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.

FALMOUTH HOSPITAL 67 & 100 TER HEUN DRIVE FALMOUTH, MA 02540 Oct. 18, 2017
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on records reviewed and interviews, Hospital A failed for one (Patient #1) of ten medical records sampled to facilitate an effective and timely physician communication process to transfer a patient from Hospital A to Hospital B.

Findings include:

The Emergency Department (ED) Physician Note, dated 6/13/17, indicated that Physician #1 made multiple phone calls to Hospital B in an attempt to transfer Patient #1 to Hospital B for continued bleeding. The ED note indicated that Physician #1 conducted call #1 to Hospital B's Gastroenterology Specialist on-call who identified that Patient #1 would require a colorectal surgeon. The ED note indicated that Physician #1 placed call #2 to Hospital B's ED who stated they needed to check bed status. The ED note indicated that Hospital B never called back. The ED note indicated that Physician #1 placed call #3 to Hospital B's ED and this time Hospital B questioned why Patient #1's bleeding could not be treated by Hospital A's general surgeon. The ED note indicated that Physician #1 placed call #4 to Hospital A's on-call general surgeon. The ED note indicated that the general surgeon was not able to repair the complication of the banding procedure (bleeding after rectal surgery). The ED note indicated that Physician #1 placed call #5 to Hospital C (a tertiary care facility) who accepted Patient #1 in transfer.

The Surveyor interviewed Physician #1 at 9:00 A.M. on 10/17/17. Physician #1 said he made multiple calls to Hospital B without a confirmed acceptance from Hospital B. Physician #1 said he decided to arrange for helicopter transport to Hospital C to treat Patient #1 for continued bleeding.

The Hospital's Internal Investigation, dated 10/16/17 regarding Patient #1, indicated that Hospital A identified the transfer process between Hospital A and Hospital B required corrective action.

The Surveyor interviewed the Chief Medical Officer (CMO) at 1:15 P.M. on 10/16/17. The CMO said that the transfer process between Hospital A and Hospital B required improvement.

The Surveyor interviewed the ED Chief/Medical Director at 10:00 A.M. on 10/17/17. The ED Director said that a new transfer process was not fully implemented.