HospitalInspections.org

Based on document review and interview, it was determined the Hospital failed to ensure compliance with 42 CFR 489.24

Findings include:

1. The Hospital failed to ensure to accept transfer of patients who needed specialized care. (A-2411)

Based on document review and staff interviews, it was determined that for 3 of 4 (Pt. #21, Pt #23, and Pt #24) patient requests for transfer acceptance, the Hospital failed to accept transfer of patients who needed specialized ENT (ear, nose and throat) or otolaryngology care.

Findings include:

1. A review of the on call schedule for "2024 ENT Call" was conducted during the survey. The on call schedule indicated there was ENT coverage throughout 2024 without any gap in coverage. MD (E #7) was on call on 8/23/24 and MD (E #10) was on call on 7/7/24 and 7/10/24.

2. A review of the Hospital Declination log (7/5/24-8/27/24) was conducted during the survey. The Declination log included declined transfers for Pt #21, Pt #22, Pt #23 and Pt #24.

3. Pt #21's referral was made on 7/7/24 at 11:55 AM, chief complaint anemia. The disposition noted "Denied (service not available- ENT (ear, nose, and throat)." Pt #21's "Intake Communication Log " noted, "11:20:...requested ICU (Intensive Care Unit) transfer. Patient needing ENT on ventilator ...11:55: intubated 7/4 for oropharyngeal bleeding and airway compromise, unknown etiology ...12:10: Discussed with ENT Physician (E#7): (E#7) refused transfer to (Hospital). "ENT available in Bloomington." Transfer Svcs (Services) explained that there is no IP (inpatient) coverage at (two other outlying hospitals), but they refused to consult and stated patient "should not be transferred to (Hospital)." It was also noted on the intake communication log, "12:34: Discussed with (referring hospital staff) - only adding patients within (Hospital) system to the waitlist." Pt #21 was ultimately kept at the original transfer requesting hospital in the ICU. Pt #21 was discharged 10 days later.

4. Pt #23's referral was made on 7/10/24 at 9:48 AM, chief complaint abscess. The disposition noted "Denied (service not available- ENT)". A review of the intake communication log of Pt #23 noted "0302: (E#8) requesting transfer for pt with large abscess on floor of mouth with fluid and gas collection. Dr. states it has deviated mouth structure and airway...ENT consult not available for (referring Hospital) pts...05:29:...ENT not available for non (Hospital) pts...05:47:...ENT unable to take (referring Hospital) pts (patients) d/t (due to) their contract." Six hospitals had been contacted to transfer Pt #23 from (transferring hospital) and all six had declined. Five of the six declined due to no bed availability. Pt #23 ultimately was transferred to (higher level of care hospital in Rockford). The Discharge summary from the receiving hospital stated, "Patient underwent surgery for "I&D (incision and drainage) left submandibular (below the jaw) abscess with placement of penrose drains and extraction of tooth #19 on 7/12/24." Pt #23 was discharged from the hospital 3 days later on 7/13/24.

5. Pt #24's referral was made on 8/23/24 at 11:50 AM, chief complaint necrotizing fasciitis. The disposition noted "Denied (service not available- ENT)". A review of the intake communication log of Pt #24 noted "... male with worsening airway due to mandibular abscess ...ENT consulted at referring facility states pt cannot be intubated orally but will need emergent trach. Imaging shows more than mandibular abscess ...Pt condition has continued to worsen. Return call made to ED provider. Pt will now need ICU (Intensive Care Unit) level of care ...Pt is needing intubation ...Contacted physician access to be connected with ENT Physician (E#7) with (City) ENT. (E#7) was resistant to joining the call since it was an outlying hospital. ENT/OMFS (oral maxillofacial surgeon) do not accept (referring Hospital) consult requests." Pt #24 was transferred to (higher level of care hospital in Champaign). Pt #24's transferring hospital record indicated the Hospital had tried 5 other hospitals (including hospital listed in complaint) for transfers before Pt #24 was accepted at the receiving hospital. Pt #24's receiving hospital record stated, "... transfer from outside facility for necrotizing fascitis of the left maxillary region that started as a dental abscess... airway is intact on arrival... No indication for emergent intubation at this time... patient was transferred to OR in stable condition with no impeding airway impingement." Pt #24's record indicated, "incision and drainage of submandibular, sublingual (under the tongue), and massateric (cheek) space abscesses, extraction of tooth #17, #18 and any other teeth indicated." Pt #24 was admitted after surgery "for IV (intravenous) antibiotics/further monitoring for infection resolution." Pt #24 was discharged from the hospital on 8/27/24.

6. A phone interview was conducted with Transfer Coordinator (E #5) on 8/28/24 at 1:55 PM. While discussing the intake process for patients transferring into the hospital, E #5 stated, "Providers, or their nurses call the intake phone number and request a patient transfer and request the level of bed the patient will need. Once the patient is accepted the referring provider is then connected with the accepting physician to relay information regarding the patient." While discussing the process when a transfer request for a patient is declined, E #5 stated, "Usually when patients are declined it is because we do not have a bed, we are full, or we do not have a safe staffing ratio. Sometimes it's because we have a lack of coverage for a service." E #5 stated, "A couple of times a transfer request was declined by ENT because the provider said they only take transfers within our (City) region. Intake manager (E #4) talked to the referring physicians after reviewing ENT's contract. It doesn't happen a lot because we do not get a lot of consult requests for ENT."

7. An interview was conducted with Vice President and Chief of Hospital Operations (E #6) on 8/28/24 at 2:30 PM. While discussing the contract the Hospital has with the ENT providers, E #6 stated the "ENT group consists of four providers who are committed to providing ENT care to patients at their hospital and two of their sister hospitals. The providers provide phone and in-person coverage for their hospital, and phone coverage only for their sister hospitals ... The contract does not specifically say the providers only accept (Hospital system) transfer patients, but the group of ENT providers do not have the capacity to be on call for all of downstate Illinois. When ENT referrals come in, we address each referral on a case-by-case basis."

8. An interview was conducted with ENT Physician (E#10) on 8/29/24 at 4:15 PM. While discussing the Declination Log, E #10 observed the Declination Log dated 7/5/24 through 8/27/24 and denied recognizing any of the patient's names on the log who requested ENT services. I'm a general ear nose and throat doctor, (E#7) is a general ear nose and throat doctor. We are what we would call a community-based practice. We do tonsils and tubes, and we might have different areas that we're comfortable in, but I stopped doing complicated head neck cancers 10 years ago." E #10 observed the Intake Communication log for Pt #21 and stated, "So, when somebody calls me and says there's a patient with oropharyngeal bleeding who's on Eliquis, when you say 'oropharyngeal bleeding' on somebody like that we're all automatically thinking like OK this is going to be a big thing. Then when I see the patient was a former smoker and on oxygen, these are the things that to me say there is a tumor in there that I may not be equipped to take care of. They should probably not send that person to me because now you've sent somebody to a hospital that may be able to handle it, but I can't take out that tumor. I may not be able to stop the bleeding... In those sorts of situations, I will frequently say send the patient to a tertiary care center." E #10 observed the Intake communication log for Pt #23 and stated, "This patient has Ludwigs Angina which is a big abscess in the mouth and is something that would require an oral surgeon in addition to ENT. It also said that there's gas collection, so that's something that would require potentially a fair amount of dissection in the neck. Again, that's another one of those things that wouldn't necessarily be something that we would have transferred here." E #10 observed the Intake Communication log for Pt #24 and stated, "This patient doesn't even have an airway, I don't accept patients who don't have airways. If this patient died in transit, everyone would be in trouble. In fact, at (another outlying hospital) we have a list of things with (another outlying hospital), because we take call there too, that we don't accept. They know, don't even call us because we don't accept these types of transfers."

9. The ENT contract was reviewed and did not include that the ENT providers could only care for their own hospital system patients. The contract states multiple times they will "follow EMTALA regulations."

10. Attempts were made to interview the other ENT providers. E #7 never responded to facility when attempts were made to contact. Another ENT provider was on vacation and would not respond to messages left by the facility.