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ORLANDO HEALTH 52 W UNDERWOOD ST ORLANDO, FL 32806 Feb. 22, 2017
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on interview, record review and facility policy review, the facility failed to provide appropriate transportation and medical supervision for transfer for 1 of 10 sampled patients (#6).


Findings:

Patient #6 went to the hospital on [DATE] via the emergency department (ED) with chief complaint of abdominal pain and vomiting. The patient was admitted to the pediatric special care unit.

The pediatric critical care progress note, dated 1/09/17, summarized past medical history listed forty-nine (49) diagnoses for patient #6, and included a 36-week premature infant, total colonic aganglionosis, status post resection, isolated intestinal transplant in December 2007, acute necrosis of transplanted small bowel and colon, status post resection, ostomy creation, history of acute rejection in 2008 treated with OKT3 and plasmapheresis, immuno-suppression, [DIAGNOSES REDACTED], tracheostomy and ventilator dependent at night, gastrostomy tube dependent, status post re-section of transplanted bowel and closure of abdomen on 10/17/13 and 10/24/ 2013, and a history of a necrotic liver tip.

The history of present illness documentation read, "well know to our services due to his complex medical history .... Upon arrival at the ED, he was awake and alert. He was connected to his home ventilator....is being admitted to the pediatric special care unit for further monitoring and management of care...." The plan included to admit to the pediatric special care unit under services of the gastro-intestinal (GI) team, hydration, nothing by mouth (NPO), and remain on home ventilator. Documentation read, "Per dad, he can be sprinted off the ventilator intermittently throughout the day, but he does have the ventilator replaced once he is sleeping overnight and napping during the day...."

The pediatric critical care progress notes dated 1/10/17 included history of gastroenteritis, likely viral, concern for rejection, acute kidney injury, likely secondary to dehydration, dehydration, secondary to increased ostomy output, increased ostomy output, abdominal distention, vomiting, fevers, sepsis, likely secondary to a viral process, ileu, likely secondary to viral process, developmental delay, tracheostomy and ventilator - dependent, gastrostomy tube, immunosuppression, total colonic aganglionosis, status post resection and transplant of small bowel and colon, and ostomy.

The plan included NPO, operating room for colonoscopy and ileoscopy, assessment postoperatively, and follow-up with the GI team for recommendations. Documentation read, "Plan of care has been discussed with the parents at bedside."

Progress notes on 1/11/17 showed plan for transfer to hospital in Miami due to "grade 1 rejection....Parents have been updated on plan of care at this time.." Pediatric GI progress note, dated 1/10/17, recent past medical history read, "Recall, we had to transport him down emergently in October 2013 when he presented with acute necrosis of his transplant...he stayed down in Miami for about 2 months."

The discharge planning daily notes dated 1/11/17 read, "Clinician spoke with (name of referring hospital transport team) informing of all details regarding this request for transfer, and the fact that the patient will need to fly air ambulance; ground transportation is not an option...."

Discharge planning daily note on 1/11/17 showed that the receiving hospital transfer center was contacted, and the patient's clinical documentation was faxed as requested. The "Reciprocal Transfer Agreement" form, signed by administration, was faxed to the receiving hospital and read, "Clinician spoke with patient's mother....by phone and informed of the co-pay amount of $ 4,088.61. Mother states that she agrees to pay this amount, and understands that it would need to be paid up front in order to transport this patient via AMR (America Medical Response) air ambulance. Mother asked if ground transportation was an option, but wanted to ask GI team if this is an option. Clinician spoke with Dr...who indicated that the patient must go air ambulance. Clinician informed both mother and Dr...that the insurance company is reviewing the documentation, and that AMR air ambulance does not have a plane today but might be able to fly tomorrow 1/12/17." The daily note, dated 1/11/17, showed correspondence between the insurance company, AMR air ambulance, and the receiving hospital, and read, "patient's insurance will not proceed on this request for authorization until they receive an inpatient authorization for admission, and this must come from (name of receiving hospital)." The note showed documentation for contact with the insurance company, AMR air ambulance, and the receiving facility, and documented once again the following, "Patient's clinician ...confirmed via Dr...that patient needs to be transported via air ambulance due to transplant rejection...."

The discharge assessment/instructions dated 1/12/17 showed patient #6 was discharged on [DATE] to the receiving facility for direct admission.

The physician discharge note read, "Completed ileoscopy for transplant surveillance 1/10/17 that showed apthous ulcers in the transplanted bowel grossly and grade 1 rejection on pathology results. Dr...is the accepting physician in Miami. High risk for worsening status and transplant rejection if not transferred to the transplant center."

Pediatric critical care progress notes dated 1/12/17 read, "He is stable from a respiratory standpoint and is now off his ventilator during the day. His parents are planning on driving him to Miami. I spoke with mom and updated her on the plan of care. No further recommendations."

Physician order dated 1/14/17 was "Discharge Patient from Hospital...mother to transfer patient to Miami for direct admission."

On 2/22/17 at 10:35 AM, the corporate risk manager from the receiving facility said on 1/11/17 the facility physician accepted transfer of patient #6 from the referring facility, and started on the reciprocal, by late afternoon they had an authorization #. At 11 PM, all papers were "good to go" but family did not want the patient transferred in the night. The corporate risk manager said the receiving facility was not against the transfer of patient #6, they were concerned that such a highly compromised patient was allowed to travel via private vehicle for 4 hours, without any medical supervision. She said this was no longer considered a transfer, but an admission. On arrival to the ED at the receiving facility, the patient was hypertensive, and admitted to pediatric intensive care unit for further management.

Transfer order from the receiving facility transfer center showed communication between case management at the referring hospital, the insurance company and the receiving facility. On 1/11/17, documentation at 7:25 PM read, "Pending nurse report...they were informed earlier that pt (patient) can be transfer since we have a reference number from the insurance...."

1/12/17 at 8:40 AM, report received that the patient had left the referring hospital at 7 AM and report was being called. The receiving facility's Transfer center clinical documentation on 1/12/17 8:59 read, "Received a call from (name) of United Health advising that this case will be canceled and no authorization will be provided. Ms (name) mentions that she called the r/f ( referring facility) for additional information and was informed that the patient had been discharged and is in route via car to our facility...." At 9:10 AM, a call was placed to the pt's mother "to advise that the pt is to present to the ED and not report to the floor being that he was discharged from the r/f. The mother was initially in disagreement as she mentioned the physician of the r/f assured her that the pt would be a direct admit. She was informed that (name of hospital) was unaware of the discharge and now request that the pt is presented to the ED." The transfer center consult notes on 1/12/17 showed that patient #6 arrived at the receiving facility at 12:30 PM.

On 2/22/17 at 11:15 AM physican D said his role in the discharge process included communication to make sure nursing, and social work (SW) were on the "same page", calling the transfer center, and communicating how the patient should be transferred. Physican D said patients with transplant, and liver issues would be transferred via air ambulance. If a patient had transplant rejection, the patient would be transferred by air ambulance. Transfer by private vehicle would be a "special case", and would be if the facility could not get an air ambulance fast enough. When asked if this had happened at any time, the MD said "months" ago, but the child was stable.

On 2/22/17 at 11:35 AM, assistant nurse manager C said if patients were to be transferred by air ambulance, patients were not allowed to go in private car without medical supervision from institution to institution.

On 2/22/17 at 4:40 PM, registered nurse (RN) A said she discharged patient #6. She said she came on duty at 7 AM on 1/12/17, and the report given to her by the off-going staff was that patient #6 was waiting on air transport. RN A said patient #6's mother was on the phone with the physican about why they had not left the hospital, the mother came and grabbed her, and said they had to leave now. The RN said the mother was adamant she told the mother she did not have a discharge order and needed to call the physican. RN A reported she called the physician fell ow and obtained discharge order, stating, "D/C (discharge) patient home for mother to drive to Miami." RN A said the patient was clinically stable, and the mother did not want to wait for insurance approval for air transport. She said patient #6's mother refused D/C instruction. She said she gave report to the receiving hospital ICU (intensive care unit) nurse, and informed her that patient #6 was on his way being transported by his mother. The RN said overall, she had a total of 45 minutes with the patient. When asked if she thought this was a safe d/c, the RN said the patient was "stable".

Progress notes by RN A, dated 1/12/17 at 7:17 AM, read, "Spoke with Dr...about patient being discharged . Mom is demanding patient be discharged at this moment, but I have no discharge order and was told the patient would be going by air flight. Dr...notified me patient was being discharged and mom would be transporting patient to Miami for a direct admission. Dr...wrote discharge orders and completed med (medical) reconciliation."

On 2/22/17 at 4:55 PM, nurse manager (NM) B said when patient #6 was first admitted , he was to be transported by air. She was told that he was stable and mother was going to take him. When asked if she believed it was a safe discharge, NM B said patient #6 was stable at his baseline condition - trached and vented.

Review of the medical record did not show any documentation by physician D to indicate it was safe for patient #6 to travel by private car. There was no documented update by case management/discharge planning, to indicate the family was unable to pay, or a denial of insurance for transfer by air ambulance. There was no documentation by medical or nursing regarding the condition of the patient on discharge.

Review of receiving facility's transfer center notes showed communication between the referring facility and the insurance company, authorization number was received, and patient #6 was accepted as a transfer to the pediatric intensive care unit (PICU).

The receiving facility was not notified that the patient was traveling by car until the day of the discharge.

A review of the patients' medical condition, and past medical history revealed patient #6 was a medically compromised patient. Arrangements were made per physician orders for the patient to be transferred by air ambulance. There was no documentation to indicate review/change of necessity for transfer by air ambulance. The facility discharged the patient, and allowed patient's #6 mother to transport him via private car for the 4 hours journey from Orlando to Miami, without medical supervision.

The facility's policy for "Discharge Planning" read, "Coordinate with the Logistic Center a secure and safe discharge."

The Risk manager could not say if this was considered a safe discharge.