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METHODIST HEALTHCARE MEMPHIS HOSPITALS 1265 UNION AVE SUITE 700 MEMPHIS, TN 38104 July 24, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on hospital EMTALA policy, ambulance request procedure review, Inter-facility Transfer Form review, medical record review and interview, it was determined the hospital failed to ensure the Dedicated Emergency Department (DED) provided an appropriate transfer of a patient who's condition was documented as "guarded" and failed to utilize transportation equipped with emergency medical equipment and qualified personnel for 1 of 22 (Patient #10) sampled patients transferred from the hospital to a higher level of care.
Refer to findings in deficiency A-2409.
VIOLATION: APPROPRIATE TRANSFER Tag No: A2409
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on EMTALA policy, ambulance request procedure review, Inter-facility Transfer Form review, medical record review and interview, it was determined patients requiring transfer to a higher level of care were not transported by qualified personnel and with medically appropriate equipment for 1 of 22 (Patient #10) sampled patients (Pt).

The findings included:

1. Review of the facility policy, "Screening, Stabilization, Treatment and Transfer of Individuals in Need of Emergency Medical Services - EMTALA" revealed, "F. Transfer of Patients...The unstable individual may be transferred: (1) If the transfer is an appropriate transfer (meaning all of the following conditions (a) through (d) are met);...(d) The transfer should be effected through appropriately trained professionals and transportation equipment, including the use of necessary and medically appropriate life support measures during the transfer. The physician should be responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer..."

2. Review of the facility procedure, "AMBULANCE REQUESTS" revealed, "...[the names of 2 transport companies including the company that transported Pt #10] are the approved vendors for these transports. This service is only available for NON medical patients, as they provide no medical services..."

3. Medical record review for Patient #10 revealed the patient presented to Hospital #1's Emergency Department (ED) at 10:10 AM on 6/19/14 with abdominal pain, nausea, vomiting, vaginal bleeding and had a mass near her ovaries. She had been at Hospital #1's Pre-admission Testing Department for pre-surgical lab work when the patient's abdominal pain became worse and she was taken by staff to Hospital #1's emergency department. The patient's pain was rated a 10/10 and she was assigned an acuity level of 3-urgent. A transvaginal ultrasound was done at 10:28 AM which showed a chronically dilated left fallopian tube that was filled with fluid and without evidence of inflammatory changes within its wall similar to that seen on previous multiple imaging studies back to 2008 and a right sided [DIAGNOSES REDACTED] with embryonic demise dated to approximately 8 weeks 4 days.

At 12:45 PM the ED nurse documented, "Pt was here for pre-admission check up for RLQ [right lower quadrant] mass to be removed next week; pt stated that the mass usually hurts to where she is unable to function; she stated that ultrasound [ultrasound technician] informed her that she had an [DIAGNOSES REDACTED]; AOX3 [alert/oriented times 3]; VSS [vital signs stable]; pt in bed; family at bedside."

At 12:58 PM an intravenous needle therapy (INT) was started in the patients left antecubital. At 14:30 another INT was inserted in the patients right antecubital. There was no documentation the INT's were removed prior to the patient being transferred to Hospital #2.

At 1:45 PM the ED Provider Note revealed the Gynecologist (GYN) on call was notified and stated Hospital #1 did not see obstetrics (OB) and the GYN physician recommended the patient be transferred to Hospital #2. The Physician at Hospital #2 was called by Hospital #1 and Hospital #2 accepted the patient for transfer. The patient's condition was documented as "guarded" by Hospital #1 with a diagnosis of [DIAGNOSES REDACTED]

Review of Hospital #1's Inter-facility Transfer Form revealed the mode of transportation was to be Advanced Life Support (ALS) ambulance.

Review of Hospital #1's Physician Certification of Medical Necessity for Ambulance Transportation revealed the physician revealed, "...Why does this patient require ambulance transport?... IV/cardiac monitor/oxygen/medication/respiratory support or other acute medical monitoring/assistance needed during transport ..."

Review of Hospital #1's Transfer Information Report revealed a van transportation company, not equipped with emergency medical equipment and with a non-medical driver, was contacted by Hospital #1 and transferred the patient to Hospital #2. The form documented the patient was ambulatory.

Review of the non-medical van transport company's "Ambulatory/Wheelchair/Invalid Call Ticket" form dated 6/19/14 revealed Pt #10 was delivered to Hospital #2 at 15:27.

4. Medical record review from Hospital #2 for Pt #10 revealed an admission date of [DATE] and at at 15:37. The method of arrival was "wheel chair" and the reason for admission was "ectopic." Review of the physician's progress note dated 6/19/14 at 16:10 revealed, "pt transferred from [Hospital #1] for suspected unruptured [DIAGNOSES REDACTED];..." At 16:11 the (Medical Doctor) MD documented, "...1. Ectopic: On call to OR for removal..."
The Intraoperative Record dated 6/19/14 revealed Pt #10 arrived in the operating room at 18:01 for a left salpingectomy (excision of the Fallopian tube) for a massive hydrosalpinx (collection of watery fluid in the Fallopian tube) and a right salpingostomy (opening the Fallopian tube) for an [DIAGNOSES REDACTED]. Post operative findings revealed a moderate amount of blood in the abdomen, large left hydrosalpinx with copious clear serous fluid, right ectopic within the tube, "significant pelvic adhesive disease" and unable to define the planes of ampulla which necessitated a salpingostomy. The patient was discharged from Hospital #2 on 6/20/14 with a follow-up MD appointment 2 weeks later.

5. During an interview in the administrative conference room on 7/15/14 at 1:59 PM, Clinical Director (CD) #1 was asked who makes the decision to transfer patients to a higher level of care using ALS or basic life support (BLS). The CD stated it was the decision of the doctor and nurse in the ED. The CD stated the non-medical van driver transferred patients in a van without emergency medical equipment. The CD stated the non-medical van driver transferred Patient #10 from hospital #1 to Hospital #2 in a van. The patient was seated in the van during the transfer. The CD stated Hospital #2 called the charge nurse at Hospital #1 with concerns that the patient was brought over to hospital #2 in a wheelchair. The charge nurse immediately talked to nurse #1 and #2 and explained it was contraindicated to be in a wheelchair with her diagnosis.

On 7/15/14 at 2:48 PM in the administrative conference room, Nurse #2 was interviewed. She stated, "... This patient [pt #10] came to us from the outpatient pre-admission area because she was having so much pain. After workup she had an ectopic [pregnancy] and was to be transferred [to Hospital #2].... When they [the non-medical vendor van transportation company without emergency medical equipment] brought in a wheelchair to pick her [Patient #10] up, I didn't think anything about it because she [Pt #10] had been ambulating to the bathroom and she was brought to us in a wheelchair...someone had called from the hospital [hospital #2] and said they [the non-medical vendor van transportation company without emergency medical equipment] did not take her to Labor and Delivery [L&D] but took her to the front and left her."

On 7/16/14 at 8:45 AM nurse #1 was interviewed by telephone and stated she had called for transportation to have Patient #10 transferred to Hospital #2. Nurse #1 verified the patient had 2 INT's but was not receiving fluids through them at the time of transfer. Nurse #1 stated the patient left Hospital #1's ED in a wheelchair and was transferred to Hospital #2. Nurse #1 stated Hospital #2 called Hospital #1 when the patient arrived and asked Hospital #1 why the patient was dropped off at the front door and not brought in to the Labor and Delivery Department ED? Nurse #1 stated, "I know now to make sure if patients are transferred to another hospital they go by ambulance and I get the names and titles of who took them."

On 7/16/14 at 10:35 AM in the administrative conference room, the Vice President, Chief Administrative and Compliance Officer of the non-medical van transport company who transferred Pt #10 to Hospital #2 stated, "[Name of transport driver] was the transporter for [Pt #10]. She [the transport driver] is a wheelchair driver not EMS [Emergency Medical Services]. They [the transport drivers] are CPR certified, have training in basic first aid, blood borne pathogens and how to use blood spill kits. They will secure the patient into the van using seat belts. Usually one driver to a vehicle." The Surveyor asked if they routinely conduct ED-to-ED transfers with a wheelchair van and he stated, "No. The drivers have no clinical experience, don't do vital signs."

On 7/16/14 at 10:45 AM the van transport driver who transferred Pt #10 to Hospital #2 was interviewed via telephone. She stated, "I picked patient up at [name of Hospital #1] and secured her in the van. She was able to walk. Her mother rode with her too. When I got to [the address of Hospital #2], I went into the building and told the receptionist I needed a wheelchair to bring a patient in. She said they had no wheelchairs and asked me why the patient was coming. I didn't know so I went out and asked her [Pt #10]. When I came back in the receptionist told me I needed to take her to L&D [labor and delivery]. Security found me a wheelchair. I took her to [Hospital #2's] L&D department after getting the patient out of the van. When we went in the building we couldn't go into L&D because it was on a security lock down. So we waited with some other folks. Then they cleared it and I took her in and left her. She was alert and talking to her mom and on her cell phone. She signed my form and I left."

6. Review of the Hospital #1's Provision of Care Event form dated 6/19/14 revealed the Clinical Director documented, "...This was an educational moment for a new RN in orientation and her preceptor.... Although the patient [Patient #10] was ambulating, to do so at the particular time and under those circumstances was contraindicated. It was truly a breakdown in communication."

7. Additionally, a gynecologist was on call, but for some reason obstetrics service's were not available and it was not clear why a patient with an OB problem could not be managed at the hospital.