HospitalInspections.org

Based on policy and procedure review, medical record review, staff and medical staff interviews the critical access hospital (CAH) failed to follow their policy regarding providing an appropriate medical screening examination (MSE) for 1 (P21) of 23 sampled records, stabilizing treatment and appropriate method of transport for 1 (P14) of 7 sampled transfer medical records. This failed practice has the potential to affect all patients who present and require transfer from the CAH. According to facility provided information the Emergency Department (ED) sees on average 134 patiens per month and transfers an average of 15 patients per month.

See citation C2407 and C2409, that also resulted in C2400 to not be met.

Based on policy and procedure review, medical record review, staff and medical staff interviews the critical access hospital (CAH) failed to provide stabilizing treatment for 1 (P14) of 7 sampled transfer medical records. This failed practice has the potential to affect all patients who require stabilizing treatment prior to transfer from the CAH. According to facility provided information the Emergency Department (ED) transfers an average of 15 patients per month.

See citation A2400 and A2409, that also resulted in A2407 to not be met.

Findings include:

A. Review of facility policy, "Emergency Examination and Transfer Policy (EMTALA)-(Howard County)," approved 2/2023 revealed, "stabilized means: with respect to an EMC (emergency medical condition) other than a woman in labor, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility."

Further examination and treatment revealed, "If the MSE (medical screening exam) reveals that the individual has an EMC, the hospital shall provide either: within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition; or appropriate transfer to another medical facility."

B. Review of P14's medical record revealed, P14 presented to the CAH on 10/19/2022 at 1:10PM via private vehicle, walk in with a chief complaint of shortness of breath (not able to breath), dyspnea on exertion for the past 3 days (difficulty breathing with activity), a past medical history of Chronic Obstructive Pulmonary Disease (COPD)(breathing disorder that can flair up and cause respiratory problems).

-1:10PM P14 arrived on room air (patient independently maintaining oxygen levels on their own without the need for supplemental oxygen).
-1:20PM P14 required 3 liters of oxygen via nasal cannula (the amount of oxygen delivered through a nasal tube to supplement).
-2:40PM P14 required 5 liters of oxygen via nasal cannula (the amount of oxygen was increased to supplement needs).
-3:33PM P14 required 6 liters of oxygen via nasal cannula (the amount of oxygen was increased again).
-4:00PM An Arterial Blood Gas (ABG) was drawn, and revealed pH 7.39, pCO2 23.4, pO2 60, HCO3 14.5, Base excess -10.3, Oxygen saturation of 91% on 6 liters of oxygen via nasal cannula [the entire ABG revealed abnormal levels] (blood levels drawn to determine patient respiratory gas exchange status.)
-4:44PM P14 required 15 liters of oxygen via a non-rebreather mask (the amount of oxygen was increased to the maximum and delivery method was changed from tubes in the nose, to a mask covering the nose and mouth).

P14 left the CAH at 5:20 PM on 15 liters non-rebreather with an unstabilized EMC of respiratory distress with a plan to transfer from the CAH via ground ambulance approximately 120 miles to ACF-B for acute respiratory distress (not able to breathe or maintain oxygen levels to live).

The ground ambulance was diverted to ACF-A 23 miles enroute from the CAH to ACF-B during an interfacility transfer of the patient, pregnant at 29 weeks gestation with an EMC of profuse vaginal bleeding (pregnant woman bleeding a lot putting mom and baby at high risk). P14 required intubation (a tube inserted into the patient's airway to provide life sustaining breaths when the patient can't breathe on their own) to stabilize respiratory status and air helicopter transport at ACF-A prior to transfer to ACF-B on 10/19/2022.

C. During an interview on 6/24/2024 at 11:27AM, RN-A revealed, P14 had no vaginal bleeding prior to transfer. If a patient in the emergency department requires intubation the procedure is the physician on call manages the airway. The CAH has capability to intubate by either a Physician, Advanced Practice Provider or CRNA, and has a ventilator at the facility.

During an interview on 6/24/2024 at 11:55AM, CRNA-A revealed, Physician-A called to have CRNA-A on standby at the CAH with the capability to intubate P14 if ordered. CRNA-A revealed that Physician-A did not consult (order) for P14 to be assessed or intubated by CRNA-A prior to transfer.

During an interview on 6/24/2024 at 1:16PM, Physician-A revealed, CRNA-A was called in by Physician-A, and present at the CAH incase P14 required intubation prior to transfer. Physician-A decision making was to not intubate P14 prior to transfer, due to "P14 maintained oxygen saturations on 15L non-rebreather (maximum amount of oxygen that can be used on the mask/delivery method) prior to transfer [by ground ambulance approximately 120 miles away from CAH]. Physician-A revealed P14 was provided stabilizing treatment of broad-spectrum antibiotics (when source is unknown the physician will start antibiotics to prevent sepsis/blood infection), steroids (medication to reduce swelling), and oxygen (given to sustain life with respiratory complications) prior to transfer..

Based on policy and procedure review, medical record review, staff and medical staff interviews the critical access hospital (CAH) failed to provide an appropriate transport method for 1 (P14) of 7 sampled transfer medical records. This failed practice has the potential to affect all patients who require transfer from the CAH. According to facility provided information the Emergency Department (ED) transfers an average of 15 patients per month.

See citation A2400 and A2407, that also resulted in A2409 to not be met.

Findings include:

A. Review of facility policy, "Emergency Examination and Transfer Policy (EMTALA)-(Howard County)," approved 2/2023 revealed, "stabilized means: with respect to an EMC (emergency medical condition) other than a woman in labor, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility."

Appropriate transfer in Unstabilized EMC revealed, Transfer of an individual in an unstabilized EMC to another hospital facility requires the following: "Within the hospital's capabilities, medical treatment must be provided that minimizes the risks to the individual's health...."

Responsibilities of the Physicians revealed, "In the case of transfer, determine mode of transportation and qualified accompanying personnel."

Review of P14's medical record revealed, P14 presented to the CAH on 10/19/2022 at 1:10PM via private vehicle, walk in with a chief complaint of shortness of breath (not able to breath), dyspnea on exertion for the past 3 days (difficulty breathing with activity), a past medical history of Chronic Obstructive Pulmonary Disease (COPD)(breathing disorder that can flair up and cause respiratory problems).

-1:10PM P14 arrived on room air (patient independently maintaining oxygen levels on their own without the need for supplemental oxygen).
-1:20PM P14 required 3 liters of oxygen via nasal cannula (the amount of oxygen delivered through a nasal tube to supplement).
-2:40PM P14 required 5 liters of oxygen via nasal cannula (the amount of oxygen was increased to supplement needs).
-3:33PM P14 required 6 liters of oxygen via nasal cannula (the amount of oxygen was increased again).
-4:00PM An Arterial Blood Gas (ABG) was drawn, and revealed pH 7.39, pCO2 23.4, pO2 60, HCO3 14.5, Base excess -10.3, Oxygen saturation of 91% on 6 liters of oxygen via nasal cannula [the entire ABG revealed abnormal levels] (blood levels drawn to determine patient respiratory gas exchange status.)
-4:44PM P14 required 15 liters of oxygen via a non-rebreather mask (the amount of oxygen was increased to the maximum and delivery method was changed from tubes in the nose, to a mask covering the nose and mouth).

P14 left the CAH at 5:20 PM on 15 liters non-rebreather with an unstabilized EMC of respiratory distress with a plan to transfer from the CAH via ground ambulance approximately 120 miles to ACF-B for acute respiratory distress (not able to breathe or maintain oxygen levels to live).

The ground ambulance was diverted to ACF-A 23 miles enroute from the CAH to ACF-B during an interfacility transfer of the patient, pregnant at 29 weeks gestation with an EMC of profuse vaginal bleeding (pregnant woman bleeding a lot putting mom and baby at high risk). P14 required intubation (a tube inserted into the patient's airway to provide life sustaining breaths when the patient can't breathe on their own) to stabilize respiratory status and air helicopter transport at ACF-A prior to transfer to ACF-B on 10/19/2022.

C. During an interview on 6/24/2024 at 1:16PM, Physician-A revealed, they did not recall speaking to a transport service prior to P14's transfer, "the nurses handle that." The CRNA-A was called in by Physician-A, and was present at the CAH incase P14 required intubation prior to transfer. Physician-A decision making was to not intubate P14 prior to transfer, due to "P14 maintained oxygen saturations on 15L non-rebreather (maximum amount of oxygen that can be used on the mask/delivery method) prior to transfer [by ground ambulance approximately 120 miles away from CAH]. Physician-A revealed P14 was provided stabilizing treatment of broad-spectrum antibiotics (when source is unknown the physician will start antibiotics to prevent sepsis/blood infection), steroids (medication to reduce swelling), and oxygen (given to sustain life with respiratory complications) prior to transfer.