HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure compliance with 42 CFR 489.24.

Findings include:

1. The Hospital failed to ensure a timely medical screening exam by a qualified provider. See deficiency at A-2406.

2. The Hospital failed to stabilize the patient prior to transfer. See deficiency at A-2407.

The immediate jeopardy (IJ) began on 3/8/2023, due to the Hospital failure to ensure a timely medical screening exam by a qualified provider; and the failure to stabilize a patient prior to transfer, by not identifying a pneumothorax (collapse lung) or performing a complete abdominal examination. Subsequently, the patient expired on 3/8/2023 at 6:51 AM at Hospital B (Receiving Hospital). The IJ was identified on 5/31/2023 and announced on 6/1/2023 at 9:00 AM during a meeting with the President/Chief Executive Officer, the Executive Vice President/Chief Operating Officer/Chief Nursing Officer, Quality Risk Specialist, Director of Emergency Services and Director of Quality. The IJ was not removed by the survey exit date of 6/1/2023.

Based on document review and interview, it was determined that for 1 of 5 (Pt. #1) patients presenting to the Hospital with an EMC (emergency medical condition), the Hospital failed to ensure a timely medical screening exam by a qualified provider. Subsequently, the death of a patient with an emergency medical condition occurred.

Findings include:

1. The Hospital's policy titled, "Evaluation and Treatment: Guideline Usage (8/2020)", was reviewed on 5/3/2023 and included, "A. Any patient who presents to the emergency Department (ED) seeking medical care will receive a medical screening exam and stabilization by a qualified healthcare provider..."

2. The Hospital's "Medical Staff Rules and Regulations (10/2022)", was reviewed on 5/3/2023 and included, "...Emergency Services...The examination must be conducted by a Physician who is a Member of the Hospital's Medical Staff with appropriate clinical privileges..."

3. The Hospital's policy titled, "Triage and Registration of Patients: Emergency Services (9/13/2022)" was reviewed on 5/3/2023 and included,"Level I patients require immediate attention and the Emergency providers will be notified of their arrival."

4. The clinical record of Pt. #1 was reviewed on 5/2/2023. Per the ambulance run sheet, Pt. #1 presented to the Hospital's emergency department (ED) on 3/8/2023 at approximately 12:27 AM with chief complaint of MVA (motor vehicle accident).
- A helicopter was requested for a rendezvous (agreement to meet at a location) at Hospital A due to the helicopter being 28 minutes away from the crashsite.
- The ambulance advised that Pt. #1 would required resuscitation and stabilization upon arrival to the Hospital.
- Full report was given by the ambulance provider 5 minutes prior to arrival (approximately 12:22 AM).
- The ambulance run sheet included that the ED replied on the radio that this was just a rendezvous with the helicopter directly on the helipad. The ambulance replied that Pt. #1 was inappropriate to fly direct at this time. It was reiterated that Pt. #1 would need resuscitation and stabilization upon arrival. Per the ambulance run sheet Pt. #1 arrived to the Hospital's ED at 12:27 AM
- ED Registered Nurse (RN )(E#1) advised ambulance personnel to go to room #6 to wait for helicopter. E#1 advised EMS to continue to assume care in the ED. ED staff informed that (Pt. #1) was unstable. Hospital staff then assumed care. Triage: Level I.
- The Physician's note included, "Time seen by provider: 3/8/2023 at 12:40 AM (13 minute delay in seeing patient from the time of Pt. #1's arrival to the ED at 12:27 AM).
- Pt. #1 was transferred via helicopter to Hospital B on 3/8/2023 at 1:19 AM.

5. REACT (helicopter personnel) arrived at bedside at 12:36 AM (prior to physician) to assume care. REACT intubated Pt. #1. Pt. #1 coded (heart stopped) in the ED and REACT staff conducted code.

6. The clinical record of Pt. #1, dictated by the receiving trauma surgeon from Hospital B on 3/8/2023 at 5:34 AM, was reviewed on 5/4/2023. The history of present illness included, "The helicopter rendezvoused with EMS (emergency medical service) at [Hospital A] where [Pt. #1] was evaluated by [MD#1]. [MD#1] called to request transfer during intubation of [Pt. #1]. [MD#1] contacted me again after intubation ... [MD#1] requested transfer prior to obtaining imaging there to expedite definitive treatment of [Pt. #1's] injuries."
- Upon arrival to Hospital B at 1:52 AM, Pt. #1 was given multiple units of blood and taken to surgery at 2:26 AM for internal bleeding and large liver laceration.
- Pt. #1 expired on 3/8/2023 at 6:51 AM.

7. During an interview on 5/3/2023 at approximately 9:13 AM, the ED nurse (E#2) stated that the primary nurse told EMS that the patient (Pt. #1) was a rendezvous patient (directly from ambulance to helicopter). The Hospital would not be providing care and EMS would assume care until the helicopter arrived. E#2 stated that EMS would use their own supplies because (Pt. #1) was not in the Hospital's care. Once EMS said that they needed help, the primary nurse and (MD#1) took over (12:40 AM). E#2 stated that she assisted with bagging (providing oxygen) when the flight crew took over to intubate the patient.

Based on document review and interview, it was determined for 1 of 5 (Pt. #1) patients transferred, presenting with an EMC (emergency medical condition), the Hospital failed to stabilize the patient prior to transfer. Subsequently, the death of a patient (Pt. #1) requiring stabilizing treatment occurred.

Findings include:

1. The Hospital's policy titled, "Evaluation and Treatment: Guideline Usage (2/2016)" was reviewed on 5/3/2023 and required, "Any patient who presents to the Emergency Department seeking medical attention will receive a medical screening examination and stabilization by a qualified healthcare provider."

2. The clinical record of Pt. #1 was reviewed on 5/2/2023. Per the ambulance run sheet, Pt. #1 presented to the Hospital's emergency department on 3/8/2023 at approximately 12:27 AM with chief complaint of MVA (motor vehicle accident).
- The emergency department physician's (MD#1) quick interpretation of portable chest x-ray on 3/8/2023 1:37 AM included, "No pneumothorax (collapsed lung)."

3. The chest x-ray report, dictated/approved by a radiologist on 3/8/2023 at 7:40 AM (6 hours after Pt. #1 left Hospital A) included, "... Left sided pneumothorax is seen extending to the left base approximately 15%."

4. The clinical record of Pt. #1, dictated by the receiving trauma surgeon from Hospital B on 3/8/2023 at 5:34 AM, was reviewed on 5/4/2023. The history of present illness included, "The helicopter rendezvoused (agreement to meet at a location) with EMS (emergency medical service) at [Hospital A] where [Pt. #1] was evaluated by [MD#1]. [MD#1] called to request transfer during intubation of [Pt. #1]. ... I recommended a chest x-ray and FAST [check abdomen for fluid] after intubation, as well as stabilization. [MD#1] contacted me again after intubation ... reported chest x-ray without pneumothorax. reported stable pelvis on exam and abdomen being soft and non-distended. He [MD#1] was unable to do FAST. ... [MD#1] requested transfer prior to obtaining imaging there to expedite definitive treatment of [Pt. #1's] injuries."
- Upon arrival to Hospital B at 1:52 AM, Pt. #1 was given multiple units of blood and taken to surgery at 2:26 AM for internal bleeding and large liver laceration.
- Pt. #1 expired on 3/8/2023 at 6:51 AM.

5. During an interview on 5/3/2023 at 12:09 PM, the emergency department physician (MD#1) stated that there is only one physician overnight. MD#1 stated that care was assumed immediately, [Pt. #1's] blood pressure was dropping. MD#1 gave orders to start an IV (tube in vein to give fluids). MD#1 stated that Pt. #1 was intubated, but does not recall who did that. MD#1 stated that he did not notice a collapsed lung on the chest x-ray. MD#1 stated that if this patient presented without a planned pick up from the helicopter, they would stabilize in the ED, which might include getting IV access, x-rays, central lines, chest tubes (if lung collapsed), as they were arranging transport.