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Based on record reviews and interviews, the hospital failed to ensure a patient was accepted for admission when the hospital had the capacity and capability to provide orthopedic services.This deficient practice is evidenced by the hospital refusing to accept 3 (#1, #18, #19) of 3 (#1, #18, #19) medically cleared patient from an emergency room when the hospital had the capacity and capability to provide orthopedic services.

Findings

Based on record reviews and interviews, the hospital failed to ensure a patient was accepted for admission when the hospital had the capacity and capability to provide orthopedic services. This deficient practice is evidenced by the hospital refusing to accept 3 (#1, #18, #19) of 3 (#1, #18, #19) medically cleared patient from an emergency room when the hospital had the capacity and capability to provide orthopedic services.

Findings:

A review of OLOLRMC's Orthopedics Transfer Request document revealed in part:
- Limitations/ Notes:
We do not have ER hand call for Ascension or OLOL (even if hand surgeon is taking general ortho call. Do not accept external hand request. Exception: Region 2 trauma that meets trauma activation criteria.
- Special Considerations
- External ER to ER compartment syndrome- notify ortho on call if accepted.
- Shares Spine call with neuro surgery. Check on call link: Physician On- Call.

Patient #1
A review of OLOLRMC's Transfer Center Request Log for October 2023 revealed Patient # 1 had a request on 10/17/2023 at 1:09 p.m. as an ED to ED transfer from Hospital A to OLOLRMC for orthopedic care. Further review revealed the request was declined due to capability.

A review of Patient #1's Medical Record Revealed he presented to Hospital A on 10/17/2023 with right hand pain and swelling after removing a piece of metal a month prior. A CT of the hand showed a deep lesion within the muscles of his right hand.
Patient requested to be transferred to Our Lady of the Lake Regional Medical Center. The admitting ED physician called the OLOLRMC Transfer Center and was denied the transfer stating, it is the Lake's policy not to accept isolated hand injuries.

Patient #1 was transferred to Hospital B after OLOLRMC denied the requested transfer.
A review of Patient #1's medical record from Hospital B revealed S7OrthMD was consulted, who was the same orthopedic surgeon on call at OLOLRMC. S7OrthoMD recommended admission. S6OrthoMD, a hand specialist and partner of S7OrthoMD, was consulted and performed an incision and drainage on 10/18/2023 without complications.

In an interview on 10/26/2023 at 10:00 a.m. S2SrDirED verified Patient #1 was denied acceptance due to OLOLRMC not accepting isolated hand injuries. She also verified that S7OrthoMD was on call that day and that S6OrthoMD is a partner and hand specialist with S7OrthoMD.

In an interview on 10/25/2023 at 12:30 p.m. S4MedSt verified S7OrthoMD was the Orthopedist on call on 10/17/2023. She also verified S7OrthoMD is credentialed to: Evaluate, diagnose, provide consultation, treat and medically and surgically manage patients with congenital deformities, trauma, infections, tumors, metabolic disturbances of the musculoskeletal system, deformities, injuries, and degenerative disease of the spine, hands, feet, knee, hip, shoulder and elbow.

Patient #18
A review of the hospital Transfer Center Request October 2023 revealed Patient #18 was listed as EMTALA Denial. Patient #18 request was on 10/06/2023, external ED to ED, emergency transfer, needs specialized level of care- Ortho from Hospital C to OLOLRMC. Decline reason listed as capability.

A review of Patient #18's record located in the Transfer Center system revealed the following:
Patient #18 was located at Hospital C and the EMTALA request was for specialized level of care orthopedics. On 10/06/2023 at 9:24 a.m. documentation reveals Hand surgery, Tenosynovitis, Notified we are currently at capability/ capacity and are unable to accept patient at this time. Review of the documentation revealed at 9:27 a.m. the patient was declined as a transfer to Our Lady of the Lake Regional Medical Center and Our Lady of the Lake Ascension (offsite of Our Lady of the Lake Regional Medical Center). Review of the documentation revealed the patient was declined due to capability of the hospitals.

A review of OLOLRMC Orthopedic Call Roster for Lake ER Unassigned Patients revealed on 10/06/2023 S5OrthoMD was on call.

A review of Patient #18's Medical Record from Hospital C revealed the following:
Patient #18 presented to the ED on 10/06/2023 at 2:32 a.m. with a chief complaint of cellulitis to the right hand. This was Patient 18's third visit to the ED. He was initially treated with antibiotics and hand appears to be worsening. Disposition decision transfer request 10/06/2023 at 6:14 a.m.
8:00 a.m. Called placed to transfer center for update on transfer request and there has not yet been acceptance for patient.
11:00 a.m. Call received by staff stating Patient #18 was accepted for transfer to Hospital E.
Patient #18 was transferred from Hospital C ED on 10/06/2023 at 1:39 pm.

A review of OLOLRMC Orthopedic Call Roster for Lake ER Unassigned Patients revealed on 10/06/2023 S5OrthoMD was on call.

In an interview on 10/26/2023 at 09:15 a.m. S2SrDirED verified the above record information.

In an interview on 10/25/2023 at 1:30 p.m. S2SrDirED stated if a patient presented to the hospital's ED with hand injuries and was unassigned and no physician, the hospital ED MD would consult Ortho on call.


In an interview S2SrDirED on 10/26/2023 at 9:20 a.m. reviewed the Orthopedics Transfer Request document and verified OLOLRMC does not accept cases requiring hand surgery, even if a hand surgeon is taking general orthopedic call.


Patient #19
A review of the OLOLRMC Transfer Center Request Log for October 2023 revealed Patient #19 was listed as EMTALA Denial. Patient #19 request was on 10/01/2023 at 1:24 p.m., external ED to ED, emergency transfer, needs specialized level of care orthopedics from Hospital D to OLOL. Decline reason listed as capability

A review of Patient #19's record located in the Transfer Center system revealed the following:
Patient #19 was located at Hospital D and on 10/01/2023 an EMTALA request was for specialized level of care orthopedics. Patient #19 slammed her left index finger in her car door and now has an open fracture with partial amputation, but finger still attached. At 1:24 pm documentation revealed the patient was declined the transfer request to OLOLRMC and OLOL Ascension (offsite to Our Lady of the Lake Regional Medical Center) as transfer destinations. The denial of the transfer was documented due to capability of the hospitals.

A review of OLOLRMC Orthopedic Call Roster for Lake ER Unassigned Patients revealed on 10/01/2023 S5OrthoMD was on call.

In an interview on 10/26/2023 at 9:20 a.m. S2SrDirED verified the above record information.

A review of Patient #19's Medical Record from Hospital D revealed the following:
Patient #19 presented to Hospital D on 10/01/2023 11:45 am after slamming her left index finger in a car door, with partial amputation to the tip of the left index finger, bleeding controlled.
Hospital D did not have hand surgery on call. Hospital D call LERN, Louisiana Emergency Response Network, for transfer to a hospital with hand surgery. LERN is an agency of state government with the responsibility of care coordination for patients suddenly stricken with serious injury or time sensitive illness.
On 10/01/2023 at 2:16 pm Patient #19 was accepted at Hospital F.

A review of Patient #6, #7, #14, #16, #17 and #20's medical record revealed hand orthopedic cases. These hand orthopedic cases were either seen in OLOLRMC Main ED by the on call orthopedist or transferred to OLOLRMC Main ED from one of the hospital's offsite location for on call orthopedic services.

A review of Patient #6's Medical Record revealed he was admitted to OLOLRMC ED on 09/01/2023 for pain and swelling to his right index finger. S11OrthoMD was on orthopedic call and consulted for suspicious osteomyelitis of the right index finger. Patient #6 was evaluated by orthopedics and admitted to the Hospital Medicine Group.

A review of Patient #7's Medical Record revealed he was admitted 08/01/2023 to OLOLRMC ED after being seen in an Urgent Care the day before. S12OrthoMD was consulted on 08/31/2023 and directed Patient #7 to go to OLOLRMC for ZS6OrthoMD to see for admission and surgery.

A review of Patient #14's Medical Record revealed he was admitted on 09/10/2023 to OLOLRMC ED after being seen at OLOLRMC offsite free standing emergency department in north Baton Rouge. Patient #14 presented to OLOLRMC North Baton Rouge ED after he punched through a window injuring his left hand and forearm. There was concern for tendon involvement on the middle finger; therefore he was transferred to OLOLRMC Main ED for Orthopedic surgery evaluation by S13OrthoMD.

A review of Patient #16's Medical Record revealed he was admitted to OLOLRMC ED on 10/24/2023 after being transferred from OLOL Livingston (offsite location of OLOLRMC). S7OrthoMD was consulted and took Patient #16 to surgery for finger amputation.

A review of Patient #17's Medical Record revealed he was admitted to OLOLRMC ED on 10/21/2023 after being transferred from OLOL Ascension (offsite location of OLOLRMC) with a right thumb dislocation. S8OrthoMD was consulted and he then consulted S9OrthoMD. Patient #17 was admitted and S9OrthoMD completed a surgical open reduction of her right thumb.

A review of Patient #20's Medical Record revealed he was admitted to OLOLRMC ED on 08/14/2023 after being transferred from OLOL North Baton Rouge free standing ED (offsite location of OLOLRMC) with an open fracture to the metacarpals of the left hand. Patient #20 had a hand injury after a tire blew. Patient #20 was seen by S14OrthoNP and surgery was done by S15OrthoMD on 08/15/2023.

In an interview on 10/25/2023 at 4:00 p.m. S10Quali verified OLOL and Hospital B utilizes the same city call schedule for unassigned patients to include Orthopedic surgery. She also verified that Hospital A does not perform any surgeries and that Patient #1 was denied acceptance at OLOL.

In an interview on 10/26/2023 at 9:20 a.m. S2SrDirED stated she was not able to find out if the Transfer Call Center document was approved by any hospital committees or physicians. S2SrDirED verified the Physician Call Schedules and medical records reviewed. S2SrDirED also verified Patients #6, #7, #14, #16, #17 and #20, had hand injuries and OLOLRMC provided orthopedic on call services to these patients.

In an interview on 10/26/2023 at 12:20 p.m. S16TranCenMgr reviewed the Orthopedic Transfer Request form and verified OLOLRMC does not accept cases requiring hand surgery, even if a hand surgeon is taking general orthopedic call. She also said she was not aware if any committee approved the processes and denied meeting with any service line to include but not limited to orthopedics.

In an interview on 10/26/2023 at 12:35 p.m. S1Reg verified the Transfer Call Center form was never sent to or approved by any hospital committee.