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CHI ST LUKE'S PATIENTS MEDICAL CENTER 4600 EAST SAM HOUSTON PARKWAY SOUTH PASADENA, TX 77505 Oct. 27, 2011
VIOLATION: DISCHARGE PLANNING Tag No: A0799
Based on record review and interview, facility failed to operationalize it's policy and procedure to ensure 1/1 unstable patients from a sample of of 10 patients
was transferred from the facility to a hospital with appropriate specialized equipment and support measures which were medically appropriate to stabilize the patient and to sustain the patient during transfer.

Finding :

Review of patient #'1's clinical record ( Memorandum of Transfer) revealed the patient was transferred from hospital (A) to hospital (B) on 10/08/2011.

Review of the patient's clinical record revealed no evidence of an assessment of the patient's condition immediately prior to transfer by the registered nurse or a physician. Review of the patient's clinical record revealed, the Memorandum of Transfer was not signed by a physician at the transferring hospital. There was no order in the patient's clinical record as to specialized equipment and support measures which are medically appropriate to stabilize the patient and to sustain the patient during transfer.

Review of physician's progress ( from receiving hospital B) notes dated 10/08/2011 at 8:20 p.m. revealed the following assessment of the patient: "When patient came to the unit , obtunded, not following the command , tachypnic, very cyanotic, no peripherals pulse (+) cyanosis , dilated pupils not reactive." The progress notes further indicated that the patient had fixed pupils, not able to follow commands and the patient was intubated immediately.

The patient was maintained on ventilator with vasopressors medications. Physician's progress notes at hospital (B) dated 10/10/2011 indicated that the patient had no spontaneous breathing, pupils were fixed and dilated and the patient was declared dead at 9:11 a.m.

Cross reference A-0837
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on records review and interviews, the facility failed to operationalize it's policy and procedure to ensure that 1 of 1 unstable patient from a sample of 10 patients
was transferred from the facility to a hospital with appropriate specialized equipment and support measures which were medically appropriate to stabilize the patient and to sustain the patient during transfer. citing patient #1


Findings:

Review of facility's Current Policy and procedure on Patient transfer

Review of the facility's policy and procedure on patient transfer #115.09 directed staff as follows:

"The transferring physician will personally examine and evaluate the patient before an attempt to transfer is made. However, after receiving a report on the patient's condition from the hospital nursing staff by telephone or radio if the physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal evaluation of the patient will unnecessarily delay the transfer to the detriment of the patient, the physician on call may order the transfer by telephone or radio. If the physician on call issues orders for the transfer by telephone or radio, those orders shall be reduced to writing in the patient's medical record, signed by the hospital staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible.

Physician ' s duties:
(1) The transferring physician shall determine and order life support measures which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during transfer
(2) The transferring physician shall determine and order the utilization of appropriate personnel and equipment for transfer.
(3) In determining the use of medically appropriate life support measures, personnel , and equipment ,the transferring physician shall exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locally would use for the transfer
(4) Except as modified above , when delay of transfer would appear to be a detriment to the patient , prior to each patient transfer , the physician who authorizes the transfer shall personally examine and evaluate the patient to determine the patient ' s medical needs and to assure that the proper transfer procedures are used.
(5) Prior to transfer the transferring physician shall secure a receiving physician at a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient ' s medical treatment and hospital care. "


Patient #1

Review of the patient's clinical record (demographic data) revealed that she presented to the above facility's Emergency Department on 10/07/2011. The patient presented to the emergency room with chief complaint of pain from fall. The patient's history and physical indicated admitting diagnosis of [DIAGNOSES REDACTED].

Review of a progress notes by the Consulting pulmonologist (Dr B) dated 10/07/2011 revealed the following assessment of the patient : "Prognosis very very guarded."

Review of the patient's clinical record revealed a progress notes dated 10/08/2011 at 4:10 a.m. written by Dr A (a gastroenterologist) which stated : "Discussed care with Dr. B Pt to get trial of BiPAP." Review of the patient's clinical record revealed a physician's order dated 10/08/2011 at 4:20 a.m. written by Dr A to transfer patient to Hospital B.

Review of a follow up progress notes dated 10/08/2011 at 3:08 p.m. revealed the following documentation by Dr. B (pulmonologist ): "Encephalopathic, Shock , on dialysis now. Multiorgan failure, Septic Shock. On full face mask decrease air entry bilaterally, CNS drowsy and confused. Plan : on BiPAP, Oxymetry ok . No need for intubation."

Review of the patient's clinical record (nurses notes) dated 10/08/2011 at 1:45 p.m. revealed the following entry by the registered nurse: "Pt. BP = 76/29. Levo increased to 15 mic from 10 mic. Pt remains on BiPAP 18/5 and tolerating well. RR=20's. O2 SAT= 94%. axillary temp 95. Warming blanket applied at 10:30 Dr--- notified."

Review of a subsequent nurse's progress notes dated 10/08/2011 at 14:45 revealed the following documentation: "Anesthesia MD at bedside to eval resp status for possible intubation. 14:30 ABG results given. No plans for orders for intubation at this time."

Review of the patient's clinical record revealed a final entry by the registered nurse assigned to the patient dated 10/08/2011 at 18:00: " --- EMS here to transfer pt to ---- Downtown. Breathing Tx given by RT. Pt. placed on NRM for transport. 02 sat 94%. RR =22, BP= 114/92. Hr + 81. Pt to leave shortly."

Review of the patient's clinical record revealed no further assessment by the registered nurse.
Review of the patient's clinical record revealed no evidence of an assessment of the patient's condition immediately prior to transfer by the registered nurse or a physician. Review of the patient's clinical record revealed the memorandum of transfer was not signed by a physician at the transferring hospital. There was no order in the patient's clinical record as to specialized equipment and support measures which are medically appropriate to stabilize the patient and to sustain the patient during transfer.

Memorandum of Transfer

Review of the patient's medical record from transferring /accepting hospital revealed a Memorandum of Transfer signed by the patient's mother on 10/08/2011 at 17:00. Medical record revealed the following entry: "Transfer of unstabilized patient: Reason for Transfer Higher level of care. Risk of transfer worsening." The Memorandum of Transfer indicated that the facility requested special equipment of BiPAP, monitors, and pumps. Personnel needed; Paramedic ACLS.

Review of physician's progress notes (from receiving hospital B) dated 10/08/2011 at 8:20 p.m. revealed the following assessment of the patient: "When patient came to the unit, obtunded, not following the command, tachypnic, very cyanotic, no peripherals pulse (+) cyanosis, dilated pupils not reactive." The progress notes further indicated that the patient had fixed pupils, not able to follow commands and the patient was intubated immediately.

The patient was maintained on ventilator with vasopressors medications. Physician's progress notes at hospital B dated 10/10/2011 showed that the patient had no spontaneous breathing, pulse were fixed and dilated, and the patient was declared dead at 9:11 a.m.

Paramedic statement

Review of a statement dated 10/08/2011, written by the licensed paramedic who transferred the patient from hospital (A) to hospital (B) revealed the following entry: "Hospital staff----- informed EMS personnel that pt family specifically requested that patient be transported with a service with BIPAP capabilities Mr-- and Ms-- were informed multiple times that -- ambulance did not have BIPAP capabilities.

At approximately 10 minutes into transport, O2 sat on portable pulse ox ( attached to forehead) began to fluctuate and drop. O2 dropped into the 60's but continued up and down between the 60s and 80%. Pt remained conscious and was moving her arm, but not with the same vigor as previously noted. At that time the decision was made to to begin assisting PT, ventilations with BVM.at the rate of 12 - 15 breaths per minute."


Interview with intensive care Charge Nurse

In an interview with Intensive Care unit Charge Nurse (C) on 10/26/2011 at 11:15 a.m. in the chief nursing officer's office. She stated that she was the charge nurse in the intensive care unit during patient #1's transfer from the hospital. . She stated that she could recall details of the event although she was not directly assigned to her She stated that RN (D) was assigned to the patient. She said the accepting hospital called her and confirmed that it was OK to transfer the patient. She said she went to locate the Memorandum of Transportation ( MOT ) which she thought was filled out from the night before but there was none. She said she seek the help of a case manager to help her with completing the MOT.

Charge Nurse (C) said she did not directly conduct a need assessment on the patient but based on the information from the nurse who was assigned to the patient, she called the ambulance for transfer. She said she told the ambulance that the patient needed BiPAP and equipment to intubate along with a paramedic. Charge Nurse (C) said she did not notify the physician of the transfer since the nurse assigned to the patient told her that they were working on the transfer since earlier in the day. She said she spoke with the patient's mother and sister and told them that there were risks involved in transferring the patient. She said the patient was taken off the BiPAP machine and placed on a non re-breather mask for the transfer. The Surveyor asked the charge nurse if she had an order to change the BiPAP to a non rebreather mask. She stated no. She stated that she did not see the patient leave the unit and since she was not assigned to the patient she did not write a note on the event of the transfer.

Further interview with Charge Nurse (C) at 2:34 p.m. in the CNO office, she stated that she spoke with the patient's brother- in law via the telephone. She said he wanted to know the patient's vital signs, which she provided. She also assured him that the patient would be transferred in an ambulance which had BIPAP, the capability to intubate, ACLS personnel and pump . She said after providing him with the information on the transfer, he was ok with the transfer. She said she was not aware that the ambulance did not have BIPAP capability. Did not know who switched the patient from BIPAP to a non - re- breather mask.

The charge nurse said she did not know a lot about the patient , she only knew that the patient had liver problem and was been transferred to see a liver specialist. She said as the charge nurse she was assigned two patients of her own along with charge responsibility and precepting registered nurse (D) who was working in the facility less than 90
days.

Interview with Registered Nurse (D)

During an interview with Registered Nurse (D) on 10/26/2011 at 2:25 p.m. in the CNO's office, he stated that he was assigned to the patient during the transfer. Said he provided care to the patient from 7:00 a.m. He said he walked in the patient room in time to assist the EMS personnel with transferring the patient from the bed to the stretcher. He said there were two EMS personnel ' s in the room but he did not know their names. He said the shorter of the two EMS personnel made a comment that he did not have BIPAP capability on the ambulance. He said he did not notify his charge nurse of the lack of BIPAP capability.
Registered nurse (D) said he spoke to the patient's covering attending physician approximately 7:30- to 8:00 a.m. on 10/08/2011. He said he cannot recall mention of transportation of the patient via life flight , neither can he recall the physician telling him that that he needed to revaluate the patient after hemodialysis. He said he did not think to stop and call the physician prior to the transfer.


Interview with Dr E

During an interview with Dr (E) on 10/26/2011 at 11:43 a.m. via the telephone , he stated that he was the covering physician for the patient's attending physician. He stated that he saw the patient at approximately 8:00 a.m. in the unit. He said at the time that the renal physician was present along with the gastroenterologist. He said that the renal physician was in the process of inserting a catheter to dialyze the patient . He said he and the gastroenterologist discussed arranging for transfer post hemodialysis. He said he spoke to the nurse assigned to the patient and informed him that he would revaluate the patient post hemodialysis treatment since the patient was critical and on vasopressors. He said he spoke with nurse assigned to the patient and told him that the patient may need life flight.

Dr ( E) said that the nurse did not inform him about the patient's condition on transfer and that he had not seen or examine the patient after hemodialysis treatment. He said that he was of the opinion that at the time of transfer the attending physician needed to be called to discuss the patient's vital signs and the condition of the patient. He said the transfer order was written earlier in the morning by the consulting hematologist. He stated "To be frank with you, when I opened the patient's chart I did not know what time the patient left because I could not find any info. I spoke with the patient's attending physician the following Monday and informed him that the patient left the facility without been seen by me."


Interview with Dr (A)

During and interview with DR (A) (gastroenterologist) on 10//27/2011 at 10: 36 a.m. in the CNO's office, he stated that he ordered the transfer of patient #1 to a facility with liver transplantation capacity. He stated "I was worried about her that's why I came back I contemplated intubation."

Dr (A) stated "I don't order what equipment to be on board. They needed an ambulance specifically to deal with her condition. I am a consultant, I take care of her liver. Every one knew that the patient was to be transferred, and what specialized equipment she needed. She was on BiPAP all day."

Interview with Dr (B)

During an interview with Dr (B) (pulmonologist) on 10/27/2011 at 1:25 p.m., he said he assessed the patient on 10/08/2011 at approximately 3:08 p.m., and at that time after assessing the patient he made a determination that the patient did not need intubation but needed to continue on BiPAP. He said he spoke with the patient's mother and sister, and assured them that "we will reassess the patient when a bed becomes available in the intensive care unit of ( hospital B) ". Dr (B) said he had no direct or indirect contact with the patient or the family after that visit until approximately 9: 00 p.m., the patient's brother- in - law called him on his cell phone and told him that the patient was transferred from the hospital to the receiving hospital without BiPAP . Dr. B said that based on his assessment at 3:08 p.m. the patient should have been transferred on the BiPAP. He said his assessment at 3:08 p.m. revealed the patient was responsive but confused, but less confused than when he assessed her on 10/07/2011. He said when he saw the patient on 10/08/2011 at 3:08 p.m. the patient's pupils were reactive to light and the patient was not comatose. Dr (B) states "No one asked my opinion on the transfer. No doctor was called on the transfer, no one from the hospital or the EMS company." He said he called the administrator on call the same night and notified him that the patient was transferred without BIPAP capability.