HospitalInspections.org

Based on review of medical records, policies and procedures, Emergency Department (ED) logs, transfer call recordings/logs, Medical Staff By-Laws/Rules and Regulations, and interviews, it was determined the hospital with specialized capabilities and facilities refused to accept an appropriate transfer from a referring hospital for a patient with an emergency medical condition for 1 (Patient #1) of 20 sampled patients.

Findings include:

Cross Refer to findings in A-2411.

Based on review of medical records, policies and procedures, Emergency Department (ED) logs, transfer call recordings/logs, Medical Staff By-Laws/Rules and Regulations, and interviews, it was determined the hospital with specialized capabilities and facilities failed to accept an appropriate transfer from a referring hospital for a patient with an emergency medical condition for 1 (Patient #1) of 20 sampled patients.

Findings:

A review of Patient # 1's medical record from TRANSFERRING FACILITY revealed Patient # 1 was admitted to the Emergency Department (ED) on 4/14/20 at 2:58 p.m. with a complaint of abscess on the left side of her neck. Patient # 1 noticed it one week prior to this visit. She had been seen at her primary physician's office where she received a shot of antibiotics and a prescription to take at home. She presented on this date to the ED stating the abscess had gotten larger and was tender to touch. Past medical history included but was not limited to asthma/bronchitis (disorder that affects the lungs and is characterized by airway constriction that leads to shortness of breath, chest tightness, and wheezing), deep vein thrombosis (a serious condition that occurs when a blood clot forms in a vein located deep inside your body), essential hypertension (high blood pressure that doesn't have a known secondary cause), hyperlipidemia (A condition in which there are high levels of fat particles (lipids) in the blood), and morbid obesity (A disorder involving excessive body fat that increases the risk of health problems.) Patient # 1's height was 5 feet 4 inches and her weight was 250 pounds and 4 ounces. Her body mass index (is a measurement of estimate of body fat based on height and weight) was calculated at 43 kilograms per square meter. Patient # 1's vital signs were as follows: Blood Pressure (BP) 116/77 (Normal 90-140/60/90), Pulse-74 beats per minute (bpm) (Normal 60-100, Respirations - 18 breaths per minute (normal 14-20), and Temperature 36.8 Centigrade © (unit of measurement). Patient # 1 was alert, oriented, and answered all questions. Consent for treatment was given verbally and cosigned by two Registered Nurses at 3:28 p.m.
At 3:09 p.m., Physician's Assistant (PA) performed a medical screening exam and revealed Patient #1 was stable for work up. Blood tests and a Computed Tomography (CT) (medical imaging procedure that allows Doctors to see inside your body) scan of the neck area was ordered. Pain medications and antibiotics were administered as ordered at 4:22 p.m. At 6:47 p.m. Medical Doctor (MD) documented in a progress note that the blood work was benign (descriptive term for conditions that present no danger to life or well-being). The CT scan results revealed this mass could be an abscess or could be a primary neoplasm (abnormal mass of tissue that results when cells divide more than they should or do not die when they should). Neoplasms may be benign (not cancer), or malignant (cancer). Progress note revealed the case and the CT scan results were discussed with the on-call physician who felt the case should be sent to a facility with otolaryngology ( medical specialty which is focuses on the ears, nose, and throat). At 7:50 p.m., an acute care facility with specialized capabilities accepted Patient #1 for transfer to their facility. At 10:22 p.m. Patient # 1 was discharged in stable condition to Emergency Medical Services for transport to a receiving facility with capabilities to provide further treatment. Transfer papers included Patient #1's demographics, Emergency Department Visit, Lab results, and CT results.

A review of the transferring facility's transfer call recording from 5/4/20 at 9:00 a.m., revealed the initial call was placed on 4/14/20 at 6:50:37 p.m., from the Transferring Facility Registered Nurse (RN) KK. She spoke with Bed Coordinator Technician (Tech) GG. At 6:52:57 the call was transferred to House Supervisor Registered Nurse (RN) CC. Transfer Facility RN KK gave identifying information on Patient # 1 to RN CC and said Patient # 1 had a neck mass. Transfer Facility RN KK provided information that Patient #1 had been treated at a private physician's office and was taking antibiotics, but it was not getting any better. Transferring facility RN KK told RN CC the mass had been there about a week.

At 6:54:38, RN CC spoke with transferring facility MD II. Transferring Facility MD II reported to RN CC that he thought it was probably an abscess. Transferring facility MD II said Patient # 1 had noticed it about a week ago and Patient # 1 was not having any airway problems. He told RN CC that the radiologist said it could possibly be a necrotic tumor. Transferring facility MD II said he had consulted with one of his surgeons who said if she did an acute excision and it turned out be a tumor we could do more harm to Patient # 1 than good. Transferring MD II told RN CC that Patient # 1 was tolerating antibiotics and labs were normal. RN CC asked transferring facility MD II if he thought hospitalization was needed right now or could Patient # 1 be seen by someone in the office the next day. RN CC explained the receiving facility was "getting close on beds." At 6:56:29 p.m., transferring facility MD II said Patient # 1 is elderly and at risk for decompensation. After speaking with Patient # 1, transferring facility MD II told RN CC that Patient # 1 was "hurting pretty bad" and did not feel she should go home. Transferring MD II explained that elderly could decompensate quickly despite normal labs and transferring facility MD II felt Patient # 1 should go ahead and be admitted. RN CC said she would speak with on call Ear Nose and Throat (ENT) MD AA and call back.

A continued review of transfer center call logs revealed a call came in on 4/14/20 at 7:04:39 from the receiving facility RN CC, with the On-call ENT MD AA to speak with transferring facility MD II. At 7:05:48 p.m., both physicians were on the call with RN CC and transferring facility RN KK. On-call ENT MD AA said to transferring facility MD II, "convince me I have to take this patient tonight". Transferring MD II responded, "just tell me you don't want to take it and I'll go somewhere else". The On-call ENT MD AA said this is something that could be worked up outpatient-an asymptomatic neck mass. Transferring facility MD II explained it was not asymptomatic, it had an acute onset, pain, and the swelling is significant. Transferring MD II said he suspected an abscess, but the radiologist said it was potential for a necrotic mass. Transferring MD II said he had consulted with his surgeon who told him if it was a tumor, she would be doing Patient # 1 a disservice by cutting into it. The On-call ENT MD AA told transferring MD II that he had just received an abscess from them yesterday. He asked if they could distribute Patient # 1 to someone else. Transferring facility MD II responded to the On-call ENT MD AA if he could not do it or did not want it, they would send it somewhere else. The On-call ENT MD AA said your (transferring) facility's Chief Executive Officer said we should not be getting calls from you, that you have an agreement with Macon. Transferring facility MD II said he was not aware of an agreement and could be heard asking his transfer center if they knew of an agreement. Transfer center coordinator RN KK said she was not aware of one. Transferring facility MD II said he did not want to push this on anyone and said to the On-call ENT MD AA, if he was not interested, they would send Patient # 1 somewhere else. The On-call ENT MD AA said, "I don't want to have a patient in the hospital for something I usually do outpatient". The On-call ENT MD AA said if the transferring facility wanted to get the receiving facility's hospitalist to take Patient # 1, he would consult. The On-call ENT MD AA told transferring MD II that he was not admitting Patient # 1 at night. ENT MD said he would be glad to see Patient # 1 in his office. Transferring facility MD II said he would try somewhere else, that it would be better.

A review of Policy # 2.002 (HPP 105), Emergency Medical Treatment and Patient Transfer Policy, approved 4/1/19 revealed the purpose of the policy to provide guidelines and procedures for compliance with the Emergency Medical Treatment and Labor Act (EMTALA) by providing appropriate Medical Screening Examination (MSE), Stabilization and Treatment or Transfer of individuals seeking examination or treatment for a medical condition or an Emergency Medical Condition. The policy defines the following:
"Capabilities" means physical space, equipment, supplies and services (including ancillary services) that are available. The capabilities of staff mean the level of care that personnel can provide within the training and scope of their professional licenses.
"Capacity" means the ability to accommodate the individual requesting a medical screening examination or to provide necessary stabilizing treatment of an individual who is diagnosed with an emergency medical condition (including transferred individuals).
Emergency Medical Condition" ("EMC") means:
A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, or symptoms of substance abuse) such that absence of immediate medical attention could reasonably be expected to result in: (a) placing the individual (or, the health of a pregnant woman's unborn child) in serious jeopardy; (b) serious impairment to bodily functions; or (c) serious dysfunction of any bodily organ or part.

RECEIPT OF TRANSFERS
Transfer from other facilities shall be accepted of an individual who requires specialized capabilities or facilities if SGHS has such specialized capabilities or facilities and also has the Capacity to treat the individual.
SGHS is required to report to the Georgia Department of Human Resources Office of Regulatory Services or the Centers for Medicare & Medicaid Services (previously known as the Health Care Financing Administration) any time it has reason to believe it has received an individual suffering from an Emergency Medical Condition who was not Stabilized prior to the Transfer or if the Transfer did not comply with the Transfer procedures set forth above. Any employee who believes that an individual has been inappropriately Transferred shall immediately notify his/her Department Manager, who will in turn notify the Director of Risk Management.

CENTRAL LOG
The Emergency Department will maintain a central log on each individual who comes to a Dedicated Emergency Department seeking medical care for an Emergency Medical Condition.
All logs will be available in a timely manner for survey or review and shall be retained for five (5) years from the date of transfer.
The Central log must contain:
--Name of the individual seeking assistance; and
--The disposition (individual refused treatment, Stabilized and Transferred, admitted and treated, discharged).

PHYSICIANS ON-CALL
An on-call list of physicians on the Medical Staff will be maintained in a manner that best meets the needs of those receiving the medical services required under this policy, in accordance with the resources available, including the availability of on-call physicians.
Physicians on-call are required to appropriately respond to a call for emergency medical services within thirty (30) minutes from the time of the call.

A review of Medical Staff Policy # 5, Emergency Medical Treatment and Active Labor Act (EMTALA), effective date 9/17/08, reviewed and reformatted 4/17 revealed the purpose of the policy is to establish the obligations of physicians who provide on-call coverage to the facility's Emergency Department. Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in:
---Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
---Serious impairment to bodily functions;
---Serious dysfunction of any bodily organ or part;

Patient means (1) an individual who has begun to receive outpatient services resulting from direct personal contact between the individual and physician or other authorized person in order to furnish hospital services for diagnosis and treatment (other than treatment required under this Policy); and (2) an individual who has been admitted as an inpatient.
Stabilize means to provide such medical treatment of an Emergency Medical Condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to occur during the Transfer of the individual from the Hospital, or, with respect to a pregnant woman who is having contractions, that she has delivered a child (including the placenta).

The facility maintains an on-call list of physicians on the Active Medical Staff in a manner that best meets the needs of those receiving the medical services required in accordance with the resources available to the facility, including the availability of the on-call physicians.

Members of the Active Medical Staff are required to take Emergency Department call, as determined by the individual Medical Staff clinical departments taking into account the needs of the community and the number of Active Staff Members available in that specialty. The Emergency Department physician is responsible for determining whether the on-call physician must physically assess a patient in the Emergency Department.

A review of Policy # 2.020 (HPP 07), Admission, Transfer, and Discharge, revised 8/27/19 revealed the policy is a resource for patient admission, transfer and discharge. The Transfer Center will assign an available room and bed consistent with the patient's care needs (e.g., diagnosis, age). This will occur in collaboration with the nursing unit and the Patient Flow Coordinator/Administrative Coordinator. Providers may admit patients to the hospital either by written, electronic or verbal order. Patients will be admitted and discharged on the order of a provider, who is a member of the medical staff with admission/discharge privileges.
Direct admissions from other facilities must be accepted for admission by a facility medical staff member, the Administrative Coordinator/DON or designee, and/or the Patient Flow Coordinator, Charge Nurse or PCC (as appropriate). The Administrative Coordinator and/or Patient Flow Coordinator will verify availability of a bed prior to acceptance of the patient.

A review of the facility's on-call physician log for the past six months revealed active staff members were on call every day for the following specialties: Ear, Nose, Throat/Gastroenterology/Family Practice/Cardiology/Neonatology/Obstetrics and Gynecology/General Surgery/Infectious Diseases/Nephrology/Neurosurgery/Oral Surgery/Orthopedics/Plastic surgery/Oncology/Podiatry/Psychiatry/Urology/Pediatrics.

A review of Medical Staff By-Laws, Adopted by Medical Staff 2/18/20 revealed in
Article III that to be eligible to apply for initial appointment or reappointment and individual must, if applying for Active Staff Membership, agree to fulfill all responsibilities regarding emergency call;
Article IV revealed all members of the active medical staff should belong to a specific department or service and are required to attend Staff meetings and fulfill all obligations set forth in these bylaws. Including, but not limited to assuming all functions and responsibilities required to provide coverage for the applicable Staff Member(s), including where appropriate, care for patients, emergency service care and consultations; and assuming all the functions and responsibilities of appointment to the Active Staff, including care for unassigned patients, emergency service obligations and consultation. In Article X, the duties of the Emergency Patient Care Committee are defined. The duties include serving as a liaison between physicians, nurses, emergency medical technicians and other personnel in the Emergency Room and ambulance services, and the Medical Staff and the Administration. The Emergency Patient Care Committee is responsible for maintaining an up to date roster of on-call Physicians responding to emergency calls and a current list of available specialists. The Patient Care Committee is responsible for developing policies to ensure that the Medical Staff complies with Emergency Medical Treatment and Labor Act (EMTALA)

Interviews

A telephone interview (due to COVID 19) was done with Chief Medical Officer (CMO) HH on 5/1/20 at 11:30 a.m. CMO HH said when calls come into the transfer center, the operator answers the call and gets basic information before connecting the caller with the appropriate Emergency Department (ED) staff member or the appropriate physician to get details on the patient and accept the patient for the facility's care. All these calls are recorded, and a digital transcript is saved. There are times a call will be forwarded to the house supervisor who is a registered nurse. CMO HH said if the call goes to the House Supervisor, he/she is on their own cell phone and it is not capable of providing a recording. He explained in those cases there will not be a digital printout of the recording. CMO HH said the House Supervisor shares an office with the transfer center and will at times intercept calls from the transfer center to appropriately facilitate that patients are transferred to the appropriate referral or the most appropriate physician for receiving a transfer.

A telephone call (due to COVID 19) was received from the Chief Nursing Officer EE of facility. CNO EE on 5/1/20 at 12:55 p.m. He introduced himself and added that Director of Risk Management MM was also on the call. CNO EE said they wanted to be up-front with what they had found and thought to be the situation surrounding this complaint. CNO EE said they had an idea of what this complaint was regarding. He said when they realized this was specifically related to transfers, they looked back and originally thought it was a patient who had been transferred from a neighboring facility on 4/13/20. CNO EE said as their management was discussing the details, they realized another call had come from the same facility the next day regarding another patient. He said the House Supervisor (HS) CC remembers a call coming into the transfer center on 4/14/20 that was similar in nature to the one from the previous day. She told them she had forwarded the call to MD AA. CNO EE said they have just begun to do a root cause analysis.

A telephone interview (due to COVID 19) was conducted on 5/1/20 at 11:40 a.m. with Medical Doctor (MD) AA. MD AA said he has been at this facility for 21 years. He said he is an Ear, Nose, and Throat (ENT) Specialist. MD AA asked if he could give a brief background of the standing with the transferring facility. MD AA said his facility has been intermittently covering ENT for the transferring facility for a long time. He said the transferring facility used to have ENTs but because of retirement, attrition, and other things their numbers of ENTs have dwindled. MD AA said he did not even know if they had ENT's that took call for their Emergency Department (ED). MD AA said he had had conversations with the transferring facility requesting their call log, so they could see if his group was "on the hook" to take the transferring facility's calls. MD AA said he has seen many of the transferring facility's patients recently. He said, just the day before, he took a transfer from the same transferring facility that should have been handled by the transferring facility's ENT specialists.
MD AA said he remembers he got a call from RN CC telling him of Patient # 1 who had a neck mass that the x-ray showed an abscess or possibly a necrotic tumor that the transferring facility wanted to send to him.
MD AA said when he spoke with transferring facility MD II, he remembers there was no airway obstruction or sepsis. MD AA said he told transferring facility MD II that these patients were done in outpatient surgery of his office. He asked if anyone there had looked at her. MD AA said transferring facility MD II said their surgeon had looked at Patient # 1 and said, if she did an acute excision and it turned out to be a tumor, it would do Patient # 1 more harm than good. MD AA said he asked transferring facility MD II if he had talked with Macon because the transferring facility had an agreement with a facility in Macon to take ENT patients. He said Transferring facility MD II told him that he knew of no such agreement. MD AA said he told transferring facility MD II that he was not refusing to see Patient # 1, but Patient # 1 would have to be admitted to a hospitalist and MD AA would provide a consult. MD AA said transferring facility MD II said he would find someone else to take the patient.
He said when he talked with the transfer facility, transferring facility MD II gave him details which did not necessitate immediate transfer.


A telephone interview (Due to COVID 19) with Manager of Accreditation and Regulatory Compliance (MARC) LL was conducted at 2:00 p.m. She responded to an earlier e-mail for request of a policy for the Transfer Center regarding guidelines for calls. She said there is no current policy for the Transfer Center. She explained the old policy had been overwritten and the new one had not been approved through all the channels. MARC LL said the Transfer Center was going by the new recommendations that had not been signed by the Medical Staff. MARC LL said they had all looked for Patient # 1's name in their files and their logs, but they were unable to find it anywhere. When asked about Patient #1's name not being found anywhere in their system, MARC LL said they had looked everywhere but could not find any documentation on a request for a patient being refused services on 4/14/20. MARC LL said the facility rarely refuses patients from other facilities. She explained the night-shift house supervisor had been out due to an illness, and no one had picked up the slack in documenting in the logs. MARC LL said there is no documentation in the log or of the call regarding Patient # 1.


A telephone interview (due to COVID 19) was conducted with Transferring Facility's Medical Doctor (MD) II on 5/1/20 at 12:00 p.m. Transferring facility MD II said he remembers Patient # 1's coming to the Emergency Department (ED). Transferring facility MD II said he had treated Patient # 1. Transferring facility MD II said Patient # 1 presented to the ED with a neck mass that she said had been there for over a week. Transferring facility MD II said Patient # 1 reported that she had seen her primary MD and was given a shot of antibiotics and a prescription to take antibiotics by mouth. He said Patient # 1 said she had been taking the antibiotics since seeing her primary MD, but nothing seemed to help. Patient # 1 reported the mass was getting bigger and was tender. Transferring facility MD II said he done a work-up and the findings suggested she needed an immediate evaluation. He said the mass could be an abscess ( a confined pocket of pus that collects in tissues, organs, or spaces inside the body), but it could also be a neoplasm (abnormal mass of tissue that results when cells divide more than they should or do not die when they should. Neoplasms may be benign (not cancer), or malignant (cancer). Transferring facility MD II said he had asked their on-call surgeon to look at the case. He said their on-call surgeon recommended a referral to a specialist. Transferring facility MD II said the on-call surgeon had said this was outside her realm and could do more harm than good if she cut into the mass and it was a neoplasm. The on-call surgeon recommended referral and transferring facility MD II agreed. Transferring facility MD II said he called their transfer center and asked for the nearest Ear, Nose, and Throat specialist. He said the Transfer Center contacted the receiving facility and he spoke with House Supervisor (HS) CC. Transferring facility MD II said he then talked with MD AA from the other facility. MD II said MD AA was very resistant immediately. Transferring facility MD II said MD AA told him that he needed to call a facility in Macon with whom the transferring facility had an agreement. Transferring facility MD II said he did not know they had an agreement and at the time his transferring center did not know of an agreement either. Transferring facility MD II said about 10 minutes into the call, MD AA said he would not admit Patient # 1. Transferring facility MD said that with Patient # 1's age and underlying health conditions, he felt she immediately needed further evaluation. Transferring MD II said he immediately called a facility in Macon and that facility accepted Patient # 1.

During a telephone interview (due to COVID 19) on 5/04/2020 at 11:01 a.m., the House Supervisor (HS) CC for the Transfer Center (TC) reported that there are normally 3 staff in the TC consisting of a nurse, a bed coordinator (tech) GG and the House Supervisor. HS CC stated that she does remember the nurse being on another line and tech GG asked her to take a call from another TC requesting to speak with the on-call Medical Doctor (MD) (ENT - ears, nose, and throat) AA. HS CC contacted MD AA and a 4-way call was initiated between HS CC, MD AA, the transferring facility's TC, and the transferring facility's MD II. Transferring facility MD II reported that he had a patient with a neck mass, or possible neck abscess that he would like to transfer. HS CC recalls that the MD II reported that the patient was swallowing and breathing fine. HS CC stated that the MD AA suggested transferring the patient to their ED, have the hospitalist admit the patient and consult ENT for evaluation. HS CC stated that the transferring facility MD II was not satisfied with MD AA not accepting the patient and stated that he would send the patient somewhere else. HS CC explained that this call was not logged in the electronic call log and it was not recorded. She stated that the nurse on duty in the call center has the responsibility of logging calls into the electronic call sheet. She explained that the nurse that is usually working in the TC has been out sick. She also explained that when a call gets transferred from the TC phone line to the HS phone, the call is no longer recorded. HS CC stated that her phone is not a recorded line.

The facility failed to accept from a referring hospital an appropriate transfer of Patient # 1 on 4/14/2020 who required such specialized services of the on-call Otolaryngology capabilities; and the hospital had the capacity to treat Patient # 1 when the referring facility made a request for transfer.