The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

GRACE COTTAGE HOSPITAL PO BOX 216 TOWNSHEND, VT 05353 April 30, 2015
VIOLATION: MEDICAL SCREENING EXAM Tag No: C2406
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon interview and record review, the facility failed to provide an appropriate medical screening examination within the capability of the hospital's Emergency Department (ED) to determine whether or not an emergency medical condition existed for 1 of 20 patients, in the applicable sample, who was admitted to the ED with a potential stroke, discharged , and transported to another hospital via air ambulance. (Patient #15) Findings include:

Per interview and electronic medical record review review of admission and discharge times, the Chief Nursing Officer confirmed on 4/29/15 at 10:02 AM, Patient #1 arrived in the emergency room (ER) at 19:26 PM on 4/23/15 and was registered as an ER patient. Patient #1 was sent for a Computerized Axial Tomography Scan (CT Scan) immediately and was discharged on [DATE] 19:40 PM. The CNO confirmed on 4/29/15 at 10:02 AM that Patient #15 was admitted and discharged from the facility within 14 minutes. In addition, the CNO confirmed that Rescue Inc Ambulance transfer form states transfer from facility occurred at 19:45 PM on 4/23/15. (A CT Scan is a special x-ray test that uses x-rays and a computer to produce an image of the body).

Per interview and record review, the emergency room (ER) Provider confirmed on 4/30/15 at 8:07 AM, that he/she did not do a medical screening exam prior to discharge for Patient #15 on 4/23/15.

Per interview and record review, the emergency room (ER) Provider confirmed the following on 4/30/15 at 8:16 AM for Patient #15: Stabilizing Treatment and Appropriate Transfer was not done for Patient #1 on 4/23/15 prior to discharge from the facility; Confirmed receiving Hospital #1 Emergency Department Medical Doctor ( Hospital #1 ED MD) was not called prior to Patient #15's discharge from the facility; Confirmed the "Patient Transfer Form" was not completed prior to Patient #15's transfer; Confirmed Patient #15's consent was not obtained prior to transfer; Confirmed "Patient Transfer Form" information is incorrect; Confirmed the "Patient Transfer Form" states transfer was accepted on 4/23/15 at 17:58 (5:58 PM) by MD at the receiving facility; Confirmed the receiving Hospital #1 ED MD was not contacted prior to Patient #15's discharge from the facility. (Per electronic medical records Patient #15 was discharged at 19:45 PM or 7:45 PM on 4/23/15); Confirmed the time 17:58 PM (5:58 PM) as stated on the Patient Transfer Form is incorrect and should read 19:59 PM (7:59 PM); Confirmed he/she did not do a Medical Screening Exam or provide Stabilizing Treatment and only saw the feet of Patient #15 as he/she was entering the CT Scan; Confirmed Patient Transfer Form states Patient #1 is stable. Per interview, ER Provider confirmed on 4/30/15 at 9:01 AM, that he/she did not know the CT results before Patient #15 was discharged .

Per interview and medical record review, CMO/ED Medical Director confirmed on 4/29/15 at 9:52 AM, for Patient #15 the emergency room (ER) Provider did not do a medical screening exam, did not provide stabilizing treatment , and did not appropriately transfer Patient #15 to another facility on 4/23/15. Per record review and interview, the CMO/ED Medical Director confirmed on 4/29/15 at 9:56 AM, the emergency room progress note states the provider's medical screening exam was based upon the "Chief Complaint" from the Nursing Triage Note for Patient #15. In addition, CMO/ED Medical Director confirmed that the provider did not see Patient #15, did not contact the receiving Hospital #1 ED MD prior to Patient #1's discharged from the hospital, the Patient Transfer Form was not completed for Patient #1 prior to discharge, Patient #15 did not sign the Patient Transfer Form consent to transfer prior to discharge from the ED, the receiving Hospital #1 ED MD was not contacted until after Patient #15 was discharged , and the receiving Hospital #1 ED MD did not accept Patient #15 to Hospital #1 prior to discharge.
VIOLATION: STABILIZING TREATMENT Tag No: C2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon interview and record review, the hospital failed to provide, within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition and for transfer of the individual to another medical facility for 1 of 20, patients in the applicable sample, who was admitted to the emergency department with a potential stroke, discharged , and transported to another hospital via air ambulance. (Patient #15). Findings include:


Per interview and electronic medical record review of admission and discharge times, the Chief Nursing Officer confirmed on 4/29/15 at 10:02 AM, Patient #15 arrived in the ER at 19:26 PM on 4/23/15 and was registered as an ER patient. Patient #15 was sent for a Computerized Axial Tomography Scan (CT Scan) immediately and was discharged on [DATE] 19:40 PM. The CNO confirmed on 4/29/15 at 10:02 AM that Patient #1 was admitted and discharged from the facility within 14 minutes. In addition, the CNO confirmed that Rescue Inc Ambulance transfer form states transfer from facility occurred at 19:45 PM on 4/23/15. (Note: a CT Scan is a special x-ray test that uses x-rays and a computer to produce an image of the body).

Per interview and record review, the emergency room (ER) Provider confirmed the following on 4/30/15 at 8:16 AM for Patient #15: Stabilizing Treatment and Appropriate Transfer was not done for Patient #15 on 4/23/15 prior to discharge from the facility; Confirmed receiving Hospital Emergency Department Medical Doctor ( Hospital #1 ED MD) was not called prior to Patient #1's discharge from facility; Confirmed the "Patient Transfer Form" was not completed prior to Patient #15's transfer; Confirmed Patient #15's consent was not obtained prior to transfer; Confirmed "Patient Transfer Form" information is incorrect; Confirmed the "Patient Transfer Form" states transfer was accepted on 4/23/15 at 17:58 (5:58 PM) by MD at the receiving facility; Confirmed the receiving Hospital #1 ED MD was not contacted prior to Patient #1's discharge from the facility. (Per electronic medical records Patient #15 was discharged at 19:45 PM or 7:45 PM on 4/23/15); Confirmed the time 17:58 PM (5:58 PM) is incorrect as stated on the Patient Transfer Form and should read 19:59 PM (7:59 PM) ; Confirmed he/she did not do an Medical Screening Exam or provide Stabilizing Treatment and only saw the feet of Patient #15 as he/she was entering the CT Scan; Confirmed Patient Transfer Form states Patient #15 is stable. Per interview, ER Provider confirmed on 4/30/15 at 9:01 AM, that he/she did not know the CT results before Patient #15 was discharged .

Per interview and medical record review, CMO/ED Medical Director confirmed on 4/29/15 at 9:52 AM for Patient #15 the emergency room (ER) Provider did not do a medical screening exam, did not provide stabilizing treatment , and did not appropriately transfer Patient #15 to another facility on 4/23/15.

Per interview and record review, the CMO/ED Medical Director confirmed on 4/29/15 at 9:56 AM, the emergency room progress note states the provider's medical screening exam was based upon the "Chief Complaint" from the Nursing Triage Note for Patient #15. In addition, CMO/ED Medical Director confirmed that the provider did not see Patient #15, did not contact the receiving Hospital #1 ED MD prior to Patient #1's discharged from the hospital, the Patient Transfer Form was not completed for Patient #15 prior to discharge, Patient #15 did not sign the Patient Transfer Form consent to transfer prior to discharge from the ED, the receiving Hospital #1 ED MD was not contacted until after Patient #1 was discharged , and the receiving Hospital #1 ED MD did not accept Patient #15 to Hospital #1 prior to discharge.
VIOLATION: APPROPRIATE TRANSFER Tag No: C2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based upon interview and record review, the hospital failed to assure the appropriateness of a patient transfer for 1 of 20 patients, in the applicable sample, who was admitted to the emergency department with a potential stroke, discharged , and transported to another hospital via air ambulance by not informing the patient of the hospital's obligations, risks and benefits of the transfer in writing, providing medical treatment within its capacity that minimized the risks to the patient's health, and assuring the receiving facility had available space and qualified personnel for the treatment of the individual, had agreed to accept transfer of the individual, and provide appropriate medical treatment. (Patient #15 ). Findings include:


Per interview and electronic medical record review of admission and discharge times, the Chief Nursing Officer confirmed on 4/29/15 at 10:02 AM, Patient #15 arrived in the ER at 19:26 PM on 4/23/15 and was registered as an ER patient. Patient #1 was sent for a Computerized Axial Tomography Scan (CT Scan) immediately and was discharged on [DATE] 19:40 PM. The CNO confirmed on 4/29/15 at 10:02 AM that Patient #15 was admitted and discharged from the facility within 14 minutes. In addition, the CNO confirmed that Rescue Inc Ambulance transfer form states transfer from facility occurred at 19:45 PM on 4/23/15. (Note: a CT Scan is a special x-ray test that uses x-rays and a computer to produce an image of the body).

Per interview and medical record review, CMO/ED Medical Director confirmed on 4/29/15 at 9:52 AM, for Patient #15 the emergency room (ER) Provider did not do a medical screening exam, did not provide stabilizing treatment, and did not appropriately transfer Patient #15 to another facility on 4/23/15.

Per record review and interview, the CMO/ED Medical Director confirmed on 4/29/15 at 9:56 AM, the emergency room progress note states the provider's medical screening exam was based upon the "Chief Complaint" from the Nursing Triage Note for Patient #15. In addition, CMO/ED Medical Director confirmed that the provider did not see Patient #15, did not contact the receiving Hospital #1 Emergency Department Medical Doctor (Hospital #1 ED MD) prior to Patient #15's discharged from the hospital, the Patient Transfer Form was not completed for Patient #15 prior to discharge, Patient #1 did not sign the "Patient Transfer Form" consent to transfer prior to discharge from the ED, the receiving Hospital #1 ED MD was not contacted until after Patient #15 was discharged , and the receiving Hospital #1 ED MD did not accept Patient #15 to Hospital #1 prior to discharge.


Per interview and record review, the ER Provider confirmed on 4/30/15 at 8:07 AM, that he/she did not do a medical screening exam prior to discharge for Patient #15 on 4/23/15. Per interview and record review, the ER Provider confirmed the following on 4/30/15 at 8:16 AM for Patient #15: confirmed Stabilizing Treatment and Appropriate Transfer was not done for Patient #15 on 4/23/15 prior to discharge from the facility; confirmed receiving Hospital #1 ED MD was not called prior to Patient #15's discharge from facility, confirmed the "Patient Transfer Form" was not completed prior to Patient #15's transfer, confirmed Patient #15's consent was not obtained prior to transfer; confirmed "Patient Transfer Form" information is incorrect; confirmed the "Patient Transfer Form" states transfer was accepted on 4/23/15 at 17:58 (5:58 PM) by MD at the receiving facility; confirmed the receiving Hospital #1 ED MD was not contacted prior to Patient #1's discharge from the facility. (Per electronic medical records Patient #15 was discharged at 19:45 PM or 7:45 PM on 4/23/15); confirmed the time 17:58 PM (5:58 PM) as stated on the Patient Transfer Form is incorrect and should read 19:59 PM (7:59 PM); confirmed he/she did not do an Medical Screening Exam or provide Stabilizing Treatment and only saw the feet of the patient #15 as he/she was entering the CT Scan; confirmed Patient Transfer Form states Patient #15 is stable.

Per interview and record review, the ER Provider confirmed on 4/30/15 at 8:16 AM, the provider did not speak with receiving Hospital #1 ED MD prior to Patient #15's discharge on 4/23/15; Confirmed the DHART air ambulance helicopter was already in the air when he/she notified the receiving Hospital #1 ED MD that Patient #15 was in route and he/she had not seen Patient #15, except for his feet; provider confirmed that he/she not know if Patient #15 was stable and believed Patient #15 was stable due to nursing triage note, nursing minimal assessment and vital signs; provider stated he/she told the receiving Hospital #1 ED MD that he/she had not personally assessed Patient #15.

Per interview on 4/30/15 at 2:00 PM, the Co-ED Director confirmed the following: On 4/23/15, the ER Provider asked the Co-ED Director to facilitate the transfer call to Hospital #1 ED MD for Patient #15. Stated at this time, Patient #15 was in the DHART Air Ambulance and the ER Provider believed Patient #15 was under the care of the Hospital #1 ED MD . Initially, Hospital #1 ED MD refused to accept Patient #15 as they did not have a neuro interventionist on duty. Also, Hospital #2 ED MD refused to accept Patient #15, as they did not have a neuro interventionist on duty. In addition, there was discussion to contact Hospital #3 during the phone call, but the DHART Air Ambulance crew indicated they were running out of fuel and Hospital #3 was not contacted. Hospital #1 ED MD accepted Patient #15's transfer to Hospital #1.

Per interview and confirmed with CMO/ED Medical Director at 8:30 AM 4/30/15, the DHART Air Ambulance can fly without notifying Hospital #1 ED MD.