HospitalInspections.org

Based on record review, interview, and policy review, the hospital failed to comply with the provider agreement as defined in ?489.24(f). Findings include:

1. Review of a 4/14/11 2:00 a.m. ED referral form revealed:*Another hospital provider had requested the transfer to this facility of patient 27 with a cerebrovascular accident (stroke).
*The patient had not been accepted, and "physician" had been circled as the reason for non-acceptance.

Review of a 4/15/11 diversion analysis form revealed the reason for diversion had been due to no physician coverage.

Refer to A2411.

Based on record review, interview, and policy review, the provider failed to ensure:
*The provider's revised May 2009 diversion temporary closure to transfers in policy and procedure had been followed for the acceptance of one of one patient (27) transfer request from another provider.
*Complete and accurate data was provided on all emergency department (ED) patient diversions.
*Ongoing evaluation of the hospitals ED diversion system had been completed when unable to accept emergency transfers from other healthcare or hospital providers.
Findings include:

1. Review of a 4/14/11 2:00 a.m. ED referral form revealed:*Another hospital provider had requested the transfer of patient 27 with a cerebrovascular accident (stroke).
*The patient had not been accepted, and "physician" had been circled as the reason for non-acceptance.

Review of the undated hospitalists (physician who strictly works in a hospital setting) schedule revealed:
*Seven hospitalist's and one certified nurse practioner (CNP) were scheduled daily from 7:00 a.m. to 5:00 p.m.
*One admitting hospitalist was scheduled daily from 2:00 p.m. to 10:00 p.m.
*Two nocturnists and one CNP were scheduled daily from 5:00 p.m. to 7:00 a.m.

Interview on 5/3/11 at 9:15 a.m. and again at 1:30 p.m. with the vice president of quality, safety, and risk management revealed:
*There were two nocturnists (hospitalist physicians that strictly work nights) and one CNP scheduled during the night to handle admissions.
*Patients could also be admitted by their attending physicians if those physicians had privileges.
*Occasionally patients would have to be diverted to another provider due to no beds being available or the hospitalist service was too busy to admit more patients.
*There was a maximum of 120 patients per day for the hospitalist service.
*She stated the 120 patient census was a guideline that was used.
*Occasionally the hospitalist service would have more than 120 patients per day on their service, up to 124.
*She was part of the diversion sub-committee that met on a bi-monthly basis.
*She compiled the data for the diversion sub-committee.
*She received all diversion analysis reports.

Interview on 5/3/11 at 2:15 p.m. with the assistant director of the ED and the administrative director of outpatient services revealed:
*ED physicians took all the referral calls.
*The ED physician would coordinate with the hospitalist and the hospital coordinator on physician availability, bed availability, staffing, and equipment.
*The ED physician would make the determination if the patient would be accepted or diverted based on that information.
*The ED physicians were to fill out the referral forms.

Interview on 5/4/11 at 10:30 a.m. with the administrative director of patient care and the director of clinical coordination and staffing revealed:
*An e-mail was sent out every morning with the number of hospitalist patients on service.
*A phone call was placed to the hospital coordinator and hospitalist if the number was close to being capped.
*The hospital coordinator was to be called on all bed availability.
*The hospital coordinator on duty was also part of the rapid response team. code team, and managed the nurse staffing.

Interview on 5/4/11 at 10:50 a.m. with the chief medical officer, the administrative director of hospitalist program, the care coordinator of hospitalist's, and the co-medical director for the hospitalist program revealed:
*The number set for the hospitalist patient census was actually 122 patients.
*The census number was a guideline gathered from information on other hospitalist programs for safe patient care.
*Between 12 and 17 patients was the average number of patients routinely seen by hospitalists across the country.
*The guideline set for this program was 16 patients per hospitalist.
*That number could vary depending on the hospitalist.
*The hospital coordinator was updated approximately every one-half hour on the hospitalist patient census from 7:00 a.m. to 5:00 p.m.
*The only written hospitalist census recorded was at 7:30 a.m., 2:00 p.m., and 5:00 p.m.
*An assigned hospitalist/nocturnists had the census from 5:00 p.m. to 7:00 a.m. to communicate to the emergency department physicians.
*The chief medical officer stated two hospitalists were scheduled to start in July 2011.

Review of a 4/15/11 diversion analysis form revealed:
*The reason for diversion had been due to no physician coverage.
*The hospital coordinator had not been called prior to diverting the patient.
*The comments section stated "No physician coverage, beds available."
*The nursing administration/risk management review had not been completed until 4/20/11.
*No further analysis had been completed.
*The hospitalist census at that time was not documented.

Review of the 4/13/11 at 5:00 p.m. through 4/14/11 at 7:17 a.m. ED patient daily list revealed there had been eleven patients admitted from the ED to the hospital. At 5:00 p.m. on 4/13/11 the hospitalist service had 109 patients on its service. The list did not indicate if all eleven of those admissions had been handled by the hospitalist service. The hospitalist patient census at 7:30 a.m. on 4/14/11 was 118 patients.

Review of the hospitalist/nocturnists patient census revealed:
*On 4/13/11 at 7:30 a.m. the census was 118 patients.
*On 4/13/11 at 2:00 p.m. the census was 107 patients.
*On 4/13/11 at 5:00 p.m. the census was 109 patients.
*On 4/14/11 at 7:30 a.m. the census was 118 patients.
*On 4/14/11 at 2:00 p.m. the census was 107 patients.
*On 4/14/11 at 5:00 p.m. the census was 109 patients.

Review of the 4/13/11 ED referrals revealed:
*There were 19 referral calls:
-Six patients were diverted due to a high hospitalist census.
-One patient was diverted due to no pediatric bed availability.
-Nine patients were accepted and seen in the ED.
-One was unknown as the form had incomplete data.
-One patient did not show up.
-One patient was directed to radiology.

Review of the 4/14/11 ED referrals revealed:
*There were 19 referral calls.
-One patient was diverted due to a high hospitalist census.
-Three were unknown as the form had incomplete data.
-Twelve patients were accepted and seen in the ED.
-One patient was not transferred.
-One patient did not show up.
-One patient was directed to radiology.

Review of the active medical staff roster revealed there were 24 hospitalists on staff as of 5/3/11.

Review of the provider's revised May 2009 diversion temporary closure to transfers in policy revealed:
*Potential categories for temporary diversion would be based on:
-Bed availability diversion due to saturation would be prevented/avoided to the extent possible by effective resource utilization and effective patient flow.
-An inadequate number of nursing staff. That criteria would assume an aggressive effort had occurred utilizing the appropriate staffing resources, policies, and procedures.
-The physician or specialist necessary to provide care to the transfer patient was unavailable due to commitment to an ongoing operative procedure or the physician specialist required to provide medical management was not available.
*The hospital coordinator and the nursing administrator on-call would determine the need for temporary diversion, on a case by case basis, if possible, in conjunction with the the following individuals or their designee as applicable for the criteria met:
-ED director and/or ED physician on duty.
-Applicable department directors.
-Medical staff department chair or designee on-call.
*The involved individuals would determine the following:
-The anticipated length of the diversion.
-The time frame and necessary participants for re-evaluation of temporary diversion status.
*The nursing administrator on-call would coordinate the notification of the following departments of the category of diversion, the anticipated length, the time frame for re-evaluation, and notification when the diversion was canceled.
*The hospital coordinator would keep a log of the date, time, and category for temporary diversion as well as individuals involved in the decision making process.
*All medical staff were requested to notify the hospital coordinator with each occurrence of a patient diversion.

Review of the provider's 9/21/10 performance improvement risk management/safety (PIRMS) committee meeting minutes on patient diversions revealed:
*Different process and communication on patient diversion was being looked at.
*Reinforcement of the phone number that hospital coordinators used exclusively to contact/communicate with the ED physicians.
*The hospital coordinators called the hospitalist every hour or two if in red status.
*The ED chair physician was willing to follow-up on diversion reports to see if the hospitalist was called.

Review of the provider's PIRMS committee meeting minutes on 10/19/10, 12/21/10, 1/18/11, 2/15/11, 3/22/11, and 4/19/11 had no information on patient diversions.

Review of the 3/29/11 executive committee meeting minutes revealed:
*The hospital performance monitoring for patient flow: diversions related to high census alerts had been reviewed.
*The data was for January 2010 through December 2010.
*The target was for one diversion a month.
*Diversion numbers were listed as follows:
-January 2010 - 11.
-February 2010 - 19.
-March 2010 - 33.
-April 2010 - 35
-May 2010 - 45.
-June 2010 - 40.
-July 2010 - 27.
-August 2010 - 10.
-September 2010 - 46.
-October 2010 - 33.
-November 2010 - 12.
-December 2010 - 11.
*The opportunity for improvement and actions/recommendations for diversions related to high census alerts revealed:
-Diversions fluctuated dependent on bed availability and access to physicians. Continue to evaluate each diversion for solutions to issues.
-Primary issue for September was related to hospitalist or specialty.
-Bed issues could mostly be resolved if the hospital coordinator was notified to ensure bed availability before the patient was diverted.

Review of the provider's diversion reports from July 2010 through March 2011 revealed:
*July 2010 - Of the 27 diversions 19 were related to the availability of a hospitalist.
*August 2010 - Of the 10 diversions 3 were related to the availability of a hospitalist.
*September 2010 - Of the 46 diversions 41 were related to the availability of a hospitalist.
*October 2010 - Of the 33 diversions 24 were related to the availability of a hospitalist.
*November 2010 - Of the 12 diversions 5 were related to the availability of a hospitalist.
*December 2010 - Of the 11 diversions 5 were related to the availability of a hospitalist.
*January 2011 - Of the 18 diversions 9 were related to the availability of a hospitalist.
*February 2011 - Of the 7 diversions 3 were related to the availability of a hospitalist.
*The March 2011 and April 2011 data had not yet been analyzed.

Based on record review, interview, and policy review, the provider failed to ensure:
*The provider's revised May 2009 diversion temporary closure to transfers in policy and procedure had been followed for the acceptance of one of one patient (27) transfer request from another provider.
*Complete and accurate data was provided on all emergency department (ED) patient diversions.
*Ongoing evaluation of the hospitals ED diversion system had been completed when unable to accept emergency transfers from other healthcare or hospital providers.
Findings include:

1. Review of a 4/14/11 2:00 a.m. ED referral form revealed:*Another hospital provider had requested the transfer of patient 27 with a cerebrovascular accident (stroke).
*The patient had not been accepted, and "physician" had been circled as the reason for non-acceptance.

Review of the undated hospitalists (physician who strictly works in a hospital setting) schedule revealed:
*Seven hospitalist's and one certified nurse practioner (CNP) were scheduled daily from 7:00 a.m. to 5:00 p.m.
*One admitting hospitalist was scheduled daily from 2:00 p.m. to 10:00 p.m.
*Two nocturnists and one CNP were scheduled daily from 5:00 p.m. to 7:00 a.m.

Interview on 5/3/11 at 9:15 a.m. and again at 1:30 p.m. with the vice president of quality, safety, and risk management revealed:
*There were two nocturnists (hospitalist physicians that strictly work nights) and one CNP scheduled during the night to handle admissions.
*Patients could also be admitted by their attending physicians if those physicians had privileges.
*Occasionally patients would have to be diverted to another provider due to no beds being available or the hospitalist service was too busy to admit more patients.
*There was a maximum of 120 patients per day for the hospitalist service.
*She stated the 120 patient census was a guideline that was used.
*Occasionally the hospitalist service would have more than 120 patients per day on their service, up to 124.
*She was part of the diversion sub-committee that met on a bi-monthly basis.
*She compiled the data for the diversion sub-committee.
*She received all diversion analysis reports.

Interview on 5/3/11 at 2:15 p.m. with the assistant director of the ED and the administrative director of outpatient services revealed:
*ED physicians took all the referral calls.
*The ED physician would coordinate with the hospitalist and the hospital coordinator on physician availability, bed availability, staffing, and equipment.
*The ED physician would make the determination if the patient would be accepted or diverted based on that information.
*The ED physicians were to fill out the referral forms.

Interview on 5/4/11 at 10:30 a.m. with the administrative director of patient care and the director of clinical coordination and staffing revealed:
*An e-mail was sent out every morning with the number of hospitalist patients on service.
*A phone call was placed to the hospital coordinator and hospitalist if the number was close to being capped.
*The hospital coordinator was to be called on all bed availability.
*The hospital coordinator on duty was also part of the rapid response team. code team, and managed the nurse staffing.

Interview on 5/4/11 at 10:50 a.m. with the chief medical officer, the administrative director of hospitalist program, the care coordinator of hospitalist's, and the co-medical director for the hospitalist program revealed:
*The number set for the hospitalist patient census was actually 122 patients.
*The census number was a guideline gathered from information on other hospitalist programs for safe patient care.
*Between 12 and 17 patients was the average number of patients routinely seen by hospitalists across the country.
*The guideline set for this program was 16 patients per hospitalist.
*That number could vary depending on the hospitalist.
*The hospital coordinator was updated approximately every one-half hour on the hospitalist patient census from 7:00 a.m. to 5:00 p.m.
*The only written hospitalist census recorded was at 7:30 a.m., 2:00 p.m., and 5:00 p.m.
*An assigned hospitalist/nocturnists had the census from 5:00 p.m. to 7:00 a.m. to communicate to the emergency department physicians.
*The chief medical officer stated two hospitalists were scheduled to start in July 2011.

Review of a 4/15/11 diversion analysis form revealed:
*The reason for diversion had been due to no physician coverage.
*The hospital coordinator had not been called prior to diverting the patient.
*The comments section stated "No physician coverage, beds available."
*The nursing administration/risk management review had not been completed until 4/20/11.
*No further analysis had been completed.
*The hospitalist census at that time was not documented.

Review of the 4/13/11 at 5:00 p.m. through 4/14/11 at 7:17 a.m. ED patient daily list revealed there had been eleven patients admitted from the ED to the hospital. At 5:00 p.m. on 4/13/11 the hospitalist service had 109 patients on its service. The list did not indicate if all eleven of those admissions had been handled by the hospitalist service. The hospitalist patient census at 7:30 a.m. on 4/14/11 was 118 patients.

Review of the hospitalist/nocturnists patient census revealed:
*On 4/13/11 at 7:30 a.m. the census was 118 patients.
*On 4/13/11 at 2:00 p.m. the census was 107 patients.
*On 4/13/11 at 5:00 p.m. the census was 109 patients.
*On 4/14/11 at 7:30 a.m. the census was 118 patients.
*On 4/14/11 at 2:00 p.m. the census was 107 patients.
*On 4/14/11 at 5:00 p.m. the census was 109 patients.

Review of the 4/13/11 ED referrals revealed:
*There were 19 referral calls:
-Six patients were diverted due to a high hospitalist census.
-One patient was diverted due to no pediatric bed availability.
-Nine patients were accepted and seen in the ED.
-One was unknown as the form had incomplete data.
-One patient did not show up.
-One patient was directed to radiology.

Review of the 4/14/11 ED referrals revealed:
*There were 19 referral calls.
-One patient was diverted due to a high hospitalist census.
-Three were unknown as the form had incomplete data.
-Twelve patients were accepted and seen in the ED.
-One patient was not transferred.
-One patient did not show up.
-One patient was directed to radiology.

Review of the active medical staff roster revealed there were 24 hospitalists on staff as of 5/3/11.

Review of the provider's revised May 2009 diversion temporary closure to transfers in policy revealed:
*Potential categories for temporary diversion would be based on:
-Bed availability diversion due to saturation would be prevented/avoided to the extent possible by effective resource utilization and effective patient flow.
-An inadequate number of nursing staff. That criteria would assume an aggressive effort had occurred utilizing the appropriate staffing resources, policies, and procedures.
-The physician or specialist necessary to provide care to the transfer patient was unavailable due to commitment to an ongoing operative procedure or the physician specialist required to provide medical management was not available.
*The hospital coordinator and the nursing administrator on-call would determine the need for temporary diversion, on a case by case basis, if possible, in conjunction with the the following individuals or their designee as applicable for the criteria met:
-ED director and/or ED physician on duty.
-Applicable department directors.
-Medical staff department chair or designee on-call.
*The involved individuals would determine the following:
-The anticipated length of the diversion.
-The time frame and necessary participants for re-evaluation of temporary diversion status.
*The nursing administrator on-call would coordinate the notification of the following departments of the category of diversion, the anticipated length, the time frame for re-evaluation, and notification when the diversion was canceled.
*The hospital coordinator would keep a log of the date, time, and category for temporary diversion as well as individuals involved in the decision making process.
*All medi