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Based on records reviewed and interviews the Hospital failed for one of ten patients (Patient #1)to conduct a comprehensive Quality Assessment Performance Improvement review when a contract ambulance service did not meet the standards of care while transporting Patient #1 from the Emergency Department (ED) of Campus #2 to Campus #1's Intensive Care Unit (ICU).

See A-0286

Based on records reviewed and interviews the Hospital:
1.) failed to perform a comprehensive analysis of Patient #1's transport by a contracted ambulance service from the ED of Hospital Campus #2 to the ICU of Hospital Campus #1;
2.) failed to implement improvement opportunities;
3.) failed to document and measure compliance with the corrective action plan; and
4.) failed to ensure that a like event did not occur.

CMS defines contract services as indirect arrangements, formal contracts, joint ventures, informal agreements, shared services or lease arrangements.

The Surveyor reviewed Patient #1's medical record on 7/29/2020 and 7/30/2020. Patient #1's medical record indicated that he/she had presented to the ED of Hospital Campus #2 for evaluation of increasing shortness of breath. Patient #1 underwent a comprehensive medical work up that included laboratory work and imaging. Patient #1's medical record indicated that he/she was to be admitted to Campus #2's ICU. Patient #1's medical record later indicated the decision was changed to admit the Patient #1 to Campus #1's ICU.

The Surveyor interviewed Campus #2's Intensivist (a physician who specializes in ICU care) at 7:45 A.M. on 7/29/2020. The Intensivist said he went to the ED to examine and review the medical record for Patient #1 before accepting the patient for admission to the ICU. The Intensivist said because of the pulmonary (lung) and nephrology (kidney) needs of Patient #1 the decision to admit Patient #1 to Campus #1's ICU was made.

Patient #1's medical record indicated that he/she was critically ill with a low percentage of oxygen in the blood, low blood pressure, and was diagnosed with pneumonia. Patient #1's medical record indicated that after treatment with bilevel positive airway pressure (BiPAP), IV fluid and antibiotics, Patient #1's blood pressure improved and his/her pulse oximetry was 94% (normal is 95-100%). Patient #1's medical record indicated that the ED physician was aware of the plan to transfer Patient #1 to the ICU at Campus #1.

Patient #1's medical record indicated that the patient arrived at the ICU at Campus #1 unresponsive and cyanotic (blueish skin) and required immediate intubation (a medical procedure that passes a breathing tube into the patient's lungs). Patient #1 experienced several cardiac arrests and expired hours later (date of death 7/22/2019).

The Surveyor interviewed the Emergency Medical Service (EMS) Manager at 2:15 P.M. on 7/28/2020. The EMS Manager said that he reviewed Patient #1's case and run sheet (the documentation that EMS transport uses) and notified the Ambulance Company of some concerns that he had with Patient #1's transport. The EMS Manager said that the regulatory agency, The Office of Emergency Medical Services (OEMS), for ambulance service conducted an investigation.

The Surveyor reviewed the Complaint Investigation Report (date of closure 12/17/19) on 7/28/2020 and 7/29/2020. The report indicated that the paramedics assigned to the transfer failed to contact medical control prior to transferring Patient #1 as required; made changes to Patient #1's BIPAP settings without notifying medical control as required; failed to notify medical control when they noticed a change in Patient #1's condition and bypassed Campus #1's (the receiving facility) ED after Patient 1's condition had worsened.

The Surveyor interviewed the Director of Quality and Patient Safety at 9:00 A.M. on 7/29/20. The Director said she had not seen the OEMS report until 7/28/2020, day one of this survey, despite the external investigation being completed more than six months before.

The Surveyor interviewed the ED Chief at 10:45 A.M. on 7/29/2020. The Chief said he had not seen the OEMS report until 7/28/2020, day one of this survey, despite the external investigation being completed more than six months before.

The Surveyor interviewed the EMS Manager at 10:00 A.M. on 7/29/2020. The EMS Manager said that he requested a copy of the OEMS report from the ambulance service and that he and the Medical Control Physician Director agreed on a corrective action plan which the EMS Manager had monitored from 9/1/2019 through 2/28/2020. The EMS Manager said that he reviewed all the transports from the Ambulance Company that had been cited while they used the CPAP, BIPAP or Ventilator equipment without identifying any issues. The EMS Manager said that he kept no written records of the monitoring. The EMS Manager said that the process he followed was to include the Medical Control Physician Director in the corrective action plan then to submit the report to the Regulatory Compliance Officer for filing.

The Surveyor interviewed the Medical Control Physician Director at 1:15 P.M. on 7/29/2000. The Medical Control Physician Director reviewed the deficient practices that were cited in the OEMS report and agreed that he had worked with the EMS Manager to design the corrective actions and assure compliance from the Ambulance Company that had been under investigation.

Because of the process used by the Hospital to review the external investigation of the Ambulance Company, neither the Hospital's Quality Team nor the ED Administration were aware of the investigation and thus failed to initiate a comprehensive performance improvement review and follow-up. There was no assessment of the other sixteen Hospital contracted ambulance services, initiation of a formal monitoring process, follow-up communication with the Hospital's ED staff, or other interventions designed to prevent a like event from occurring. Also, there was no evaluation of whether this occurrence met the criteria for disclosure to Patient #1's family as described in the Hospital Policy titled "Communication of Unanticipated Outcomes and Medical Errors".