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Based on medical record review, receiving hospital record review, staff interview, and policy review, the facility failed to ensure the receiving hospital accepted transfer for 1 of 1 sample patients (#2) who had an emergency medical condition and then experienced cardiac arrest.

Refer to A2409 for details concerning facility failure to inform the accepting physician of the cardiac arrest and confirm the receiving facility agreed to accept the patient, whose condition had significantly changed and was no longer stable.

Based on medical record review, receiving hospital record review, staff interview, and policy review, the facility failed to ensure the receiving hospital accepted transfer for 1 of 1 sample patients (#2) who had an emergency medical condition and then experienced cardiac arrest. The findings were:

Review of the emergency department (ED) record showed patient #2 was admitted to the ED on 10/1/17 at 11 AM with a complaint of fever and cough. The review showed the patient received a medical screening examination, and treatment which included lab tests and x-rays. Further review showed the ED physician contacted physician #1 at a local hospital on 10/1/17 at 12:20 PM and received acceptance to transfer the patient with a diagnosis of sepsis. Physician #1 was not the ED physician, and the plan was to admit the patient to the intensive care unit. The review showed EMS (emergency medical services) was contacted for transport. Review of the "Memorandum of Transfer" form showed the patient's risks were "worsening sepsis." The review showed the patient was stable for transfer via EMS and had vital signs which included a temperature of 98.8 degrees Fahrenheit, pulse of 144 beats per minute, respirations of 44, blood pressure of 92/54, and an oxygen saturation of 72%. The following concerns were identified:
a. Further review of the ED record for patient #2 showed the patient had a significant change in status on 10/1/17 at 12:35 PM. At that time the respiratory therapist called the registered nurse to the patient's room. The assessment showed the patient was cyanotic and unresponsive, was not breathing, and had no pulse. By 12:40 PM the ED team had called a "code blue" and CPR (cardio-pulmonary resuscitation) was in progress. The code continued, and at 12:53 PM the physician was able to insert an endo-tracheal tube for assisted respirations. At 12:55 PM the team applied a Lucas device (device to perform mechanical compressions for the heart). PEA (pulseless electrical activity) was noted as the patient's heart rhythm at that time. At 1 PM a member of the arriving EMS team reinserted an endo-tracheal tube for assisted respirations. At 1:07 PM PEA was still noted. At 1:09 PM the patient was being transferred to the ambulance for transport and was noted to still be receiving mechanical compressions with the Lucas device. At 1:10 PM another pulse check was performed and the patient had no pulse. At 1:13 PM the ambulance left the facility parking lot with the patient.
b. Review of the ED record showed the ED physician failed to document any contact with a physician #1 concerning the patient's change in status. The review showed the ED nurse contacted the receiving ED and gave report on 10/1/17 at 12:45 PM. Review of the "Memorandum of Transfer" form showed the facility failed to update the patient's risks from "worsening sepsis" to include cardiac and respiratory arrest. Further review of the "Memorandum of Transfer" form showed the facility failed to update the vital signs to reflect the status of no pulse, no respirations, and the patient being unresponsive.
c. Review of the receiving hospital "ED Provider Note" dated 10/1/18 and not timed showed "after initial evaluation" the sending physician contacted physician #2 at the receiving facility ED and gave a report, which included the patient's code status. The note showed the patient was coded for 52 minutes at the receiving facility and the code was stopped "due to futility." Review of the entire receiving facility medical record showed no indication the sending ED physician had spoken to any physician at the receiving facility after the patient's significant change in status prior to transport.
d. Interview with the sending ED physician by phone on 3/22/18 at 8:37 AM confirmed the transfer documentation had not been updated to reflect the patient's significant change in condition. He further confirmed he had failed to document any contact with physician #1 after the patient's change in condition, and could not remember if he had contacted her after the patient's significant change in status.
e. Review of the facility "Emergency Services" policy titled, "EMTALA: Medical Screening Examination and Stabilizing Treatment," showed the following, "...B. Stabilizing Care. i. If the MSE demonstrates that an EMC (emergency medical condition) exists, [the facility] will provide Stabilizing Treatment within [the facility's] Capabilities, even if [the facility] must transfer the Patient....ii. A Patient with an EMC is stabilized when the physician/QMP (qualified medical practitioner) determines that: ...2. The Patient is stable for transfer (i.e., when the physician or QMP has determined, within reasonable clinical confidence, that the Patient is expected to leave [the facility] and be received at the second facility with no material deterioration of his/her medical condition and the treating physician reasonably believes the receiving facility has the Capability to manage the Patient's medical condition and any reasonably foreseeable complications of that condition)...H. Transfer requirements for the Patient: iv. Transfer of the Patient who is not Stable for Transfer is accomplished as follows: ...3. The Transfer is affected through appropriate means consisting of the necessary, qualified personnel and transportation equipment including the use of life support measures. In all cases a physician to physician conversation must occur prior to acceptance and initiation of the transfer process."