HospitalInspections.org

Based on facility policy review, medical record review, and interview, the facility failed to ensure an appropriate transfer was provided for 4 patients (Patients #5, #11, #12, and #13) of 4 transferred Emergency Department (ED) patients of 13 ED patients reviewed.

The findings include:

Review of Facility A's policy titled "Emergency Medical Treatment and Patient Transfers" revised 2/2020 showed "...When an individual comes to the Emergency Department of the hospital, or to any location on hospital property...and a request is made on the individual's behalf for a medical screening examination or treatment, an appropriate medical screening examination, within the capabilities of the emergency department (including ancillary services routinely available to the emergency department), shall be provided to determine whether an emergency medical condition exists, or with respect to a pregnant woman having contractions, whether the woman is in labor...If the hospital transfers a patient, the hospital will provide to the receiving physician and receiving hospital a copy of those portions of a patient's medical record that are available and relevant to the transfer and to the continuing care of the individual. These records will accompany the patient to the receiving hospital...The medical records shall contain information relating to the individual's emergency medical condition, including a brief description of the individual's medical history...and physical examination, working diagnosis and recorded observations of physical assessment of the patient's condition at the time of the transfer, treatment provided, results of any tests performed...Stabilizing Treatment for Emergency Medical Conditions and Women in Labor...If it is determined through a medical screening examination that an emergency medical condition exists or that a woman is in labor, emergency department personnel shall: Provide such further medical examination and treatment as may be required to stabilize the medical condition or provide treatment to the woman in labor, within the capabilities of the staff and facilities available at the hospital..."

Medical record review of an ED Nurse's documentation at Facility A showed Patient #5 presented on 9/11/2021 at 9:28 AM with a complaint of Abdominal Pain. The patient was triaged as a level 3 (non-urgent) on the Emergency Severity Index (ESI) system. Patient #5 was transferred to Facility B on 9/11/2021 for surgery.

Medical record review of a radiology report of a Computed Tomography (CT) of the Abdomen and the Pelvis completed at Facility A for Patient #5 dated 9/11/2021 at 10:17 AM showed "...Findings of high-grade small-bowel obstruction...in the right lower quadrant of the abdomen. The stomach and distal esophagus are also distended with fluid..."

Medical record review showed no documentation a MSE, including a history and physical or a physical assessment was performed by a Qualified Medical Provider (QMP) at Facility A for Patient #5 prior to transfer to Facility B.

Medical record review of an Admission History and Physical at Facility B showed Patient #5 was admitted to the facility on 9/11/2021 for a Small Bowel Obstruction and an Acute Kidney Injury. Patient #5 was noted to have a history of chronic constipation after a previous Colectomy (surgical removal of all or part of the colon).

Medical record review of Patient #5's Discharge Summary at Facility B dated 9/25/2021 showed the patient did not have a Small Bowel Obstruction. Further review showed Patient #5 was tolerating clear liquids and total parenteral nutrition (intravenous feeding), but the patient's condition declined, and he required intubation (artificial airway) and emergency medications. Continued review showed Patient #5 expired on 9/25/2021 and the death was attributed to "...Septic shock and severe decompensated metabolic acidosis [imbalance in the body's acid-base balance] secondary to [history of] bowel obstruction..."

Medical record review of an ED Nurse's documentation showed Patient #11 presented to Facility A's ED on 8/31/2021 at 11:15 AM. Continued review showed the patient was "...39 weeks pregnant [40 weeks is full term] and in active labor [contractions with cervical dilation]..." The patient was triaged as a level 3. Further review showed there was no documentation of how often the patient's contractions occurred or of a cervical exam [exam to check for cervical dilation] performed by the facility. Further review showed no documentation the patient was examined by a QMP.

Medical record review showed no documentation a MSE, including a history and physical or a physical assessment was performed by a QMP at Facility A for Patient #11 prior to transfer to Facility C.

Medical record review showed Patient #11 was transferred to Facility C on 8/31/2021 at 11:45 AM (30 minutes after arrival to Facility A) for "...Possible Labor/39 weeks..."

Medical record review of Facility C's Vaginal Delivery Initial Progress Note dated 8/31/2021 at 3:20 PM showed Patient #11 was in active labor and her cervix (opening to birth canal) was dilated (open) to 4-5 centimeters on arrival to the facility. Continued review showed Patient #11 delivered the baby on 8/31/2021 at 6:07 PM. Patient #11 was discharged home on 9/2/2021.

Medical record review of an ED Nurse's documentation at Facility A showed Patient #12 presented on 9/6/2021 at 8:33 PM with a complaint of Front and Back Torso (shoulders to groin) Pain and Buttock Pain. The patient was triaged as a level 3. Patient #12 was transferred to Facility C on 9/7/2021 at 1:20 AM due to a concern for multiple rib fractures.

Medical record review of a radiology report of a CT of the Chest, Abdomen, and Pelvis completed at Facility A dated 9/6/2021 revealed Patient #12 had a "...nondisplaced [has not shifted out of alignment]...left 7th and 8th rib fractures. Nondisplaced...right 10th rib fracture...Mild gallbladder wall thickening...No definitive...gallstones. Common bile duct is dilated measuring 13 mm [millimeters]...Consider a follow-up right upper quadrant ultrasound for further characterization..."

Medical record review showed no documentation a MSE, including a history and physical or a physical assessment was performed by a QMP at Facility A for Patient #12 prior to transfer to Facility C.

Medical record review of an ED Physician's Note at Facility C dated 9/7/2021 showed Patient #12 was admitted to the facility for further evaluation.

Medical record review of an Admission History and Physical at Facility C dated 9/7/2021 showed Patient #12's Computed Tomography (CT) scan completed at Facility A was reviewed by a trauma physician at Facility C and it was determined the patient did not have rib fractures. Continued review showed Patient #12's gallbladder was inflamed.

Medical record review of a Discharge Summary showed Patient #12 was discharged from Facility C on 9/9/2021 after a Cholecystectomy (removal of the gall bladder) was performed.

Medical record review of an ED Nurse's documentation at Facility A showed Patient #13 presented on 9/11/2021 at 2:41 PM with a complaint of Blood in the Urine. The patient was triaged as a level 4 (less urgent). Patient #13 was transferred to Facility D on 9/11/2021 at 8:35 PM for a referral to a Urologist.

Medical record review showed no documentation a MSE, including a history and physical or a physical assessment was performed by a QMP at Facility A for Patient #13 prior to transfer to Facility D.

Medical record review of an Admission History and Physical at Facility D stated 9/11/2021 showed Patient #13 was admitted with Hematuria (blood in urine) and History of Renal Cancer.

Medical record review of Patient #13's Discharge Summary at Facility D dated 9/16/2021 showed the patient's renal cancer had spread to other parts of the body. Patient #13 was discharged on 9/16/2021 with hospice care.

During an interview on 9/21/2021 at 12:28 PM, ED Physician #1 at Facility A revealed "...I'm the only one here for all these patients 24/7 [24 hours per day 7 days a week]. There's not enough time to document. I do patient care first...documentation can come later..." Further interview confirmed there was no documentation a MSE, including a history and physical or a physical assessment had been performed for Patients #5, #11, #12, and #13 prior to transfer to another facility.