HospitalInspections.org

Based on review of records, policy and procedures reviews, and interviews, the facility failed to: A) provide further medical examination and treatment as required to stabilize the medical condition for one (1) out of 23 Sampled Patients (SP) within the capabilities of the staff. SP#1 (Refer to findings in tag A 2407); B) arrange an appropriate transfer, provide all medical records related to the emergency condition including available history, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and informed written consent or certification for SP#1. (Refer to findings in tag A 2409).

Based on review of records, policy and procedures reviews, and interviews, the facility failed to provide further medical examination and treatment as required to stabilize the medical condition for one (1) out of 23 Sampled Patients (SP) within the capabilities of the staff. SP#1

Findings include:

Clinical record review conducted on 12/05/2022 revealed SP#1's Emergency Department Physician Note dated 11/19/2022 at 10:23 PM documented History of Present Illness: SP#1 homeless with a past medical history of diabetes and hypertension, who presents to the Emergency Department (ED) via Emergency Medical Services (EMS) for severe facial trauma with associated symptoms of double vision, decreased vision, facial pain with swelling and loss of consciousness (LOC) onset 1 hour prior to arrival due to an altercation with another homeless man. SP#1 arrived with a laceration to the left brow. SP#1 states was at a nearby storage unit when attacked by a homeless man and was continuously beaten until losing consciousness. SP#1 denies any associated signs or symptoms.

Further record review revealed SP#1 arrived at the Emergency Department on 11/19/2022 at 8:55 PM. Triage assessment was initiated at 9:15 PM. Medical screening performed by the attending physician included a review of systems and physical examination. The screening did not include ancillary services (lab work or imaging) within the capability of the emergency department to determine whether an emergency medical condition existed. SP#1 was transferred as an emergent trauma alert for ophthalmic services at 9:30 PM although SP#1 did not meet trauma alert transfer criteria and the facility license documented Emergency Services include Ophthalmology.

Medical Decision-Making Narrative documented on 11/19/2022 at 10:33 PM:
SP#1 with traumatic injury to left side of the face, with vision loss, double vision, vision loss left eye, severe facial swelling to that left eye, and left side of face, severe injury was beaten prior to arrival, emergent transfer before lab work and or imaging could be completed due to need to be seen by trauma facility and emergent trauma transfer, called ambulance through 911 emergent trauma alert transfer.

Further review of SP#1's clinical record revealed the following documentation Discharge Plan: Discharge Clinical Impression: Vision loss of left eye; Transfer Info: Did you call another Steward hospital or the 5000 lines: No; Reason Patient sent to other facility: Service not available; Service: Ophthalmology; Discharge Comment: Nearest trauma center; Discharge Date/Time: 11/19/2022 9:30 PM.

Review of the facility's policy and procedure for Emergency Medical Treatment and Active Labor Act (EMTALA) Chapter: Rights and Responsibilities Policy Number: RI 23 Origination Date: 7/24/2012 Last Revised: 10/4/2022 III. Treatment of Patients with EMCs included, but was not limited to:

1. If a patient is determined to have an Emergency Medical Condition (EMC), the Hospital must provide the patient with further medical examination and treatment, within the capabilities of its staff and facilities, to resolve or stabilize the medical condition, or undertake an "appropriate" Transfer of the patient in accordance with Section IV.

Interview with the Risk Manager / Patient Safety Officer on 12/05/2022 at 11:15 AM revealed SP#1 did not meet criteria for Trauma Alert.

Interview with the Emergency Department Attending Physician on 12/06/2022 at 1:05 PM revealed there was change of shift, possible emergent trauma. SP#1 had severe eye swelling and possible retro-degeneration of the optic nerve. The Emergency Department Attending Physician stated bloodwork and Computerized Tomography (CT) scan were not done because it may have taken hours and it was very busy that night.

Interview with the Emergency Department Medical Director on 12/06/2022 at 1:28 PM revealed ophthalmology service is available by consult or referral. The Emergency Department Medical Director stated a plain CT scan of the eye is not a problem for possible transfer if it's necessary.

The facility failed to provide further medical examination and treatment within its capability as required to stabilize the medical condition.

Based on review of records, policy and procedures reviews, and interviews, the facility failed to arrange an appropriate transfer and send all pertinent medical records related to the emergency condition upon transferring SP#1 to the receiving facility. This affected one of 23 sampled patients.

Findings include:

1) Clinical record review conducted on 12/05/2022 revealed SP#1's Emergency Department Physician Note dated 11/19/2022 at 10:23 PM documented SP#1 homeless with a past medical history of diabetes and hypertension, who presents to the Emergency Department (ED) via Emergency Medical Services (EMS) for severe facial trauma with associated symptoms of double vision, decreased vision, facial pain with swelling and loss of consciousness (LOC) onset 1 hour prior to arrival due to an altercation with another homeless man. SP#1 arrived with a laceration to the left brow. SP#1 states was at a nearby storage unit when attacked by a homeless man and was continuously beaten until losing consciousness. SP#1 denies any associated signs or symptoms.

Further record review revealed SP#1 arrived to the Emergency Department 11/19/2022 at 8:55 PM. Triage assessment was initiated at 9:15 PM. The medical screening exam performed by the attending physician consisted of a review of systems and physical examination. SP#1 was transferred as emergent trauma alert for ophthalmic services although SP#1 did not meet trauma alert transfer criteria. Communication with the receiving facility was not initiated and medical records related to the available history, preliminary diagnosis, results of diagnostic studies and treatment rendered were not sent to the trauma hospital.

Medical Decision-Making Narrative documented on 11/19/2022 at 10:33 PM:
SP#1 with traumatic injury to left side of the face, with vision loss, double vision, vision loss left eye, severe facial swelling to that left eye, and left side of face, severe injury was beaten prior to arrival, emergent transfer before lab work and or imaging could be completed due to need to be seen by trauma facility and emergent trauma transfer, called ambulance through 911 emergent trauma alert transfer.

Further review of SP#1's clinical record revealed the following documentation: Discharge Plan: Discharge Clinical Impression: Vision loss of left eye; Transfer Info: Did you call another [ Hospital name] or the 5000 lines: No;
Reason Patient sent to other facility: Service not available; Service: Ophthalmology; Transfer Facility: Other; Discharge Comment: Nearest trauma center; Discharge Date/Time: 11/19/2022 9:30 PM. SP#1 was transferred to another facility because an Ophthalmologist was not available to provide further evaluation and/ or treatment necessary to stabilize the patient.

A review of the facility's document titled "Miami-Dade County Uniform Trauma Transport Protocols" dated April 2022 documented (page 4 of 14) Adult trauma alert criteria: Injured persons with anatomical and physiological characterizes of a person 16 years of age or older meeting any one of the parameters in Category 1 or and two parameters in Category 2, are considered trauma transport criteria (TTC) patients and will be transported to the nearest State Approved Trauma Center (SATC). Category 2 includes >55 years old, respiratory rate >30, Best Motor Response (BMR) 5, sustained heart rate > 120 beats per minute (bpm), any long bone fracture sustained in a motor vehicle accident (MVC) or fall >10 feet, major degloving injury, or major flap avulsion > 5 inches, or gunshot wound to the extremities, ejection from a motor vehicle or steering wheel deformity resulting from driver impact, or death of occupants in same passenger compartment.

Interview with the Risk Manager/ Patient Safety Officer on 12/05/2022 at 11:15 AM revealed SP#1 did not meet criteria for trauma alert.

Review of the facility's policy and procedure for Emergency Medical Treatment and Active Labor Act (EMTALA) Chapter: Rights and Responsibilities Policy Number: RI 23 Origination Date: 7/24/2012 Last Revised: 10/4/2022 III. Treatment of Patients with EMCs B. Transfer of a Patient Who has not been Stabilized included but was not limited to:

2. A Transfer is appropriate under EMTALA when all the following conditions are met:

a. The Hospital has provided medical treatment within its capability (including consultation with an on-call physician, as necessary) that minimizes the risks to the patient's health;

b. A representative of the receiving facility has confirmed the availability of space and qualified personnel for the treatment of the patient and confirmed the receiving facility's agreement to accept the transfer and to provide appropriate medical treatment;

c. The Hospital sends to the receiving facility copies of all pertinent medical records available at the time of Transfer, including (i) available history; (ii) records related to the patient's Emergency Medical Condition (EMC); (iii) observations of signs or symptoms; (iv) preliminary diagnoses; (v) results of diagnostic studies or telephone reports of the studies; (vi) treatment provided; (vii) results of any tests; and (viii) a copy of the Hospital's Transfer form, including, as applicable, the certification of risks and benefits by a physician or Qualified Medical Personnel or the signed patient request;

3. Documentation Relating to Transfer

a. Documentation of Transfer must be completed for each patient being transferred to a higher level of care.

Interview with the Emergency Department Medical Director on 12/28/2022 at 10:46 AM revealed usually if trauma is suspected, they work up the patient and if maxillofacial injuries are suspected, the facility does not have maxillofacial surgery onsite and the patient would be transferred. The Emergency Department Medical Director stated there may have been suspicion of entrapment of the muscle coming from the eye causing vision loss and no workup is needed. The Emergency Department Medical Director stated the longer the facility waits, the more risk to the patient losing vision and that it's more complex. The Emergency Department Medical Director stated that the facility does have ophthalmology services in the hospital but not on-call. The Emergency Department Medical Director stated the emergency department physician is responsible for contacting an ophthalmologist to accept a patient for transfer.

Interview with the Emergency Department Medical Director on 12/06/2022 at 1:28 PM revealed ophthalmology service is available by consult or referral.