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Based on record review and interview, the hospital's emergency department staff failed to appropriately monitor Patient #1's condition before transferring to another hospital admission to the Intensive Care Unit (ICU).


Refer to 2406


Based on record review and interviews, the facility staff failed to meet the following requirements of an appropriate transfer for Patient #1 with an emergency medical condition by not explaining the risks and benefits to the patient before transfer.

Refer to 2409

Based on record review and interview, the hospital's emergency department staff failed to appropriately monitor Patient #1's condition before transferring to another hospital admission to the Intensive Care Unit (ICU).

This deficient practice had the likelihood to cause harm to all patients presenting to the ED with emergent medical conditions.

Hospital #1 located at 4920 NE Staling Dr. Nacogdoches, TX. 75965

A review of the electronic health record (EHR) revealed that Patient #1 arrived at the Emergency Department (ED) on 01/17/2025 at 3:16 PM via Emergency Medical Services (EMS). The Paramedic documented that instructions were received to place Patient #1 in the lobby until the patient could be evaluated by the triage nurse.

A review of the hospital's "Check-in, Registration, Triage & Treatment" policy dated 04/2024 revealed the following;

"Individuals presenting by EMS

I. Ideally, the pre-hospital provider will communicate their inbound information and estimated time of arrival prior to arrival at the Emergency Department.

2. The individual should be immediately greeted by an ED RN and placed in a bed in the main ED treatment area.

3. The triage/initial assessment shall be performed at the earliest opportunity by an ED RN.

4. The ED RN should initiate the computer registration process when time and patient condition
permits.

5. The ED RN and the Patient Access Registration Staff will coordinate together the time and location to further complete the registration process following the MSE guidelines listed above.

6. The individual shall have an ID armband placed at the earliest opportunity."


A review of Staff #16 (triage nurse)'s notes revealed the patient was triaged at 3:52 PM on 01/17/2025. Staff #16 documented that the patient was alert and oriented with a chief complaint was rapid heart rate, vomiting, and tremors while in dialysis. The vital signs documented at the time of triage were:

"A blood pressure of 76/41, 124 Heart Rate, 20 Respirations, 99% oxygen saturation on room air, a temperature of 103, and a pain scale of 10/10."

The patient was given an Emergency Severity Index of a Level 2. (The Emergency Severity Index (ESI) has five levels, with Level 1 representing the most urgent cases requiring immediate life-saving intervention, and Level 5 being the least urgent, needing only a basic history and physical exam; essentially ranking patients based on their acuity and the resources needed for their care.)

There was no documentation found to support that Staff #16 reported Patient #1's abnormal vital signs or the ESI level 2 designation to the ED Physician or ED Charge nurse.

The surveyor was unable to determine when Patient #1 was moved from the triage area and placed in an exam room in the main ED for further evaluation.

A review of Staff #8 (ED Physician)'s note revealed that Patient #1 received a Medical Screening Exam (MSE) at 4:36 PM on 01/17/2025. Further review of the Staff #8's note revealed the following;

"CHIEF COMPLAINT:
rapid heart rate, vomiting, tremor, while in dialysis

HISTORY OF PRESENT ILLNESS:
The patient presents with an infected catheter in her chest, which she reports is causing severe pain. The catheter was placed on December 31st at CHI. The patient states that the dialysis clinic performed some tests that indicated an infection. She reports experiencing fever at home, though the specific temperature is not provided. The patient denies nausea, vomiting, and abdominal pain. She also denies any urine output and cough.

The patient receives dialysis on a Monday, Wednesday, and Friday schedule. She reports having completed a full dialysis run today, as well as on Wednesday and Monday. The patient has a dialysis graft in her right arm, which is currently functional and was used for today's dialysis session. The chest catheter (left chest port-a-cath) was initially placed when the graft was not working, but it is now redundant as the graft is operational.

MEDICAL DECISION MAKING:
Hx obtained from: Patient

All decisions regarding above workups were done in consultation with the patient in a
SHARED DECISION MAKING manner.

IMPRESSION/PLAN:
1. Severe sepsis with septic shock R65.21
2. ESRD (end-stage renal disease) N18.6"

Patient #1 received the following treatment and medications while in the ED;

"Blood Cultures, Complete Blood Count With Auto Differential, Comprehensive Metabolic Panel Decision to Transfer, ED EKG-CernerCV, Lactic Acid Level, Magnesium Level, Manual Diff, Troponin I, and an XR Chest 1 View."

The following medications were administered;

"Maxipime, IV Piggyback administered at 5:18 PM
morphine, 2 mg, IV Push administered at 5:18 PM
Sodium Chloride 0.9% bolus, 1845 ml, IV administered at 5:17 PM
Zofran, 4 mg, IV Push administered at 5:18 PM"

There was no documentation found in the medical chart to support that Patient #1 received any other treatment while in the ED at Hospital #1.

A review of Patient #1's vital signs in the ED at Hospital #1 revealed multiple episodes of Tachypnea (fast breathing) and Tachycardia (fast heart rate). The following respirations and heart rates were documented;

3:52 PM- 124 heart rate (HR), 22 respirations
5:00 PM- 115 HR, 33 respirations
5:30 PM- 115 HR, 40 respirations
6:00 PM- 114 HR, 40 respirations
6:30 PM- 111 HR, 34 respirations
7:15 PM- 148 HR, 35 respirations
7:45 PM- 131 HR, 54 respirations
8:15 PM- 109 HR, 37 respirations

There was no documentation found to support that the abnormal vital signs were reported to the ED Physician. Also, there was no documentation found to support that Patient #1's abnormal vital signs were addressed by the hospital staff.Further review of the vital signs for Patient #1 revealed that there were no vital signs taken between 8:15 PM and 9:30 PM.

A review of Staff #17 (ED Registered Nurse)'s notes revealed the following;

4:52 PM "Pt resting at this time. Endorses generalized pain. NAD noted."
6:47 PM "Pt resting in bed at this time. NAD noted. Denies any needs."
8:51 PM "Pt resting, denies any needs. VSS. States that she texted her son for an update on her care. Per pt, okay to give information if he calls for updates."
9:30 PM "Pt left with EMS on stretcher. NAD noted. CBG 90."

A review of the hospital's "Physician Certificate Transfer" form reveals two sections. The top section is labeled "For Transfer of Stable Patient" and the bottom section is labeled "For Transfer of Unstable Patient." The top section for "For Transfer of Stable Patient" states, "I have examined the above-named patient, and in my medical opinion, this patient is not in an emergency medical condition, and transfer or the delay caused thereby will not create a medical hazard to the patient." Per the "Physician Certificate Transfer" form in Patient #1's chart, the top section of "For Transfer of Stable Patient" was signed on 01/17/2025 at 7:37 PM. The surveyor was unable to determine which ED staff member signed the form that Patient #1 was stable for transfer. Also, they was no way to determine the credentials for the staff member.


A review of the EMS run sheet revealed that the EMS crew was dispatched on 01/17/2025 at 8:27 PM and arrived at the patient's bedside in Hospital #1 at 8:40 PM. Per the EMS run sheet, the Paramedic documented the following;

"Pt is responsive to painful stimuli. Pt is pale, hands are extremely cold to touch, skin is very diaphoretic."

Patient #1 was in the ED at Hospital #1 from 3:16 PM until discharge with EMS at 9:32 PM. There was no documentation found in the chart to support when Patient #1 had a change in mental status (an individual's current psychological and cognitive state) or that the ED Physician was notified of a change in Patient #1's mental and physical condition status. Also, there was no documentation found in the chart to support that Patient #1 had any form of reassessment by the ED nurse or ED Physician prior to transferring to Hospital #2.


Hospital #2 located at 1204 N Mound St. Nacogdoches, TX. 75961

A review of the EMS run sheet revealed that the EMS unit arrived at Hospital #2 at 9:40 PM with Patient #1. The patient was taken to Hospital #2's ICU for admission.

The ICU RN documented the following nurse's note;

"ADMISSION NOTE: PT ARRIVED TO ICU 604 FROM NMC ER W/ REPORT HAVING PREVIOUSLY BEEN GIVEN TO STAFF LVN. NMC STAFF STATED THAT THE PATIENT WAS A/OX4 WITH STABLE VITAL SIGNS. EMS ARRIVED AT 2200 WITH PATIENT UNRESPONSIVE TO ALL STIMULI WITH AGONAL RESPIRATIONS. DR.WAS NOTIFIED IMMEDIATELY AND CAME TO INTUBATE PATIENT. PT UPGRADED TO ICU STATUS AND THIS RN ASSUMED CARE OF THE PATIENT. EMS STATED THAT THE PATIENT HAD BEEN UNRESPONSIVE AT NMC ER WHEN THEY ARRIVED THERE, UNRESPONSIVE THE ENTIRE RIDE OVER AND HAD A BLOOD SUGAR OF 90. ON ARRIVAL PATIENT IS COLD AND CLAMMY WITH BLOOD SUGAR OF 34. WHILE ATTEMPTING TO GIVE D50 THE IV PLACED BY NMC WAS INFILTRATED AND ALL ATEMPTS TO PLACE A NEW PIV WERE FAILED. DR PLACED A CENTRAL LINE. THE PATIENT WENT INTO CARDIAC ARREST AND ACLS PROTOCOL WAS INITIATED. SEE RESUSCITATION REPORTS X5 FOR DETAILS. PATIENT'S SISTER, MS RICHARDSON ARRIVED AT BEDSIDE SOON AFTER THE FIRST CODE BEGAN AND STATED THAT NMC ER HAD CALLED HER TO GET CONSENT TO TRANSFER THE PATIENT HERE AND STATED THAT NMC STAFF REPORTED TO HER THAT THE PATIENT WAS "A LITTLE" DROWSY D/T HAVING RECEIVED MORPHINE. UPON REVIEWING THE PATIENT'S PAPERWORK THIS RN NOTED THAT THE PATIENT'S BP WAS 70s/40s AT NMC, 4 MG OF MORPHINE WAS GIVEN, AND ADDITIONALLY THE PATIENT'S EMS RUN REPORT STATED THAT THE PATIENT WAS ALERT TO PAINFUL STIMULI, BLOOD SUGAR WAS 90, AND THAT AT THE MOMENT THE PATIENT WAS MOVED FROM THEIR STRETCHER HER MENTAL STATUS CHANGED. PATIENT REMAINED UNRESPONSIVE TO ANY STIMULI FOR THE DURATION"

Further review of Patient #1's medical chart at Hospital #2 revealed the patient experienced 6 cardiac arrest (sudden, unexpected loss of heart function, breathing, and consciousness) events after admission to the ICU. The cardiac events were documented at 10:28 PM, 10:58 PM, 11:14 PM, 1:53 AM, 2:04 AM, and 2:18 AM. The patient expired at 2:32 AM on 01/18/2025.

An interview was conducted with Staff #12 ED Charge nurse on 02/18/25 at 9:40 AM. Staff #12 stated, "All transfers are coordinated through the organization's transfer center, Tenet Transfer Center." Staff #12 reported patients who are transferring to a higher level of care, we will ask the patient or family for preference first. If there is no preference, the ED Physician will contact the closest hospital first and then branch out to other hospitals. Staff #12 stated, "For critical patients, we will do one-on-one nursing care until the patient transfers."

An interview was conducted with Staff #7 MD Medical Director on 02/19/2025 at 10:00 AM. Staff #7 was asked how the ED nursing staff communicates to the ED Physicians regarding an emergent patient or how the ED Physicians would know a patient is urgent. Staff #7 reported that during Staff #7's shifts in the ED, the nurses would verbally tell Staff #7 or that Staff #7 would monitor the tracking board at the nurse's station. Staff #7 reported that walkie-talkies are utilized.

An interview was conducted with Staff #13 (Nursing Supervisor) on 02/19/2025 at 10:30 AM. Staff #13 reported that if a patient was identified as a sepsis suspect, the sepsis protocol allows for the ED nursing staff to put in orders while waiting but they still must notify the Physician.

Based on record review and interviews, the facility staff failed to meet the following requirements of an appropriate transfer for Patient #1 with an emergency medical condition by not explaining the risks and benefits to the patient before transfer.

This deficient practice had the likelihood to cause harm to all patients needing to be transferred.

Findings include:

A review of the hospital's Memorandum of Transfer (MOT) form revealed that there was not a section for an explanation of risks and benefits or for a patient/designee to sign giving the facility consent to transfer.

A review of the MOT for Patient #1 revealed that the initial contact with the receiving hospital was made on 01/17/2025 at 7:14 PM. The receiving hospital's Physician accepted Patient #1 for transfer on 01/17/2025 at 7:55 PM and the receiving hospital accepted Patient #1 on 01/17/2025 at 8:00 PM.

An interview with Staff #13 was conducted on 02/19/2025 at 10:30 AM. Staff #13 reported that the hospital utilizes a "Physician Certificate Transfer" form and a "Consent Transfer Authorization" form for patients needing transfer to another facility. Staff #13 stated, " If a patient is unstable or unable to sign, then two physicians or 2 nurses would sign the consent to transfer if unable to locate immediate family."

A review of the hospital's "Physician Certificate Transfer" form reveals two sections. The top section is labeled "For Transfer of Stable Patient" and the bottom section is labeled "For Transfer of Unstable Patient." The top section for "For Transfer of Stable Patient" states, "I have examined the above-named patient, and in my medical opinion, this patient is not in an emergency medical condition, and transfer or the delay caused thereby will not create a medical hazard to the patient." Per the "Physician Certificate Transfer" form in Patient #1's chart, the top section of "For Transfer of Stable Patient" was signed on 01/17/2025 at 7:37 PM. The surveyor was unable to determine which Emergency Department (ED) staff member signed the form that Patient #1 was stable for transfer and the staff member's credentials.

A review of Patient #1's " Consent Transfer Authorization" revealed that the consent was not signed by Patient #1. The consent was completed as a phone consent with a family member. The surveyor was unable to determine the signatures or credentials of the hospital staff that signed the " Consent Transfer Authorization." Further review of the hospital staff roster revealed Staff #18 (Unit Secretary) as a staff member consulting with Patient #1's family and as the signature of a witness. There was no documentation found that two Physicians or two Nurses signed the consent form.

A review of Patient #1's medical chart revealed that Staff # 8 (ED Physician) and Staff # 17 (ED Nurse) documented that Patient #1 was alert and oriented during the ED visit.

There was no documentation found in Patient #1's medical chart to support that Patient #1 was unstable or unable to sign the consent form or that the risks and benefits were explained to Patient #1 before the transfer.

The surveyor requested a full copy of Patient #1's medical chart. The Surveyor was unable to find the "Physician Certificate Transfer" form and the "Consent Transfer Authorization" in the medical chart provided by the transferring hospital. The Surveyor located the "Physician Certificate Transfer" form and the "Consent Transfer Authorization" in Patient #1's medical chart provided by the receiving hospital.