the schedule) was listed as: "...on non-call days...he will try and see patient...."

Findings include:

The hospital policy titled Emergency Services Scope of Services #PC-3005, requires: "...An Emergency Room is set (sic) available to provide services to meet a patient's specialty need for...physician referral and consultation...."

The hospital's Medical Staff Rules and Regulations (dated 08/19/14), require: "...Emergency duty or on-call duty - Provider on-call roster: Respective clinical divisions provide a monthly call list, providing name of provider and appropriate contact numbers...."

1. The Laveen ED location maintains on-call physician specialists schedules for Cardiology, General Surgery, Orthopedic Surgery, Anesthesia, and Radiology. The Call Schedule(s) for May 2015, revealed the following:

Cardiology Call Schedule:

Ten (10) of 31 days: "South Mountain Cardiology" listed with business phone #, "or" another phone #. The first number was the South Mountain Cardiology physician practice office. The second number was private. The on-call schedule did not identify the individual physician's name.

Twenty-one (21) of 31 days: "IMS Cardiology" with business phone # listed. The entity's website listed 15 individual physicians. The on-call schedule did not identify the individual physician(s) name(s).

Unit Secretary #8, indicated that she has called the "on-call" physician "a couple of times", during an interview conducted on 05/15/15. She confirmed that the cardiologist on-call was listed as "IMS Cardiology", however no individual physician name was listed. She indicated that when she needs to contact an IMS cardiologist, she calls the main number and "they get a physician."

Orthopedic Surgery Call Schedule:

"Dignity Health Orthopedics (business phone #)" and one (1) identified individual physician's cellphone number. The Dignityhealth.org website associated with the listed phone number, indicated: "...employs more than 250 providers...to find a physician contact (the phone # listed on the call schedule/list)...."

The group business phone # was on the schedule 20 of 31 days. The identified individual physician was on the schedule 10 of 31 days.

2. The Chandler ED location did not maintain an on-call physician list/schedule. The ED referred to FIRST CALL, that, according to the information printed on the card/magnet indicated: "FIRST CALL transfer center for admission service, immediate beds, 24/7 coverage for emergent and non-emergent patients, and on-the-spot telemedicine cardiac consults." The card included a phone #, fax #, and listed the names of two (2) nearby affiliated hospitals.

The ED also referred the surveyor to "ResourceLink Information and Referrals" business card that included two (2) phone numbers and indicated: "...Provides access to doctors affiliated with Dignity Health...Doctor Referral...Program Information...Class Registration...Support Group Information."

ED RN #5, confirmed that the Chandler ED location does not maintain a physician on-call list, and stated: "I don't know where that list is", during an interview conducted on 05/15/15.

ED Physician #1, confirmed that the "physician referral list" is for directing patients for aftervisits, during an interview conducted on 05/15/15, however admitted that he did not know where the list was located. The surveyor inquired if the Chandler ED location maintained a list/roster for on-call physician specialists available for ED consultations. ED Physician #1 responded that "if it's after-hours, we contact FIRST CALL...the call list is a list of special physicians not published here (at the Chandler ED location)...we call the FIRST CALL number and they put us in contact with a physician."

ED Physician #2, indicated that if he needed a name of physician specialist, he would refer to the FIRST CALL number which would locate a specialist, during an interview conducted on 05/11/15 and verified by ED staff on 05/15/15. ED Physician #2 confirmed that the Chandler location did not maintain a list of on-call specialists, and also referred to the ResourceLink business card that provides access to physicians affiliated with Dignity Health. The surveyor inquired as to what he would do if he wanted a specialist to see a patient in the ED. He responded: "we really don't need to do that - I'd just transfer them (the patient) to the hospital where they have the specialist - or I'd call a buddy of mine."

3. The Laveen ED location Orthopedic Surgery Call Schedule for May 2015, revealed:

"Dignity Health Orthopedics (business phone #)" and one (1) identified individual physician's cellphone number. The Dignityhealth.org website associated with the listed phone number, indicated: "...employs more than 250 providers...to find a physician contact (same phone # listed on the call schedule/list)...."

The individual physician was on the schedule 10 out of 31 days. The schedule indicated; "...Call (the physician) on non-call days and he will try and see patient..." Additionally, it was unclear as to what the physician's criteria was for responding on his non-call days.

ED Physician #3, indicated that he provides services at both Laveen and Chandler locations, during an interview conducted on 05/15/15. He stated that "it's a different system between the Laveen and Chandler locations. The Laveen ED uses the on-call roster...the Chandler ED uses the FIRST CALL system for on-call physicians."

The hospital's Emergency Department(s) does not maintain an on-call physician speciality list at the Chandler location, and does not maintain a list of individually identified on-call physician specialists for Cardiology and Orthopedics at the Laveen location.






20771

Based on review of the Dedicated Emergency Department (DED) Logs for the past 6 months, review of policies/procedures and interviews with staff, the hospital failed to maintain a central log as demonstrated by failing to include the following required elements in the central log:

1. patients that were admitted to the hospital,

2. patients that left against medical advice (AMA);

3. patients that left without being seen or left without treatment;

Based on review of the Dedicated Emergency Department (DED) Logs for the past 6 months, review of policies/procedures and interviews with staff, the hospital failed to maintain a central log as demonstrated by failing to include the following required elements in the central log:

1. patients that were admitted to the hospital,

2. patients that left against medical advice (AMA);

3. patients that left without being seen or left without treatment;

Failing to have a complete DED log may result in a patient not receiving a medical screening examination which could result in harm to a patient.

Findings include:

This hospital has a provider-based freestanding emergency department in Chandler Arizona. The surveyor requested the central DED log, on 05/15/15 at 0815 hours. The provider was asked to include information from the provider-based freestanding DED as well as the Emergency Department (ED) located on the main campus.

The DED central log provided on 05/15/15, at the Laveen hospital, included the following information:

a. Patient Medical/Health Record Number
b. Patient Control Number
c. Patient Name
d. Admission Date (arrival date in ED)
e. Admission Hour
f. Source of Admission Visit
g. Discharge Status (admitted as an inpatient to this hospital, code 09; discharged to home, code 01; transferred to a Short-Term hospital)
h. Attending Provider Name

The DED central log provided on 05/15/15, at the Chandler provider-based emergency department, included the following information:

a. Patient Label
b. Reason for Call
c. Comments
d. Initials

During review of the central log, provided at the main hospital, the surveyor noticed none of the patients on the log indicated they were admitted to this hospital. According to the CEO and Director of Quality/Risk Management the hospital has had 100 inpatient admissions to date.

The CEO and Director of Quality/Risk Management confirmed on 05/15/15, at 1200 hours, that the central log did not include patients that were admitted. The agency running the log removed the admitted patients and did not include them on the central log. The CEO and Director of Quality/Risk Management were unaware of this until the surveyor pointed this out. Both confirmed the central log provided to the surveyors did not have admitted patients that presented to the ED.

Further review of the central log discovered that there were no patients identified as leaving against medical advice (AMA). The CEO and Director of Quality/Risk Management were unaware of this until the surveyor pointed this out. Both confirmed the central log provided to the surveyors did not include patients that presented to the ED and left AMA.

The central log for the provider-based freestanding emergency department in Chandler, did not include whether the patients were admitted, discharged, transferred, or left AMA. The Director of the ED in Chandler confirmed this and then presented another log called the "transfer log."

The DED log requested originally, was not provided. When deficiencies were identified the provider would then offer to pull another log with additional data. The hospital had a log for transferred patients, chief complaints, left without treatment (LWOT), which included AMA patients and admitted patients. The hospital presented several logs combined to make up the central log, however, all of the information required in the central log could not be merged and printed as one document.