HospitalInspections.org

Based on record review, staff and provider interviews, review of the facility Medical Staff Rules and Regulation and the Emergency Treatment and Labor Act (EMTALA) policies, the facility failed to ensure their Medical Staff Rules and Regulation and their EMTALA policy followed the EMTALA regulations regarding unnecessary transfers of patients with un-stabilized emergency medical conditions. Review of 20 sampled patients identified 3 patients (Patient's 10, 11 and 17) that were transferred to Hospital B emergency department despite the hospital having the capacity and capability to provide medical services to stabilize their emergency medical condition. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department from 4/2021-10/2021. This failure has the potential for patients to be unnecessarily transferred delaying stabilizing treatment of their emergency medical condition.

Findings are:

A. Review of facility document titled "Medical Staff Rules and Regulations" revised February 2016 under "Section 3: Medical Screening Exam" states that in accordance with the EMTALA, any patient who presents to the hospital and request examination or treatment for a possible emergency medical condition has the right to receive, within the capabilities of the Hospital's staff and facility the following: An appropriate medical screening exam; treatment which is necessary to stabilize the patient's emergent medical condition; and if necessary, an appropriate transfer to another medical facility.

B. Review of the facility policy titled "Emergency Services" with an effective date of 5/29/21 identifies: Patients shall be transferred to an appropriate care facility (one that is capable of handling the patient's condition) when the capability of the hospital (relative to the specific location) to provide emergency medical care has been exceeded.

C. Review of the hospital's Medicare Database Worksheet verified by the hospital quality coordinator on 10/21/21 revealed the hospital's capabilities include a dedicated Emergency Department, ICU-Cardiac (non-surgical); ICU-Medical/Surgical; ICU-Neonatal; ICU-Surgical; CT Scanner; Laboratory; MRI; Renal Dialysis (Acute Inpatient); Rehab Services -Inpatient & Outpatient; Respiratory Care Services; Radiology; and Pharmacy.

D. Review of the 3 Patient ED records revealed the Physician's documented reason for transfer on the Certificate of Transfer was:
1) Patient 10's 8/31/21 ED record showed, Dr A identified in Section 2-Reason for Transfer as "For equipment or services not available at this facility-Described: (lack of) COVID BEDS;
2) Patient 11's 9/3/21-9/4/21 ED record showed, Dr B identified in Section 2-Reason for Transfer as "For equipment or services not available at this facility-Described: NO COVID BEDS;
3) Patient 17's 8/30/21 ED record showed, Dr C identified in Section 2-Reason for Transfer as "For equipment or services not available at this facility-Described: Services not available-(no)bed availability for Covid +.

F. In an interview on 10/19/21 at 4:30 PM, with the Medical Director of ED related to the 3 patients (Patient 10, 11 and 17) that were diagnosed with Covid 19 and bed availability. The term on the Certificate of Transfer, "No Covid Beds or No Beds" are terms, it doesn't necessarily mean we don't have the physical beds available, but may be not adequate staff. "It's just a ED term, in these cases they were because of staffing is my understanding." When the ED doctor decides the patient needs inpatient care for a medical condition the House Supervisor is notified and the decision is made whether to keep them or transfer them.

G. Review of the in house staffing for the following days was as follows:
The facility staffs a House Supervisor-a RN with experience in all levels of patient care; Med/Surg [Medical/Surgical] RN's- a RN that provides direct care to acutely ill, recovering and post operative patient cares; PCU [Progressive Care Unit] RN- A RN that has advanced training to provide close monitoring and frequent assessments for emergent changes that aren't unstable enough to be in the ICU [Intensive Care Unit]; and ICU RN- A RN that is specialized and trained to care for highly critical level patients.
- Pt 17 on 8/30/21 arrived in ED at 3:19 AM and was transferred to Hospital B at 7:00 AM. The in house staffing for that day 7A-7P indicated there were 18 patients [which included 3 elective surgical's], staffing was 1 RN House Supervisor, 5 RN's-(3 Med/Surg RN's- 1 ICU trained RN- 1 PCU trained RN) and 2 floor techs (nurse aids). The floor staff ratio was 3-4 patients per RN.
- Pt 10 on 8/31/21 arrived in ED at 1:57 PM and was transferred to Hospital B at 6:35 PM. The in house staffing for that evening 7P-7A indicated there were 18 patients, staffing was 1 RN House Supervisor; 5 RN's (3 Med/Surg RN's- 1 ICU trained RN- 1 PCU trained RN) and 2 floor techs (nurse aids). The floor staff ratio was 3-4 patients per RN.
-Pt 11 arrived on 9/3/21 in ED at 8:58 PM and transferred to Hospital B on 9/4/21 at 1:50 AM. The in house staffing for that evening 7P-7A indicated there were 20 patients, staffing was 1 RN House Supervisor; 5 RN's (2 Med/Surg RN's- 2 PCU trained RN's and 1 ICU trained RN) and no floor techs. The floor staff ratio was 4-5 patients per RN.

H. In an interview on 10/21/21 at 12:00 noon, with the Chief Nursing Officer revealed, by the review of the census, patient load and staffing scheduled, the care of these patients could have been within in the hospitals capability.

Based on record review, staff and provider interviews, review of the facility Medical Staff Rules and Regulation and the Emergency Treatment and Labor Act (EMTALA) policies, the hospital unnecessarily transferred 3 patients with an un-stabilized emergency medical condition (Patient's 10, 11 and17) out of 20 sampled patients. The Patients were transferred to Hospital B's [An Acute Care Hospital in city limits] emergency department despite the hospital having the capacity and capability to stabilize their emergency medical condition at the time of transfer. The total sample of 20 records, was taken from the central logs of patients presenting to the Emergency Department from 4/2021-10/2021. This failure has the potential for patients to be unnecessarily transferred delaying their stabilizing treatment of their emergency medical condition.

Findings are:

A. Review of the hospital's Medicare Database Worksheet verified by the hospital quality coordinator on 10/21/21 revealed the hospital staffs for 32 beds with an average daily census of 24 and the hospital's capabilities include a dedicated Emergency Department, ICU [An area of the hospital that caters to patients with severe or life-threatening illnesses and injuries requiring constant care]-Cardiac [heart related] (non-surgical); ICU-Medical/Surgical [non cardiac high level patient care for for acutely ill, complicated illnesses and post operative patients]; ICU-Neonatal [severe or life threatening illness for newborns]; ICU-Surgical [serious or life threatening illness following surgery]; CT Scanner [a machine that takes a number of x-rays to visualize bones, vessels and tissue]; Laboratory; MRI [a scan using magnetic fields and radio waves to visualize organs and tissue inside the body]; Renal Dialysis [process to filter your blood when your kidneys are unable to] (Acute Inpatient); Rehab Services -Inpatient & Outpatient; Respiratory Care Services; Radiology; and Pharmacy.

B. In an interview on 10/21/21 at 12:00 noon, with the Chief Nursing Officer revealed, the hospital has designated 4 patient rooms, rooms 129-130-131-132 as our Covid Unit. This area is walled off on each end with isolation equipment positioned outside the patients room, and has dedicated staff assigned related to the level of care the patients need.

C. Review of the in house staffing for the following days was as follows: The facility staffs a House Supervisor-a RN with experience in all levels of patient care; Med/Surg [Medical/Surgical] RN's- a RN that provides direct care to acutely ill, recovering and post operative patient cares; PCU [Progressive Care Unit] RN- A RN that has advanced training to provide close monitoring and frequent assessments for emergent changes that aren't unstable enough to be in the ICU [Intensive Care Unit]; and ICU RN- A RN that is specialized and trained to care for highly critical level patients.

D. Review of Patient 10's 8/31/21 ED record showed the patient arrived by ambulance at 1:57 PM, with complaints of fever, low back pain, cough and worse shortness of breath over last 3 days. Further documention showed that on physical exam by Dr A, Patient 10's lungs were clear, in no acute distress, alert and oriented, vital signs were temperature 99.6-pulse 98-respirations 20-blood pressure 146/76 and oxygen level at 90% on room air. Dr A ordered testing which identified Patient 10 was positive for Covid, her oxygen level would dip to 88-90% [normal level 90-100%] so the patient was placed on 2 L n/c [Liters of oxygen per nasal cannula -in the nose]. Dr A ordered 6 minute walk test with Respiratory Therapy, the patient was unable to tolerate greater than 1 minute due to back pain. Dr A discussed outpatient follow up with the patient, but due to the patients and husbands age, the patient did not want to go home with oxygen due to managing the tanks and tubing trip hazards. She preferred to be treated in the hospital and to stay in a hospital in town. Dr A documented, "[This Hospital] is without any current COVID beds, so patient would prefer to be admitted to [Hospital B]. Patient accepted for ED to ED transfer by Dr D." Dr A identified in Section 2-Reason for Transfer as "For equipment or services not available at this facility-Described: (lack of) COVID BEDS. Vital signs on discharge at 8:30 PM was 99.2-97-20 132/99 and oxygen level at 96% with 2 L/nc of oxygen.

In an interview on 10/21/21 at 12:00 noon, with the Chief Nursing Officer indicated after review of the census, patient load and staffing scheduled on 8/31/21 the care of this patient could have been within in the hospitals capability. There was 1 patient with Covid in room 131, Rooms 129 and 130 had non covid patient other medical conditions and Room 132 was empty. The in house staffing for that evening 7P-7A indicated there were 20 patients, staffing was 1 RN House Supervisor; 5 RN's (3 Med/Surg RN's- 1 ICU trained RN- 1 PCU trained RN) and 2 floor techs (nurse aids). The floor staff ratio was 4 RN's with 4-5 patients each and 1 RN had 2 patients.

E. Review of Patient 11's 9/3/21-9/4/21 ED record showed the patient arrived by by private car at 8:58 PM , with complaints of shortness of breath and substernal chest pressure/pain over last 2 days. Further documention showed that on physical exam by Dr B, Patient 11 tested positive on 8/26/21 after being ill for 3 days with cough, aches and fever. Patient 11 indicated the chest pressure is worse with deep breath and walking, has no cardiac history. Patient 11's lungs were clear with normal respiratory effort, in no acute distress, alert and oriented, vital signs were temperature 98.1-pulse 94-respirations 16-blood pressure 133/92 and oxygen level at 93% on room air. Patient 11's oxygen level dipped to 86% [normal level 90-100%] so the patient was placed on 2 L n/c [Liters of oxygen per nasal cannula -in the nose]. Dr B ruled out cardiac issues and blood clots in lung. Dr B documented "with his chest pain, shortness of breath and elevated liver enzymes he is having worse prognostic signs tonight that I think require hospitalization." Dr B documented, "I do not have any COVID beds at this facility tonight. I did call the transfer center [a phone center to help find a receiving hospital when a transfer is needed] and the bed is found at [Hospital B]. I did speak to Dr E, the ED doctor, who agreed to accept this patient in transfer by ambulance." Dr B identified in Section 2-Reason for Transfer as "For equipment or services not available at this facility-Described NO COVID BEDS. Vital signs on discharge at 1:39 AM on 9/4/21 were 98.5-73-21-119/77 and oxygen level at 96% with 2 L/nc of oxygen.

In an interview on 10/21/21 at 12:00 noon, with the Chief Nursing Officer indicated after review of the census, patient load and staffing scheduled on 7: 00 PM 9/3/21- 7:00 AM 9/4/21 the care of this patient could have been within in the hospitals capability. There were 2 patient's with Covid in rooms 131 and 132. There were no patients in Rooms 129-130. The in house staffing for that evening 7P-7A indicated there were 20 patients, staffing was 1 RN House Supervisor; 5 RN's (2 Med/Surg RN's- 2 PCU trained RN's and 1 ICU trained RN) and no floor techs. The floor staff ratio was 4 RN's with 4-5 patients each and 1 RN had 2 patients.

F. Review of Patient 17's 8/30/21 ED record showed the patient arrived by by private car at 3:19 AM , with complaints of shortness of breath over last 24-36 hours. Further documention showed that on 8/27/21 Patient 17 tested positive to Covid at her primary care doctors office. Patient 17 has a history of Chronic Pulmonary Obstructive Disease [COPD-a chronic lung disease that causes obstructed airflow from the lungs] and does not wear oxygen at home. Dr C physical exam revealed that the patient was mildly short of breath but is able to talk in complete sentences however required to use a wheelchair due to shortness of breath with exertion. Lungs with diminished expiratory [decreased sounds when exhaling] sounds otherwise clear. Patient 17's vital signs were temperature 102.9-pulse 79-respirations 24-blood pressure 160/76 and oxygen level at 88% on room air. Patient 17's oxygen level dipped to 88% [normal level 90-100%] so the patient was placed on 4 L n/c [Liters of oxygen per nasal cannula -in the nose] initially then decreased to 2.5 L n/c. Dr C documented "that the clinical impression was Covid, and hypoxia (low oxygen level)" Dr C identified in Section 2-Reason for Transfer as "For equipment or services not available at this facility-Described: Services not available-(no)bed availability for Covid positive. I did speak to Dr F, the ED doctor, who agreed to accept this patient in transfer by ambulance." Vital signs on discharge at 6:53 AM were 101.2-77-20-142/62 and oxygen level at 95% with 2.5 L/nc of oxygen.

In an interview on 10/21/21 at 12:00 noon, with the Chief Nursing Officer indicated after review of the census, patient load and staffing scheduled on for 8/29/21 7:00 PM until 8/30/21 7:00 AM that the care of this patient could have been within in the hospitals capability. There were 0 patients with Covid and Room 129 had a patient other medical conditions. Rooms 130-131-132 were empty.] The in house staffing for that night 7:00PM - 7:00 AM indicated there were 13 patients, staffing was 1 RN House Supervisor, 4 RN's-(2 Med/Surg RN's- 1 ICU trained RN- 1 PCU trained RN) and 1 floor tech (nurse aid). The floor staff ratio was 2 RN's had 4 patients each, 1 RN had 3 patients and 1 RN had 2 patients. The morning of 8/31/21 there were 3 patients being admitted for elective surgery's. (2 patients receiving total knee replacements and 1 patient receiving a total hip replacement)

G. In an interview on 10/19/21 at 4:30 PM, with the Medical Director of ED indicated when the ED doctor decides the patient needs inpatient care for a medical condition the House Supervisor is notified and the ED care givers and the House Supervisor makes the decision whether to keep the patient or to transfer the patient.