HospitalInspections.org

Based on review of the hospital A's (Baptist Medical Center East) policies and procedures, medical records (MR), and interviews with staff it was determined the hospital failed to:

1. Inform the patient of the risk and benefits of leaving prior to the medical screening examination (MSE) and stabilizing treatment and failed to document what was refused by the patient when he/she left without being seen (LWBS).

2. Ensure a hospital policy was developed which included the provision of a description of the MSE and stabilizing treatment refused, informing the patient of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment, and steps to secure the patient's written informed refusal when LWBS.

3. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another hospital outweighed the risks of being transferred.

4. Ensure the patient and/or caregiver consented to the transfer to another hospital.

5. Ensure the patient transfer was effected through qualified personnel and transportation equipment.

6. Send to the receiving facility, all medical records related to the emergency condition which the patient had presented.

This deficient practice affected two of five MRs reviewed who LWBS, including Patient Identifier (PI) # 1 and PI # 10, and two of three transferred MR's, including PI # 13 and PI # 15, and had the potential to affect all patients served by the hospital ED.

Findings Include:

Cross Refer to A 2406 and A 2409 for findings.

Based on review of the hospital policy, medical records (MR), and interviews with staff it was determined the hospital failed to:

1. Inform the patient of the risk and benefits of leaving prior to the medical screening examination (MSE) and stabilizing treatment and failed to document what was refused by the patient when he/she left without being seen (LWBS).

2. Ensure a hospital policy was developed which included the provision of a description of the MSE and stabilizing treatment refused, informing the patient of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment, and steps to secure the patient's written informed refusal when LWBS.

This deficient practice affected two of five MRs reviewed who LWBS, including Patient Identifier (PI) # 1 and PI # 10, and had the potential to affect all patients served by the hospital Emergency Department (ED).

The findings included:

Hospital Policy: Emergency Medical Treatment and Labor Act (EMTALA) Policy
Policy Number: Not documented
Reviewed Date: 4/24

I. Purpose: The purpose of this policy is to set forth guidelines to comply with the requirements of the EMTALA including, but not limited to the performance of MSE, patient stabilization...

III. Definition of Terms:

...B. MSE: the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the patient has an emergency medical condition or not...

D. Stabilization...no material deterioration of the condition is likely, within reasonable medical probability, to result...

E. Emergency Medical Condition... A medical condition manifesting itself by acute symptoms of sufficient severity...such that the absence of immediate medical attention could reasonably be expected to result in either:

a. Placing the health of the patient...in serious jeopardy;
b. Serious impairment to bodily functions; or
c. Serious dysfunction of any bodily organ or part...

1. PI # 1 presented to the hospital ED on 1/4/25 at 12:13 AM with a chief complaint of bleeding at the surgical site following the removal of tonsils and adenoids on 1/3/25.

Review of the Triage Assessment dated 1/4/25 at 12:33 AM revealed the patient had experienced bleeding at the surgical site around 11 PM on 1/3/25 with throat and ear pain. Further review revealed there was no active bleeding during triage and pain in the mouth at an 8 on a 1 to 10 scale.

Review of the ED Depart (Departure) Nursing Note dated 1/4/25 at 3:24 AM revealed the patient left with caregivers per registration.

Review of the MR revealed no documentation of a description of the MSE and stabilizing treatment refused by the patient and/or caregiver and the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.

Review of the ED video footage on 1/15/25 revealed PI # 1 arrived with two caregivers on 1/4/25 at 12:02 AM, entered triage at 12:33 AM, exited triage at 12:38 AM, then remained in the ED waiting area. At 1:45 AM one of the caregivers went to the registration desk, spoke with Employee Identifier (EI) # 3, Patient Registration Specialist 1, walked to the ED badge registration desk, spoke with EI # 4, Patient Registration Specialist 2, then exited the ED with the patient at 1:48 AM.

An interview was conducted on 1/16/25 at 7:42 AM with EI # 5, ED Triage nurse for PI # 1. EI # 5 verbalized registration would notify him/her if a patient wants or had LWBS, if the patient is still in the ED, then he/she would encourage the patient to stay and explain the risks and benefits of staying. If the patient had already LWBS then he/she would document the LWBS in a nurse's notes. EI # 5 verbalized the patient would not sign anything related to the LWBS.

An interview was conducted on 1/16/25 at 8:00 AM with EI # 3, who verbalized when a patient and/or caregiver notifies him/her of wanting to LWBS, he/she would tell them to knock on the triage door, give them your name, and tell them you're leaving.

An interview was conducted on 1/16/25 at 2:41 PM with EI # 4, Patient Registration Specialist 2, who verbalized when a patient and/or caregiver notified her/him of wanting to LWBS, she/he would make sure that's what the patient wanted to do, she/he would document it in the comment section, and if there were any questions, she/he would refer them to the triage nurse. EI # 7 verbalized there was nothing the patient and/or caregiver signs.

An interview was conducted on 1/16/25 at 10:08 AM with EI # 2, Vice President, Quality Management and Patient Safety, who verbalized a patient and/or caregiver LWBS is encouraged to stay but the hospital does not have the patient and/or caregiver sign anything since it usually occurs from the ED lobby. EI # 2 confirmed the hospital does not have a policy which includes the provision of a description of the MSE and stabilizing treatment refused, informing the patient of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment, and steps to secure the patient's written informed refusal when LWBS.

An interview was conducted on 1/16/25 at 10:32 AM with EI # 1, Accreditation Coordinator, who confirmed there was no documentation of a description of the MSE and stabilizing treatment refused and no documentation the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.

2. PI # 10 presented to the hospital ED on 11/11/24 at 12:28 PM with a chief complaint of possibly swallowing one 20 mg (milligram) Telmisartan (medication used to treat high blood pressure).

Review of the ED Depart Nursing Note dated 1/4/25 at 3:24 AM revealed the patient's guardian notified the ED staff they were leaving.

Review of the MR revealed no documentation of a description of the MSE and stabilizing treatment refused by the patient and/or caregiver and the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.

An interview was conducted on 1/16/25 at 10:21 AM with EI # 1 who confirmed there was no documentation of a description of the MSE and stabilizing treatment refused and no documentation the patient and/or caregiver was informed of the risks and benefits of leaving prior to the completion of the MSE and stabilizing treatment.

Based on review of hospital policy and procedure, medical record (MR) reviews, and interview, it was determined the hospital failed to:

1. Provide an appropriate transfer that included signed certification by the physician that the medical benefits of treatment at another hospital outweighed the risks of being transferred.

2. Ensure the patient and/or caregiver consented to the transfer to another hospital.

3. Ensure the patient transfer was effected through qualified personnel and transportation equipment.

4. Send to the receiving facility, all medical records related to the emergency condition which the patient had presented.

This deficient practice affected Patient Identifier (PI) # 13 and PI # 15, two of three transferred MR's reviewed, and had the potential to affect all who require a transfer from this hospital.

Findings include:

Hospital Policy: Transfer Policy: Hospital to Other Facilities
Policy Number: Not documented
Reviewed Date: 5/23

I. Purpose: The purpose of this policy is to provide guidelines for the transfer...of patients from a Baptist Health hospital to a receiving facility.

II. Scope: This policy applies to all Baptist health team members in any department that discharges or transfers patients to other facilities.

...V. Policy:

A. The hospital should ensure that each patient (or legally responsible person acting on the patient's behalf) is informed about and agrees with the facility-to-facility transfer.

B. The transferring physician should inform the patient (or legal responsible person acting on the patient's behalf) of the risks, benefits, and alternatives of the transfer.

...D. The hospital should provide...copies of the patient's medical record to the receiving facility.

E. Patient should be transferred to another facility with appropriate equipment in the care of a responsible family member/person, qualified ambulance attendant...as condition warrants based on physician order.

...I. Pediatric patients should be transferred from the Pediatric unit to another acute care setting...with the appropriate equipment and in the care (of) a qualified ambulance attendant...

VI. Procedure:

A. Transfer to Another Acute Care Hospital

1. Transferring Physician Responsibilities.

...b. Inform the patient (or legal responsible person acting in the patient's behalf) of the risks and benefits of the transfer...

3. Transferring RN (Registered Nurse) Responsibilities.

...c. Document the patient's (or legally responsible person acting on the patient's behalf) transfer consent and agreement to transfer to another acute care hospital on the Facility-to-Facility Transfer Record...

f. Copy and send the following transfer documents to the receiving facility with the patient... medical record... lab and x-ray reports...

1. PI # 13, a 13-year-old patient, presented to the emergency department (ED) on 12/3/24 at 6:35 PM with a chief complaint of fever for one day.

Review of the ED Triage note dated 12/3/24 at 6:35 PM revealed the patient had a fever of 102 with Tylenol administered prior to ED arrival and was receiving chemotherapy due to Hodgkin's Lymphoma diagnosis. Further review revealed a temperature of 99.7 F (Fahrenheit), normal range 97.7 F - 99.5 F, heart rate of 132, normal range 60 - 100, respiratory rate of 22, normal range 16 - 22, and blood pressure of 91/65, normal range less than 120/80.

Review of the ED Provider note dated 12/3/24 at 7:24 PM revealed the patient had a comorbid condition of Hodgkin's Lymphoma, was administered chemotherapy earlier in the day, had an associated symptom of a headache, and the following abnormal laboratory results:

Critical Low White Blood Cell count of 0.1 (reference range of 4.1 - 10.3).
Low Red Blood Cell count of 3.14 (reference range of 4.04 - 5.48).
Low Hemoglobin of 8.4 (reference range of 10.5 - 15.5).
Low Hematocrit of 26.0 (reference range 10.5 - 15.5).
Low Platelet count of 83 (reference range of 140 - 400).
Critically Low absolute Neutrophil Count of 0 (reference range of 1.4 - 6.5).
Low absolute lymphocyte count of 0.1 (reference range 1.0 - 4.8).
Low absolute monocyte count of 0.0 (reference range of 0.1 - 0.6).

Further review of the ED Provider note dated 12/3/24 at 7:24 PM revealed the provider spoke with the patient's oncologist who stated the absolute neutrophil count, hemoglobin, and hematocrit had changed to the point where it was felt the patient required a transfer to another hospital. Further review revealed Cefepime (antibiotic) was administered in the ED, the patient's fever had dropped, and the patient would be transferred by private vehicle (POV) to the receiving hospital. There was no documentation of the reason the patient would be transferred via POV instead of by emergency medical services (EMS) with a qualified ambulance attendant or the provider explained the risk and benefits of the transfer by POV to the patient and/or caregiver.

Review of the vital sign documentation dated 12/3/24 at 8:45 PM revealed a temperature of 98.1, heart rate of 109, respiratory rate of 18, and blood pressure of 106/61.

Review of the Facility-to-Facility Transfer Form dated 12/3/24 at 10:16 PM revealed the provider selected a non-emergent transfer to the receiving hospital. There was no documentation the patient and/or caregiver were explained the risk and benefits of the transfer, consented to the transfer, or acknowledged the mode of transport for the transfer.

Review of the ED Depart (Departure) note dated 12/3/24 at 10:52 PM revealed the patient's caregiver was provided the transfer paperwork, verbally acknowledged understanding of POV transfer instructions, and the patient ambulated from the ED.

An interview was conducted on 1/16/25 at 10:22 AM with Employee Identifier (EI) # 1, Accreditation Coordinator, who confirmed there was no documentation the patient and/or caregiver consented to the transfer and no documentation the risks and benefits of the transfer were explained.

An interview was conducted on 1/17/25 at 3:00 PM with EI # 6, Physician Assistant, who was the ED Provider for PI # 13. EI # 6 verbalized the patient's caregivers had requested to be transferred by POV, instead of by EMS which is what is usually requested by the receiving hospital. EI # 6 verbalized after the caregiver's request, he/she contacted the physician at the receiving hospital who approved the patient to be transferred by POV. EI # 6 verbalized he/she did not document the conversation with the caregivers or the approval by the receiving hospital's physician for the patient to be transferred by POV.

2. PI # 15 presented to the ED on 12/13/24 at 7:34 AM with a chief complaint of a fall.

Review of the MR revealed, PI # 15 was transferred to another facility with a diagnosis of Subarachnoid Hemorrhage. There was no documentation the patient's MR was sent to the receiving hospital.

An interview conducted on 1/16/25 at 10:11 AM with EI # 1 who confirmed there was no documentation the patient's MR was sent to the receiving hospital.