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NORTHERN LIGHT INLAND HOSPITAL 200 KENNEDY MEMORIAL DRIVE WATERVILLE, ME 04901 July 8, 2011
VIOLATION: STABILIZING TREATMENT Tag No: A2407
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of medical records, review of policies and procedures and interviews with key staff on July 6 and 8, 2011, it was determined that the hospital staff failed to provide, within their capabilities, treatment as required to stabilize Patient A, prior to transfer as evidenced by:

1. A review of Patient A's medical record revealed that Patient A was admitted to the Inland ED at 9:10 and transferred to CMMC at 1413 (2:13 pm) June 22, 2011. Patient A was in the Inland Emergency Department for approximately five (5) hours.

2. The Inland Hospital policy ' EMTALA- Emergency Treatment and Transfer ' stated, "Any person with an Emergency Medical Condition identified by the screening exam receives stabilizing treatment within the capability of Inland Hospital " .... " Patients are transferred only when requiring stabilizing treatment not available at Inland Hospital " ...and " Inland Hospital must provide medical treatment, within its capacity, to minimize the risk to the individual ' s health ... "

3. A review of Patient A's medical record on July 6, 2011, revealed physician documentation that Patient A had increasing dyspnea [difficulty breathing] since the previous day , as well as lower extremity edema [swelling]. Additionally, the review of Patient A's medical record revealed documentation that Patient A had experienced diarrhea and black stools the morning of June 22, 2011, the day of admission.

4. Patient A's medical record included documentation that the laboratory results were available at 10:00. The results included a hemoglobin of 4.3, a hematocrit of 13.0, and platelets of 6. There was no documentation in Patient A's medical record that Patient A's laboratory values were treated prior to the patient being transferred.

5. The Nurses Quick Reference to Common Laboratory & Diagnostic Tests Fourth Edition by F. Fischbach and M. Dunning (2006) , page 210, states" Hct [hematocrit] of less than 20% can lead to cardiac failure and death" and " a hemoglobin value of less than 5.0g/dl (<50g/l) leads to heart failure and death." Fischbach and Dunning continue on page 214" a critical decrease in platelet value of less than [20,000] is associated with a tendency to spontaneous bleeding, prolonged bleeding time, petechiae, and ecchymosis."

6. The American College of Emergency Physicians Emergency Medicine: A Comprehensive Study Guide (6 th Edition), with Editor in Chief J. Tintinalli (2004), Section 18 Hematologic and Oncologic Emergencies, page 1349 states, " The primary reason for transfusion of PRBC's [packed red blood cells] is to increase oxygen-carrying capacity. The two indications for emergency PRBC transfusions are acute blood loss and profound anemia with impared oxygen delivery."

7. During an interview with Physician A on July 6, 2011, he stated, " I felt [Patient A] needed oncology [a service not offered at Inland] ...I knew [s/he] needed a transfusion ...I felt an oncologist should decide on the transfusion ....[s/he] was stable ... it would have taken an hour to an hour and a half to cross match [him/her] and get a transfusion ready ...I wanted to transfer [him/her] to an oncologist " . [Note: Patient A was in the Inland Emergency Department for approximately five (5) hours.]

7. During the interview with Physician A on July 6, 2011, the physician stated, " If I could do it over ....a transfusion would have been in order ....transfusions may take several hours ...the family wanted the patient to go to CMMC, I wanted to get [him/her] seen by oncology ... " . Physician A added, " My documentation sucks " .

8. During an interview with Physician B, Vice President (VP) of Medical Affairs & Emergency Department Director on July 6, 2011, he stated that he had reviewed Patient A ' s medical record. When asked if he felt that Patient A had been stabilized prior to transfer, he stated, " It ' s complicated ....[s/he] had chronic [DIAGNOSES REDACTED] ...the doctor makes the decision of whether the patient needs the transfusion. It takes 1 to 1 ? (one to one and a half) hours to get blood cross matched ...the question than becomes do you take the time to transfuse or do you transport ...there is nothing documented in the chart .... "

9. During an interview with Physician B, Vice President (VP) of Medical Affairs & Emergency Department Director on July 6, 2011, he stated, " If [Patient A] didn't want transfusions, than the care was appropriate. If [Patient A] wanted transfusions, the care was not appropriate. I don' t know the answer; there is no documentation of the discussion .... "

10. An interview was conducted with Physician C on July 8, 2011. Physician C, who admitted Patient A as a transfer, he stated, " My concern was that [Patient A ' s] platelets were low, and [his/her] H&H was low- [his/her] labs would have indicated that a transfusion was necessary ...I believe that the ED department in [the sending hospital] did not accurately access whether the patient was actively bleeding or not. There seemed to be some discrepancy between whether or not there was active bleeding .....We were told [s/he] was stable, but [s/he] actually wasn't " .

11.The potential impact of the failure to stabilize a patient within the capacity of the hospital's Emergency Department could result in heart failure and death.