HospitalInspections.org

Based on review of clinical records, hospital documents, and staff interviews, it was determined the hospital failed to ensure their off-site dedicated Emergency Department (ED) followed the same processes as the ED in the main hospital as evidenced by:

-Tag A-1102: failing to ensure Emergency Services were under the direction of a single member of the medical staff.

-Tag A-ll03: 1. failing to ensure there was documentation of communication and coordination between the FSED and the hospital. Eight of 14 patients who presented to the FSED and required admission were transferred to another acute care hospital without documentation that there was coordination between the FSED and the main hospital. (Patients #1,#3, #4, #5, #6, #11, and #12)

2. failing to ensure there were an adequate number of hospital beds and staff to meet the needs of patients who presented to the free-standing (off-site) Emergency Department (FSED) and required inpatient admission for patient care services provided at Oro Valley Hospital.

The cumulative effect of these systemic problems resulted in the hospital's failure to meet the requirements of the Conditions of Participation for Emergency Services.

Based on review of hospital documents and staff interviews, it was determined the hospital failed to ensure Emergency Services were under the direction of a single member of the medical staff.

Findings include:

Staff #2 identified Physician #1 as the Medical Director for Emergency Services at the main hospital and Physician #2 was identified as the Medical Director for the offsite Emergency Department effective May 1, 2021.

Physician #1 confirmed this during an interview on 05/26/2021.

Based on clinical record reviews and staff interviews, it was determined the hospital's Free-Standing Emergency Department (FSED) failed to be integrated with other departments of the hospital as evidenced by:

1. failing to ensure there was documentation of communication and coordination between the FSED and the hospital.
Eight of 14 patients who presented to the FSED and required admission were transferred to another acute care hospital without documentation that there was coordination between the FSED and the main hospital. (Patients #1,#3, #4, #5, #6, #11, and #12)

2. failing to ensure there were an adequate number of hospital beds and staff to meet the needs of patients who presented to the free-standing (off-site) Emergency Department (FSED) and required inpatient admission for patient care services provided at Oro Valley Hospital.

The potential risk of these deficient practices is needs of the community for inpatient services will not be available.

Findings include:

The hospital's policy titled "Plan for the Provision of Patient Care" included the following: Oro Valley Hospital serves the community as a full service, acute care hospital. The following services are provided:

-Ambulatory
-Acute Care Telemetry
-Cardiac Cath Lab
-Cardiac Imaging Center
-Cardiac Observation Unit
-Cardiopulmonary Services
-Case Management/Social Services/Utilization Management
-Clinical Laboratory
-Diagnostic Imaging / Radiology
-Emergency Department
-Endoscopy (GI Lab)
-Intensive Care Unit
-Inpatient Dialysis
-Nutritional Services
-Medical/Surgical Unit
-Perioperative Services
-Pharmacy
-PICC Service (Peripherally Inserted Central Catheters)
-Behavioral Health (Inpatient and Intensive Outpatient)
-Therapy Services Inpatient (physical therapy, occupational therapy, and speech therapy, both inpatient and outpatient)
-Wound and Skin treatment and care (inpatient)

The Plan for the Provision of Patient Care included: "The leadership of Oro Valley Hospital takes responsibility to ensure that a process is in place to coordinate care, treatment and service process among programs, services, sites or departments. These services are based on assessed and identified needs designed to improve patient care outcomes...The CEO provides for hospital compliance with applicable laws and regulations, and filing applicable documents for hospital state licensure. In addition, the CEO working with management, clinical administrative staff, provides for a well-managed organization with clear lines of responsibility and accountability within and between departments and between departments and administration...." for the Free Standing Emergency Department: "The staff of the Emergency Department works closely with the Radiology, Laboratory and Admitting Departments as well as all inpatient units. There is a matrix relationship with all other units in the hospital to provide optimal care to all patients. The department works cooperatively on interdisciplinary teams in an effort to continuously improve services to the community.

Patient #1:

Patient #1 presented to the FSED on 03/27/2021 with a chief complaint of right lower abdominal pain radiating to the back and nausea. The patient was diagnosed with acute appendicitis. The ED physician's documentation included: "This patient will require admission. Patient will be transferred to (Hospital #2) patient has been accepted in transfer...." There was no documentation of communication with Oro Valley Hospital where the general surgeon was on call and there were available beds according to the 03/27/2021 Supervisor Report. There was no documentation that the patient refused to go to Oro Valley and requested transfer to Hospital #2. Hospital #2 is an acute care hospital located approximately 8.7 miles from the FSED. It is part of the same system as Oro Valley Hospital with some shared leadership.

Patient #3

Patient #3 presented to the FSED on 04/16/2021 with a chief complaint of chest pain and pressure. The patient was diagnosed with non-ST elevated myocardial infarction. The ED physician documented: "patient's presentation and findings were discussed with the hospitalist at (Hospital #2)...who accepted in transfer...Patient was awaiting for transfer to (Hospital #2) for admission. As she was departing the ED, Cath Lab called and said that she would be going directly to Cath Lab patient is aware of the reason for transfer and agreed." There was no documentation of communication with Oro Valley Hospital where there was a cardiologist on call, a cath lab and staff available, and available beds according to the 04/16/2021 Supervisor Report. There was no documentation that the patient refused to go to Oro Valley and/or requested transfer to Hospital #2.

Patient #4:

Patient #4 presented to the FSED on 04/25/2021 with a chief complaint of pain, redness, and swelling in the left toe. The ED physician documented: "Clinical picture is consistent with a diabetic foot infection that is failing outpatient treatment...I discussed the case with the hospitalist at (Hospital #2) who is excepted (sic) for transfer there. There is no current a bed (sic) at Oro Valley Hospital." A review of the Supervisor Report dated 04/25/2021 revealed there were beds available on the two telemetry units. There were no patients on the 15 bed Medical/Surgical 3-West Unit. There were two patients holding in the ED pending admission.

Patient #5:

Patient #5 presented to the FSED on 04/25/2021 with a chief complaint of upper quadrant pain. The patient was diagnosed with acute cholecystitis. The patient was transferred to Hospital #2 for surgical intervention. There was no documentation of communication with Oro Valley Hospital where there was a general surgeon on call. There was no documentation that the patient declined to be admitted to Oro Valley Hospital and requested transfer to Hospital #2.

Patient #6:

Patient #6 presented to the FSED on 04/26/2021 with a chief complaint of abdominal pain. The patient was diagnosed with acute cholecystitis and elevated troponin levels. The ED physician's documentation included: "...I spoke to (Hospital #2) through the transfer center. I spoke to the hospitalist as well as the surgeon and he will be admitted to (Hospital #2). They are working on a bed for him. He will be going to telemetry because of his elevated troponins." The ED physician documented the "Expected Benefits of Transfer" on the Patient Transfer Form was "Gen Surgery / Admission." There was a cardiologist and a general surgeon on all at Oro Valley Hospital according to the on-call rosters, however, there was no documentation that Oro Valley Hospital was contacted and efforts made to admit the patient there. There was no documentation that the patient requested to be transferred to Hospital #2.

Patient #11:

Patent #11 presented to the FSED on 05/15/2021 with a chief complaint of weakness, fatigue and lethargy. The patient was diagnosed with acute kidney injury, hyponatremia, hypotension, dehydration, and metabolic acidosis. The ED physician's documentation included: "...At this point I do feel she will require admission with continued hydration hold of her antihypertensive medication...Patient has been accepted in transfer to (Hospital #2) under the care of...hospitalist." The ED physician documented the benefits of transfer was "Hospitalization / Nephrology." There was no documentation that the patient requested to be transferred to Hospital #2 rather than Oro Valley Hospital. There was a nephrologist on-call at Oro Valley according to the call schedule. There was no documentation that there was communication between the FSED and Oro Valley Hospital to admit the patient there.

Patient #12:

Patient #12 presented to the FSED on 05/17/2021 with a chief complaint of drainage and bleeding from the umbilicus. The patient was diagnosed with umbilical abscess and acute abdominal pain. The ED physician's documentation included: "Discussed with (name) general surgeon on-call who is agreement with plan for admission, recommending admission to the hospitalist, and will see the patient in consult." The patient was transferred to Hospital #2 on or around 7 p.m.. The ED physician documented, "...Reason for delay; no bed availability." There was no documentation of any communication with Oro Valley Hospital.. There was a general surgeon on-call at Oro Valley Hospital. There was no documentation that the patient refused admission to Oro Valley Hospital and requested transfer to Hospital #2.

Patient #14:

Patient #14 presented to the FSED on 03/26/2021 with a chief complaint of increasing shortness of breath. The patient was diagnoses including acute hypoxemic respiratory failure, COPD exacerbation and pulmonary edema. The patient was transferred to Hospital #2 for ICU admission. The reason for the transfer was documented to be "ICU admission cont (continuity) of care." There was no documentation that the patient refused to be admitted to Oro Valley Hospital and requested transfer to Hospital #2. There was no documentation of communication with Oro Valley Hospital for admission. Documentation on the Supervisor Report for 3/26/2021 revealed there beds available in the ICU.

The above records were reviewed with Staff #1 and Staff #2 who acknowledged there was no documentation of communication and coordination between the FSED and Oro Valley Hospital before the patients were transferred to Hospital #2. Staff #1 was asked during an interview on 06/03/2021 that if the above patients presented to the main ED, required admission, and there were no beds available,would the patient be held in the ED until a bed became available, and she responded, yes. Staff #1 reported the House Supervisors receive a call from the FSED with request for transfer. Staff #1 was asked if the House Supervisors maintained documentation of those calls and final disposition as to if the patient was admitted to Oro Valley or if they declined the patient admission and the reason for the decline. Staff #1 responded they did not document that information except for an Admissions Log.

Physician #1 acknowledged during an interview on 05/26/2021 that the FSED was under the license of Oro Valley Hospital and that all policies and procedures and Medical Staff Bylaws were followed. Physician #1 also acknowledged Hospital #2 was a separately licensed hospital, however, it was owned and operated by the same system. Physician #1 was asked how an ED physician at the FSED processed a patient who required inpatient admission. Physician #1 explained that if the ED physician determined a patient needed to be admitted, the physician would contact Hospital #2 because they have a larger capacity in addition to having more subspecialities available. The patient would then be told there is a bed available at Hospital #2 . If the patient requested to go to Oro Valley Hospital, then the patient would be admitted there if the necessary services were available. Physician #1 reported during a later interview that the practice for patients presenting to the ED and requiring admission was for the House Supervisor at Oro Valley Hospital to be contacted to determine if the patient could be sent there.

The CEO of both Oro Valley Hospital and Hospital #2 and was present on a conference call on 05/27/2021. The CEO stated Hospital #2 is closer to the FSED than Oro Valley Hospital (3 miles) and if Hospital #2 has an available bed, that is where the patient should go regardless of the fact that the FSED is under the license of Oro Valley Hospital.

2. Staff #1 reported the following inpatient medical/surgical units in the hospital:

ICU =18 beds
CCU = 10 beds not utilized
4 North = 15 Telemetry beds
4 West = 15 Telemetry beds
3 North = 15 Medical/Surgical beds
3 West = 15 Medical/Surgical beds
2 North = 15 Medical/Surgical beds (unit closed)

A review of 14 Supervisor Reports between the period of 03/26/2021 and 05/17/2021 revealed the following:

-3 North was not staffed on 03/26 and 03/27/2021.
-3-West was not staffed on 04/15, 04/16, 04/18, 04/19, 04/24, 04/2505/0405/05, 05/06, 05/07, 05/16, and 05/17/2021

Based on the above, the hospital utilized only two 15-bed Telemetry units and one 15- bed Medical/Surgical unit (45 of 75 licensed medical/surgical beds).

In summary, Oro Valley Hospital has a dedicated Emergency Department approximately 11 miles from the main hospital. Some patients who require inpatient admission are not sent to Oro Valley Hospital, but rather to another hospital in the "system" separately licensed (Hospital #2) without documentation of communication and coordination with Oro Valley Hospital. Hospital #2 is located approximately 9 miles from the free-standing emergency department. The CEO of both Oro Valley Hospital and Hospital acknowledged the practice. In addition, Oro Valley Hospital has 75 medical/surgical beds but only staffs 45 of those beds.