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.

Based on reviews of policy and procedure, medical records, list of trauma Centers, 911 call information, Transport Protocol for Emergency Transport and interviews, it was determined the facility did not have a written transfer certification signed by the physician documenting the medical benefits reasonably expected from medical treatment at another facility outweigh the risk of transfer; The facility did not contact the receiving facility about the patient transfer; The facility did not obtain acceptance of the patient from the receiving hospital and did not send all available medical records to the receiving facility for 1 of 29 sampled patients (SP #1).

The findings include:

Clinical record review of Sample Patient (SP)#1, Focus of Investigation conducted from 12-10-12 to 12-13-12 revealed that he walked-into [Hospital I ' s] emergency room (ER) on 10-20-12.

ER RN documentation dated 10-20-12 at 330am showed:
? Musculoskeletal: " jagged wound in left forearm thru and thru "
? Injury Description: " GSW " [gunshot wound]

ER Physician Assistant Certified (PA-C) documentation dated 10-20-12 showed:
? 348am: " Skin: entrance wound to posterior lateral FA [forearm]; large wound with significant tissue loss to medial FA; arterial bleed "
? Musculoskeletal: " weak distal pulses; pale digits compared to R [right] hand "
? 351am: " Pressure dressing applied on entrance and exit wound; hemostatic. EMS contacted; 2 large bore IV NS [Normal Saline] bolus started. Trauma alert for arterial bleed, gross tissue loss and distal vasculature deficits. "
? 355am: " Patient medically screened. "

Department of Health (DOH) APPROVED ADULT TRAUMA ALERT CRITERIA ( " posted on ER wall for quick reference " )
? Category I (any one of the following): None chosen from this category for SP#1.
? Category II (any two of the following): Major degloving injury; or
Major flap avulsion >5 inches; or ------------- (x)
GSW [gunshot wound] to the extremities -- (x)

DISPOSITION SUMMARY: 10-20-12 at 355am (as documented by ER RN)
Transfer ordered to Trauma/Neuro Facility. Diagnosis is Gun Shot Wound.
Reason for transfer: Higher level of care
Accepting physician is (Trauma Hospital) (trauma alert).
Condition is Critical.
Problem is new.
Symptoms have improved.

The 04:00 10/20/12 ER Nurses notes document, transferred by Emergency Medical Service (EMS) ground to Hospital II.
At 04:01 on 10/20/12, the ER nurses notes document, the patient left the Emergency Department (ED).

There was no documentation about the receiving hospital being contacted regarding the patients transfer.

Review of the Hospital Policy#HW.CC 1.9 conducted on 12-10-12 revealed that it is the Hospital to Hospital Transfer Policy outlining the guidelines and process of transferring a patient from [Hospital I] to another hospital/acute care facility and receiving a patient from another facility. The Policy specific to ST-Elevation Myocardial Infarction (STEMI) and Trauma Patients states that:
? " IV. Policy B. " (page 1 of 11) " STEMI and Trauma Patients at a non-trauma center are transported in accordance with ..... Fire Rescue protocol; patient will be transported to the closest .... STEMI Network facility or appropriate Trauma Center or Pediatric Trauma Referral Center. The most appropriate means of transport, air or ground, will only be determined by the closest ..FR Rescue upon patient contact. "
? " V. B. Trauma " (page 2 of 11) " Patients that are at a non-trauma center and are determined to meet the Florida Department of Health (DOH) Trauma transport Protocol (TTP) within the MAXIMUM of 30 minutes from the patient ' s arrival.
? The request must be received within a MAXIMUM of 30 minutes from identification.
? Dial 911.
? The following information will be provided to the 911 dispatcher: name of the requesting facility, name and telephone number of the requesting physician, reason for request, condition of patient(s)/diagnosis and any special information or requirements.
? All State of Florida Department of Health (DOH) Trauma Transport Protocol (TTP) patients will be transported to the closest appropriate Trauma Center or Pediatric Trauma Referral Center. "
V. D. Outpatient/Emergency Department
2. All patients must be stabilized within the capability of (Initials of Hospital I) emergency department resources.
3. Once stabilizing treatment is provided, if ... is unable to provide care required by the patient,
4. The following are required:
a. Physician order for transfer to closest facility providing service required
b. Physician consultation with patient attending or primary care physician for transfer of choice
c. Once facility is identified, RN will call receiving facility for acceptance by physician and administrator on call
d. Physician and/or surgeon will discuss case with accepting physician
e. Continue with E. General Procedure

E. General Procedure
1. Physician - Complete In-patient Acute Care Facility Transfer Order, inclusive of, but not limited to - Facility name, receiving facility, receiving physician, reason for transfer, transportation mode, chart information to be copied.
Consult and or obtain a receiving physician with admitting privileges at the receiving facility.
2. Case Management - procedure...
3. Nursing - Initiate and complete a Patient ' s Transfer Consent form; Determine patient needs and resources..; Initiate and complete a Patient Transfer Administrator On Call approval form; .....provide patient report to receiving facility ...

" VI. Documentation " (page 5 of 11) " The following components are required to be documented: (2)(f) - Sending and receiving: Facility, Physician, Administrator On Call (AOC). For STEMI and Trauma Patients, receiving data are documented as 911. "

Review of the List of .... Trauma Centers conducted on 12-10-12 revealed that [Hospital Affiliate II] is a non-trauma center.

Review of the 911 Call Information conducted on 12-11-12 revealed that all needed information mentioned above were provided to 911.

There was no documentation the required information, written certification of a transfer, by the physician documenting the medical risk and benefits of the transfer. The hospital failed to contact the receiving hospital and did not obtain acceptance of the patient. The hospital also failed to send all available medical records to the receiving hospital for SP#1.

Review of the Transport Protocol for Emergency Trauma Transport from Non-Trauma Center conducted on 12-10-12 revealed: " When any non-trauma center hospital determines that a trauma patient they have received meets trauma criteria as described in Florida Department of Health Trauma Scorecard -
? They will immediately activate the EMS [Emergency Medical System] by dialing 911 " ;
? " The dispatch center shall then dispatch the closest available ALS [Advanced Life Support] ground rescue unit which shall be responsible for emergency transportation of the patient to the nearest appropriate Trauma Center or ..... Children ' s Hospital " ;
? " All patients that have been declared a ' Trauma Alert ' by a non-trauma center hospital must have scorecard applied and Trauma Alert declared in 30 minutes or less from receipt of patient " ;
? " If the declaration occurs in greater than 30 minutes, the patient will be considered an inter-facility transfer. "

Interview with the ER PA-C conducted on 12-11-12 at 950am revealed that:
? [SP#1] walked in; within 30 seconds, opened wound, closed it; instructed Unit Secretary to call 911.
? [SP#1] was bleeding significantly from the left forearm, wrapped with shirt saturated with blood.
? The size of the wound qualified for trauma case; pressure dressing applied and controlled bleeding.
? There was significant deficit - hand white, cold; radial pulse barely palpable;
? He ordered stat IV lines.
? Once 911 called, Fire Rescue was there pretty quickly. On arrival, bleeding controlled.
? ER MD was on desk after procedure - overheard one of Rescue staff: " This does not meet criteria for trauma alert. "
? Collaborated with ER MD - agreed patient met criteria for trauma alert.

Interview with the ER MD conducted on 12-11-12 at 10am revealed that:
? He spoke with EMS onsite - discussed trauma case;
? " There was significant jeopardy of limb - large blood loss, vascular jeopardy and size of wound met criteria for trauma case " .
? He " never once had second thoughts of case as NOT trauma case; not only did patient qualify per criteria, reason why trauma alert - due to symptoms present " .
? [Hospital I] had handled many GSW [gunshot wound] cases - " in this particular case, there was imminent limb loss and functional impairment; time sensitive " .
? There was blood all over the room - significant blood loss.
? [Hospital I] had no surgical capabilities for quick medical attention that time.
? [Hospital Affiliate II] " is not a Trauma Center and would delay treatment; not appropriate transfer in the interest of the patient " .
? After 911, SP#1 was stabilized within [Hospital I ' s] capabilities.
? Fire Rescue arrived quickly - geographically near [Hospital I].
? PA-C " did appropriate initiation of care. I was not available - coming from ICU code blue " .
? PA-C did medical screen and stabilized patient.
? " I agree " with PA-C ' s evaluation, initiation and provision of [SP#1 ' s] care as a Trauma alert case.

Interview with the ER Charge RN conducted on 12-12-12 at 1110am revealed that:
? She " recalls the incident clearly - GSW: there was yelling from the lobby area in ER. Instinctively, we rush to check " .
? [SP#1] bleeding profusely. [SP#1] was taken into C (Critical) section of ER. [SP#1] was shot in the arm and bleeding so much.
? [SP#1] " is dark complexioned - but his left arm was getting lighter in color, blood spurting a lot. Pressure applied to arm; thready pulse, arterial bleed, pulsating spurts. "
? The ER staff " started 2 large bore IVs - standard trauma order. Everything happened same time. Called Fire Rescue 911; rescue came real quick - geographically close; might have already been in the area. "
? She spoke with Rescue 30 Lieutenant [named]. She gave report on [SP#1]. She stated that the Rescue Lieutenant accepted report and they agreed that [SP#1] is a trauma case.

It was determined the hospital did not complete an appropriate transfer and did not follow it's policy for Hospital to Hospital Transfers.
Based on interview and record review, it was determined the facility is not in compliance with the requirements for 489.24. The facility did not complete an appropriate transfer for 1 of 29 sampled patients. (SP #1)

Refer to A 2409