HospitalInspections.org

Based on interview and record review, the hospital failed to comply with the requirements of 42 CFR 489.24 by failing to provide medical screening exams by qualified providers, failed to stabilized a medical condition prior to a transfer, failed to provide an appropriate transfer, and failed to maintain the medical records for five years of transfer date (refer to tags A2403, A2406, A2407, and A2409).

Based on interview and record review, the hospital failed to maintain medical records of transferred patients for five years from the date of transfer for two of 42 sampled patients. This failure could result in unavailability of a patient's medical information. Findings:

On 9/3/14 at 11:00 a.m., the medical records for Patients 28 and 29 were requested for review. Both patients had been transferred from the hospital emergency department to different facilities on the evening of 12/3/13. At the time of the emergency room visits for Patients 28 and 29, the hospital was paper charting and not implementing their electronic medical record system.

On 9/3/14 at 3 p.m. during an interview with the hospital chief quality officer (CQO), she stated medical records staff were unable to produce the records for Patients 28 and 29.

During a later interview on 9/4/14 at 9:00 a.m., the CQO stated staff were looking for the records in the offsite storage facility and the receiving facilities would be contacted as well.

On 9/4/14 at 11:30 a.m., copies of both patients' records were produced. The CQO stated the original medical records had been sent with the patients during transfer. The CQO stated copies of the records were obtained from the receiving facilities and the facilities would send the original medical records to the hospital.

Based on interview and record review, the hospital failed to provide evidence three of seven labor and delivery nurses (RN A, RN B, and RN C) were deemed competent to perform medical screening examinations (the purpose of the medical screening examination is to determine whether or not an emergency medical condition exits on pregnant patients coming into the hospital for emergency services. This failure could result in inappropriate medical screening exams. Findings:

During record reviews on 9/3/14 at 2 p.m. and 9/3/14 at 8:30 a.m. of employee files, it was noted three of seven registered nurses had not completed their annual 2013 "Medical Screening Exam" competencies.

RN A's employee file had no documentation indicating she had completed her 2013 "Medical Screening Exam" competencies.

RN B's employee file had no documentation indicating she had completed her 2012 or 2013 "Medical Screening Exam" competencies.

RN C's employee file had no documentation indicating she had completed her 2013 "Medical Screening Exam" competencies.

During subsequent interviews on 9/3/14 at 2:30 p.m. and 9/4/14 at 9 a.m. with the director of perinatal services, chief nursing officer, and chief quality officer it was stated: labor and delivery nurses were required to complete an annual competency validation test for medical screening exams. Annual competency testing validates if medical screening exams are being done correctly and are required to be considered a qualified medical screening examiner.

On 9/4/14 at 10 a.m. a review of the 2013 Labor and Delivery Emergency log was conducted. The log indicated RN A performed medical screening exams for Patient 33 on 8/22/13, Patient 34 on 7/11/13, and Patient 35 on 7/29/13. RN B performed medical screening exams for Patient 36 on 9/3/13 and Patient 37 on 8/9/13. RN C performed medical screening exams for Patient 38 on 8/12/13, Patient 39 on 7/23/13, Patient 40 on 7/31/13, Patient 41 on 8/12/13, and Patient 42 on 8/12/13. In addition to the above patients in 2013, RN A, RN B, and RN C performed additional medical screening exams on laboring patients coming into the hospital for medical emergencies.

Record review on 9/3/14 at 2:45 p.m. of the hospital's policy and procedure "Standardized Procedure For Medical Screening Exam" dated 11/12 indicated; "An emergency medical screening examination will be performed by registered nurses in the Labor and Delivery unit under this Standardized Procedure. Registered Nurses may perform a medical screening examination under this Standardized Procedure after successful completion and competency validation, described herein under Education and Training... Qualifications for Registered Nurses: Minimal Education Primary RN's in L&D (labor and delivery) who have the following... Completed Annual Skills Checklist in L&D".

Based on interview and record review, the hospital failed to provide continuing inpatient care to an emergency room patient (Patient 1) with a stabilized emergency medical condition(EMC) even though it had the capacity to do so. The hospital attempted to transfer Patient 1 to another hospital, but she had a cardiac arrest during the transfer and died. Findings:

Review of Patient 1's "Prehospital Care Report" dated 12/3/13 indicated she complained of chest pain then became unconscious and incontinent of urine while on a paratransit vehicle. When the paramedics arrived, they performed an EKG (electrical tracing of heart activity) which did not show signs of a heart attack. During the ambulance ride to the hospital, Patient 1 regained consciousness but was incoherent.

Review of Patient 1's hospital medical record indicated at the emergency room, Patient 1 was confused but did not have abnormalities on physical exam except for an old abdominal scar and finger deformities consistent with arthritis. The emergency room physician (ER MD) checked Patient 1's electrolytes, blood counts, troponin (a test for heart attacks), drug screening tests, urinalysis, and another EKG. The ER MD ordered a CT (computed tomography) scan of Patient 1's head and a chest X-ray. The results of the tests showed Patient 1 possibly had an early pneumonia; was anemic and dehydrated; had slightly low sodium and potassium levels; had low protein levels in her blood and high protein levels, blood, and sloughing from her kidneys in her urine. There were no signs of a heart attack, stroke, or drug use. Patient 1 was becoming less confused and said she was having pressure around her stomach and feeling nauseated. The ER MD ordered blood cultures, antibiotics, intravenous fluids, and a "GI [gastrointestinal] cocktail" (a blend of medications which typically includes antacid and numbing medicine). Patient 1 then had coffee-ground emesis (vomit that looks like coffee grounds, concerning for GI bleeding). The ER MD tested Patient 1's stool for traces of blood (the results were no blood), and gave an anti-nausea medication and antacid. Patient 1 was connected to a heart monitor and had blood pressures checked while she was in the ER; the results were normal over the course of Patient 1's 6-hour ER visit. The ER MD diagnosed Patient 1 as having "new onset seizure, pneumonia, epigastric pain". The medical record indicated Patient 1 was being transferred to another hospital because of "access to inpatient care" and that her condition was "guarded".

Review of Patient 1's hospital medical record indicated she was picked up by an ambulance to transport her to the other hospital at 11:55 p.m. on 12/3/13. Thirty minutes later, the ambulance brought Patient 1 back to the original ER. Patient 1 was in cardiac arrest. Attempts to resuscitate her were unsuccessful and Patient 1 died.

Review of the receiving hospital's "DOCUMENTATION OF TRANSFER REQUEST" dated 12/3/13 indicated the sending hospital had requested a telemetry (cardiac monitoring) bed for Patient 1. The document indicated Patient 1 had an EMC, that the sending hospital was on strike and lacked capacity to care for Patient 1. The document did not specify whether or not Patient 1's EMC was stabilized, but indicated that her vital signs were stable.

Review of the hospital's strike contingency plan dated 12/2/13 indicated the hospital would have replacement workers available to accommodate up to 28 patients on its "Telemetry/Medical Surgical/Pediatrics" unit. Comparison of the strike plan to the hospital's census dated 12/3/14 at 11:00 p.m. indicated there were a total of 25 patients on the unit at the time of Patient 1's transfer.

In an interview on 9/2/14 at 1:29 p.m., the chief nursing officer (CNO) stated the telemetry patients were in Rooms 301 to 325. In an interview on 9/2/14 at approximately 1:45 p.m., the CNO stated each telemetry nurse could have four patients. In an interview and record review on 9/3/14 at approximately 2:00 p.m., the CNO presented an updated patient census dated 12/3/14 at 11:00 p.m. which again had a total of 25 patients. The CNO stated he had reviewed the charts of the inpatients at the time and had written on the census which nurse was caring for which patient. The census once again indicated there were a total of 25 patients. It indicated there were 13 patients in telemetry rooms (301 to 325) being cared for by four nurses. The census indicated one of the telemetry nurses had the maximum of four patients, and that three of the telemetry nurses had three patients each. In an interview on 9/3/14 at 2:07 p.m., the CNO stated the hospital could have admitted three more patients, either three telemetry patients or one telemetry patient and two pediatric patients.

Review of the hospital's "Staffing Plan for Telemetry, Med Surg and Pediatrics" dated 7/12 confirmed a telemetry nurse could care for four patients.

In an interview on 9/4/14 at 9:06 a.m., nursing supervisor 1 (NS 1) stated she was not involved in Patient 1's care but she had been advised the hospital was transferring patients during the strike and there was a second supervisor on duty that night because of the transfers. In an interview on 9/11/14 at 7:34 a.m., nursing supervisor 2 (NS 2) stated she worked for the receiving hospital and had filled out the receiving hospital "DOCUMENTATION OF TRANSFER REQUEST". NS 2 stated the reason for the transfer was the strike at the sending hospital. She stated her understanding was that if the patient's EMC was stabilized, her hospital did not have an obligation to accept the transfer, but that the conversation did not get to that point because, "We did have capacity, they didn't."

In an interview on 9/11/14 at 3:44 p.m., the ER MD stated she had been told her hospital was not admitting patients because there were either no beds or the hospital was at capacity due to nursing ratios. She stated she was concerned Patient 1 had a seizure, that pneumonia was part of the differential diagnosis, but that she did not know whether Patient 1's pneumonia was the cause of her loss of consciousness. She stated that Patient 1 probably needed serial cardiac enzymes (blood tests to rule out a heart attack not picked up by the EKG or the troponin level checked in the ER). She stated that she did not think Patient 1 had a significant GI bleed because there was no blood in the stool, the anemia was mild, and there was no bright red vomit. She stated she had requested a telemetry bed for Patient 1 so she could be monitored for any dysrhythmias (abnormal heartbeats). The ER MD stated she expected Patient 1's care to be continued as an inpatient, but her opinion was that Patient 1 had been stabilized for transfer since her vital signs were stable and her mental status was at baseline. She stated she wrote that Patient 1's condition was "guarded" at the time of transfer because Patient 1 was not ready to be discharged home. The ER MD stated she thought Patient 1 would be OK during the transfer, that there were no clues of impending problems, and she did not feel any deterioration was likely during transfer. The ER MD stated she would only transfer an unstable patient if that was the patient's only chance of survival.

Based on interview and record review, the hospital failed to provide medical treatment within its capacity before transferring an emergency room patient (Patient 1) whose emergency medical condition had been stabilized. Patient 1 had a cardiac arrest during the attempted transfer and died (Refer to A-2407).