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Based on medical record review, document review, and staff interview the critical access hospital (CAH) failed to comply with their provider agreement to provide an appropriate transfer. The CAH failed to ensure the receiving hospital had available space, qualified personnel, and agree to accept transfer for 1 out of 20 records selected for review (patient #1) from the Emergency Department (ED) log from May 2016 to November 2016. The ED treated approximately 71 patients in the six-month period and transferred approximately 12 patients in the same six months to another healthcare facility.


Failure to consult with the physician regarding the transfer of a patient with an unstable emergency medical condition placed the patient at risk for an unsafe transfer and lack of subsequent stabilizing treatment that could potentially lead to further complications or death.


Findings include:

- The hospital's policy titled "Transferring and Discharging Patients" reviewed on 11/28/2016 at 1:00 PM directed "...Transfer from ER...to another facility for further care: Transfer packet must be completed, which includes the following: Provider must order the transfer, arrange space availability, and have an accepting Provider at the facility prior to transfer. Certificate of transfer form must be completed. PCS (Physician Certification Statement) form must be completed if requiring ambulance transport ... and ... Nurse will call report on the patient to the receiving nurse".


- Patient #1's medical record review revealed he presented to the Emergency Department on 11/9/16 with chest pain and shortness of breath. The provider arrived at differential diagnoses for patient #1 of Myocardial Infarction (heart attack) and Pulmonary Embolism (Blood clot in the lungs) (both emergency medical conditions). The patient's son informed the CAH staff that he had spoken to physician Staff BB (a cardiologist who had treated the patient previously) from Hospital BB (an acute care hospital about one hour away) and he/she had agreed to accept the patient in transfer.

The CAH Physician failed to consult and confirm acceptance with Physician Staff BB or any other physician at Hospital BB regarding the transfer of this patient with an unstable emergency medical condition; failed to provide the patient with risks and benefits of the transfer; and failed to complete a certificate of transfer.


The CAH staff failed to follow their policy and procedure for transfer of a patient with an emergency medical condition by relying on the information the family provided to them and thus, they failed to ensure the receiving facility had the capacity and capability to treat this patient with an emergency medical condition.


(See further evidence at 2409)

Based on medical record review, document review, and staff interview the critical access hospital (CAH) failed to comply with their provider agreement to provide an appropriate transfer. The CAH failed to ensure the receiving hospital had available space, qualified personnel, and agreed to accept a transfer for 1 out of 20 records selected for review (patient #1) from the Emergency Department (ED) log. The ED treated approximately 71 patients in the six-month period and transferred approximately 12 patients in the same six months to another healthcare facility.


Failure to consult with the physician regarding the transfer of a patient with an emergency medical condition placed the patient at risk for an unsafe transfer and lack of subsequent stabilizing treatment that could potentially lead to further complications or death.


Findings include:


- Review of the Hospital /CAH Database Worksheet (dated 11/28/16) revealed the CAH did not provide the following services: cardiac catheterization laboratory, cardiac-thoracic surgery, cardiac intensive care unit (surgical or non-surgical), and operating rooms.


- Patient #1 presented to the Emergency department on 11/9/2016 with chest pain and shortness of breath. Patient had previous history (2009) of a massive heart attack causing cardiopulmonary arrest (sudden, unexpected loss of heart function, breathing, and consciousness) requiring resuscitation (process of correcting physiological disorders of an unwell patient). The patient had several stents (a small mesh tube that keeps an artery open) placed at that time in his coronary (heart) vessels. The patient had an implanted cardiac defibrillator (device placed under the skin, capable of monitoring the heart and treating potentially life threatening abnormal heart rhythms) in place. The medical record review revealed care and treatment at the CAH including a screening exam, nursing care, EKG (electrocardiography), cardiac monitoring, chest x-ray, oxygen, laboratory screening including cardiac markers, and medications including aspirin. ED Physician Staff B's differential diagnoses (the process of weighing the probability of one disease versus that of other diseases possibly accounting for a patient's illness) included heart attack and pulmonary embolus (blood clot in the lungs) (both emergency medical conditions). Review of the on-call schedule revealed that the CAH did not have the availability of an on-call cardiologist to further evaluate this patient. The patient had an emergency medical condition that had the potential to require access to a cardiac catheterization lab or cardiovascular surgical suite to provide stabilizing treatment, both of which the CAH did not have. Staff B documented on the "Emergency Department Provider Record" Consultation: Physician Staff BB (cardiologist at Hospital BB--an acute care hospital about 1 hour away). "Contacted by family. Physician Staff BB willing to accept patient in transfer".

Nursing Notes reviewed on 11/28/2016 at 12:00 PM revealed Registered Nurse Staff C's documentation indicated Patient #1 was being transferred to Hospital BB via ground EMS. Staff C indicated final vital signs were completed and ED Physician Staff B gave report to EMS personnel and paperwork was given to them.


- Review of Patient #1's Ambulance Run Sheet provided by EMS (Emergency Medical Services) Provider A on 12/2/16 revealed a Narrative that read in part: ...They (CAH Staff) report PT (patient) is being transferred to KU Cath Lab for cardiac evaluation and higher care. CAH staff report Hospital BB's physician staff BB has been contacted and accepted the PT...Cell phone report to Hospital BB who advise crew they are unaware of transfer. Nurse advises crew she will makes some calls and research transfer orders...Hospital BB's nurse returns call and advises crew she spoke with Physician Staff BB and was advised that he did not accept pt and did not activate cath lab. Nurse advises crew to give report on PT status. PT report given to Emergency Room (ER) nurse who advised crew to take pt to ER Triage upon arrival.

The CAH relied on the family's information and failed to confirm that the receiving hospital had the capacity and capability to accept Patient #1 in transfer and therefore, the CAH failed to arrange an appropriate transfer.

- ED Physician Staff B failed to document the name of the accepting physician and the date/time the patient was accepted in transfer to Hospital BB on the "Transfer Authorization" form. RN Staff C failed to document the name of Hospital BB's personnel who agreed to accept the patient as well as the date/time and the Unitbed/ED room number on the "Transfer Authorization" form. The form lacked a signature of the CAH's Staff who obtained acceptance of the patient to Hospital BB. A statement on the form before the blank signature line reads, "The receiving facility has the capability for the treatment of this patient (including adequate equipment and medical personnel and has agreed to accept the transfer and provide appropriate medical treatment".

ED Physician Staff B indicated s/he mistakenly failed to get verification of acceptance of Patient #1 at Hospital BB by Physician Staff BB after the patient's son communicated to them that the cardiologist (Physician Staff BB) who had provided care to the patient in the past, would accept him in transfer, that he/she was currently in the hospital, and would wait for the arrival of the patient. ED Physician Staff B revealed s/he failed to contact the receiving hospital by using the usual transfer line system that would have verified the necessary information prior to the patient transfer. This information would have included the physician-to-physician communication of the patient's information and verification of the receiving hospital's available space. ED Physician Staff B agreed there was missing documentation in the Physician section of the Transfer Agreement form and stated, "I normally make sure that the form is complete".

RN Staff C revealed s/he did speak to Physician Staff BB's RN at Hospital BB prior to transfer and believed this was a direct admission to the cardiac catheterization lab and the patient would bypass the receiving hospital's emergency department. RN Staff C confirmed this assumption is the reason s/he did not follow normal protocol and use Hospital BB's transfer line system to complete the transfer requirements. The nurses' notes lacked documentation that he/she called report to the receiving facility.


- The hospital's policy titled Transferring and Discharging Patients reviewed on 11/28/2016 at 1:00 PM directed "... Transfer from ER...to another facility for further care: Transfer packet must be completed, which includes the following: Provider must order the transfer, arrange space availability, and have an accepting Provider at the facility prior to transfer. Certificate of transfer form must be completed. PCS (Physician Certification Statement) form must be completed if requiring ambulance transport ...and ... Nurse will call report on the patient to the receiving nurse".