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Based on medical record (MR) review, facility policy and procedure, Bed Census Reports, Physician On-Call List, Hospital B receiving hospital MR, and interviews, it was determined Andalusia Health failed to complete an appropriate transfer for one of six MRs reviewed of patients transferred to another facility.

This deficient practice negatively affected Patient Identifier # 21 and had the potential to affect all patients treated at this facility.

Findings include:

Cross Refer to A2409 for findings.

Based on medical record (MR) review, facility policy and procedure, Bed Census Reports, Physician On-Call List, Hospital B, receiving hospital MR, and interviews, it was determined Andalusia Health failed to complete an appropriate transfer for one of six MRs reviewed of patients transferred to another facility.

This deficient practice negatively affected Patient Identifier (PI) # 21 and had the potential to affect all patients treated at this facility.

Findings include:

Facility Policy: EMTALA (Emergency Medical Treatment and Labor Act)- Medical Screening and Treatment of Emergency Medical Conditions

Policy Number: 16678076

Revised: 1:2021

...Purpose: To ensure that individuals coming to an affiliated Hospital's Dedicated Emergency Department...are offered stabilizing treatment within the Hospital's capabilities and/or are transferred if appropriate...

Procedure:

1. Definitions:

Appropriate transfer occurs...

i. the transferring Hospital provides medical treatment within its capacity...

ii. the receiving facility has the available space and qualified personnel for the treatment of the individual and has agreed to accept transfer...

iii. the transferring hospital sends to the receiving Hospital all medical records...related to the Emergency Medical Condition...

iv. the transfer is effected through qualified personnel, transportation and equipment...

1. PI # 21 presented to the Emergency Department on 9/26/24 at 9:01 PM with complaints of urinary problems.

Review of the Nurse's Notes, Presentation, dated 9/26/24 at 9:11 PM revealed PI # 21's spouse had been unable to pass the in and out catheter prior to arrival. An acuity level of (3), urgent, was assigned.

Further review of the Nurse's Notes, Assessment, dated 9/26/24 at 9:11 PM revealed vital signs including blood pressure 145/68, pulse 93, respirations 18, oxygen saturation 97 %, and pain level of 4/10.

Review of the Nurse's Notes, ED Course, dated 9/26/24 at 9:45 PM revealed the nurse documented a Foley catheter placement was attempted, unable to advance catheter past the prostate. The nurse further documented minimal blood drainage from penis after removing Foley catheter and Employee Identifier (EI) # 9, ED Physician, was notified.

Review of the Nurse's Notes, Vitals, dated 9/26/24 at 9:55 PM revealed the nurse documented a bladder scan was completed revealing 923 milliliters (ml) of urine remaining in the bladder.

Review of the Nurse's Notes, Emergency Department (ED) Course, dated 9/26/24 at 10:30 PM revealed the nurse documented urinary catheter placement was attempted using a 16 Fr. (French) Coude catheter. The attempt was unsuccessful and EI # 9 was notified.

Review of the Nurse's Notes, ED Course, dated 9/26/24 at 11:15 PM revealed the nurse documented urinary catheter placement was attempted using a 12 Fr Coude catheter unsuccessfully. The nurse further documented EI # 9 was notified and EI # 9 was discussing the plan of care with PI # 21.

Review of the Physician Documentation dated 9/26/24 at 11:26 PM revealed EI # 9
documented PI # 21 was "sent by (EI # 6, Urologist) for urinary catheter placement for acute urinary retention...attempted 16 Fr (French) ... as recommended by urology - unsuccessful...attempted 16 Fr. Coude - unsuccessful, attempted 12 Fr. Coude - unsuccessful. No urology on call ... transfer offered for urology services ... the patient and (spouse) have declined stating they will proceed via private vehicle to Dothan for urology ... detailed discussion with the patient and/or guardian regarding ... the need to transfer to another facility, for higher level of care. Andalusia...does not immediately have the required specialist..."

Further review of the Physician Documentation dated 9/26/24 at 11:26 PM revealed EI # 9 documented PI # 21 was a Certified Medical Emergency.

Review of the Discharge Instructions dated 9/26/24 at 11:26 PM, signed by EI # 2, Interim ED Director, revealed instructions for Acute Urinary Retention, Male with follow up instructions to follow up with EI # 6 on 9/27/24.

Review of the Nurse's Notes dated 9/26/24 at 11:35 PM revealed the nurse documented PI # 21 was "discharged home, ambulatory, with significant other. Instructions given to patient, significant other. Instructed on discharge instructions, follow up and referral plans..."

Review of the September 2024 Physician On-Call Log for Urology revealed there was no physician on-call for Urology on 9/26/24 or 9/27/24.

Review of the Bed Census Report dated 9/26/24 at 6:00 PM revealed the hospital was staffed for 18 Medical Surgical beds and had a total of 18 patients. The Intensive Care Unit was staffed for eight beds and had a total of four patients, four hospital beds were available for admissions.

An interview was conducted on 10/24/24 at 2:54 PM with EI # 8, Registered Nurse (RN), who stated PI # 21 wanted to go to another hospital by car, "I wrote out some things on a scrap piece of paper that we had done in the ED for them, like catheter attempts, how much (he/she) had in (his/her) bladder, and what was done in the ED." EI # 8 further stated that PI # 21 did not have an accepting physician and no report was called to the receiving hospital.

EI # 8 was asked about EMTALA training and what he/she remembered about the training. EI # 8 responded, "to be honest, I don't understand that legal stuff very much. I usually just ask the physician or the charge nurse. Basically, what I know is that you can't contact the other hospital unless the patient agrees to the transfer."

An interview was conducted on 10/24/24 at 3:22 PM with EI # 2 who was asked if he/she remembered PI # 21's ED visit on 9/26/24. EI # 2 stated he/she had triaged PI # 21 and remembered the spouse had been performing in and out catheters for him at home and was not able to get one in but did not remember being involved after that.

EI # 2 was asked about EMTALA training, EI # 2 responded he/she had not had EMTALA training since he/she started on 6/17/24.

An interview was conducted on 10/25/24 at 4:15 PM with EI # 9 who stated PI # 21 asked where the closest place was that had a urologist and a transfer was offered but it was declined and PI # 21 was discharged from the ED with the understanding he/she could come back. EI # 9 further stated there was no contact with the receiving facility because he/she did not know where the patient was going, just that they were leaving and going straight to the other hospital.

EI # 9 was asked what discharge instructions were given to PI # 21, EI # 9 responded "...they were familiar with the urologist. I felt ok to discharge them. PI # 21 had urine in the bladder but the amount he/she had, he/she was not at risk for bladder rupture. PI # 21 would have been ok for another two or three hours before he/she had to have a catheter."

A telephone interview was conducted on 10/25/24 at 8:30 AM with the spouse of PI # 21 who stated they had gone to Andalusia Health ED on 9/26/24 because he/she was not able to get the catheter in. He/She stated "...they said they did not have a urologist on-call and told us they would have to transfer PI # 21 to a facility in Dothan or Pensacola that had a urologist. It would have been a problem for us going by ambulance with the cost and not having a ride back home. We drove to Hospital B, the urologist came down, they gave him/her some sedation and got the catheter in."

The spouse of PI # 21 was then asked if (Hospital B) was expecting them when they arrived, he/she responded, "No, Andalusia said they would call and let them know we were coming, but they did not."

Per Google Maps, Hospital B is 71 miles from Andalusia Health.

Review of PI # 21's MR from Hospital B, receiving hospital, revealed PI # 21 arrived to the ED on 9/27/24 at 1:51 AM.

Review of the Hospital B Quick Triage dated 9/27/24 at 1:53 AM revealed a chief complaint of "pt. (patient) states that he/she just left Andalusia and they sent the pt here due to enlarged prostate and inability to urinate... A Tracking Acuity of 3, urgent, was assigned.

Further review of the Hospital B Quick Triage dated 9/27/24 at 1:53 AM revealed a blood pressure of 183/86, pulse of 89, respirations 16, temperature 97.8, and an oxygen concentration 97 %.

Review of the Hospital B, Physician Documentation/Notes dated 9/27/24 at 5:06 AM revealed the ED physician documented PI # 21 presented with urinary retention, onset eight hours prior to arrival. PI # 21 was given Intravenous sedation with Ketamine and a Foley catheter was inserted at 3:00 AM. The physician documented 1200 ml of bloody urine was returned.

PI # 21 was admitted to Hospital B with diagnoses including Acute Urinary Retention, Hematuria, and Uncontrolled Hypertension.

Review of the Urology Consultation Note dated 9/27/24 at 9:10 AM revealed the Urologist documented "...patient was on intermittent catheterization and (spouse) started having difficulties placing the catheter...seen in the Andalusia ED and multiple attempts were made without success he/she was therefore transferred here for on-call urology. A Foley catheter has been placed although the urine is dark consistent with venous bleeding..."

An interview was conducted on 10/25/24 at 1:45 PM with EI # 1, Chief Nursing Officer, who confirmed Andalusia Health did not have an on-call Urologist on 9/26/24, all staff had not received EMTALA training, and the facility policy for transfer of patients to other hospitals was not followed.

In summary, Andalusia Health failed arrange for an appropriate transfer to a hospital that had urologist services that were necessary to stabilize PI #21's identified emergency medical condition or obtain PI #21's written refusal to be transferred to a high level of care.