HospitalInspections.org

Based on policy review, review of the hospital's By-laws Rules and Regulations, medical record review and interview, it was determined the hospital failed to ensure patients were informed of the risks and benefits of refusing treatment for 4 Patients (# 4, 5, 17 and 18) sampled patients.

Based on policy review, record review and interview, it was determined the hospital failed to provide an appropriate transfer for 4 of 4 (Patients #4, 5, 17 and 18) sampled patients who presented to the Dedicated Emergency Department (DED) and were transferred to another facility.

The findings included:

1. Review of Hospital #1's bylaws documented "...SCREENING, TREATMENT & TRANSFER...Stabilization...(3) A patient is Stable for Transfer if the treating physician had determined, within reasonable clinical confidence , that the patient is expected to leave the Hospital and be received at a second facility, with no material deterioration in his/her medical condition; and the treating physician reasonably believes the receiving facility has the capability to manage the patient's medical condition and reasonably foresee complication of that condition....A patient does not have to be stabilized when...the patient, after being informed of the risks of transfer and the hospital's treatment obligations, requests and signs a transfer request form; or based on the information available at the time of transfer, the medical benefits to be received at another facility outweigh the risks of transfer to the patient, and a physician signs the certification which includes a summary of risks and benefits to this effect...Transfer...the Emergency Department shall provide a copy of appropriate medical records...informed written consent or transfer certification...All reasonable steps shall be taken to secure the written consent or refusal of the patient (or the patient's representative) with respect to the transfer. The Emergency Department Physician must inform the patient (or patients representative) of the risks and benefits of the proposed transfer..."

Review of the facility's "Transfer of Patients and Clinical Records" policy documented, "...PURPOSE...To ensure the patient's participation and a prompt and orderly transfer to another organization or level of care or service...POLICY...A. The Emergency Department will follow hospital policy and [named corporate ownership] Compliance policy/procedure for transfer of patients and clinical records...B. The patient and/or authorized representative are involved in discussions concerning the transfer and the transfer process..."

Review of the facility's "Involuntary Hold Procedure" policy documented, "...Transfer forms must be completed..."

Review of the "Patient Transfer Form" dated 11/27/13 documented, "...TO BE UTILIZED FOR ALL PATIENT TRANSFERS - EMERGENCY AND NON-EMERGENCY...COMPLETE SECTIONS A AND B FOR ALL PATIENT TRANSFER. COMPLETE SECTION C ONLY FOR EMERGENCY TRANSFERS...SECTION A...1. a. Appropriate medical records of the examination and treatment of the patient provided to the receiving facility at the time of transfer (CHECK ALL THAT APPLY)...2...Equipment Needs During Transfer...Personnel Needed During Transfer...TRANSFERRING PHYSICIAN TO DETERMINE IN ALL CASES...3. Mode of Transfer...ADDITIONAL PHYSICIAN DOCUMENTATION...TO BE COMPLETED FOR EMERGENCY TRANSFERS ONLY...The patient presented to the Hospital requesting emergency medical treatment and the Hospital has provided a medical screening examination and stabilization services to the extent possible, given the Hospital's current capacity and/or capabilities. Transfer of the patient to a hospital with additional capacity and/or capacities is medically indicated, or had been requested by the patient or the patient's legal guardian...Check only one...PHYSICIAN CERTIFICATION...EMERGENCY MEDICINE PHYSICIAN TO COMPLETE...Expected Benefits of Transfer...Specific Risks of Transfer...Patient...Date...Time...Facility...Department..."

2. Review of the medical record for Patient #4 at Hospital #1 dated 11/27/13 revealed the patient presented to the DED with complaints of a fever.

Review of the patient's laboratory results revealed a C-reactive protein of 4.7 [Reference Range 0.1-0.9 milligrams/deciliter] and a erythrocyte sedimentation rate of 61 [Reference Range 0-15 millimeters/hour].

Review of the "Physician Documentation" dated 11/27/13 at 2:12 AM documented, "...Chief Complaint...FEVER...pt [patient] states he has had fever of 103 f [Fahrenheit] yesterday at lunch time, and sever [severe] pain of left leg and left arm, he had a fall from a roof 10 days ago and was seen at [name of Hospital #3], he obtained a fracture of left radius, left femur, pelvis and had surgery to repair fx [fracture] of left radius and left femur and pelvis, he has significant swelling and bruising of left femure [femur] and left radius and pain...CONSULTATION & [and] CRITICAL THINKING...Case discussed with [name of Physician #5 at Hospital #3]...[name of Physician #5] reviewed pt's chart from surgery 4 days ago, he feels that the abnormal labs [laboratory values] are due to recent surgery but will accept pt for further evaluation...at the [name of Hospital #3]...Certified Med [medical] Emerg [emergency]: Patient's condition was emergent..."

Review of the "Nurse Documentation" dated 11/27/13 at 6:45 AM revealed, "...Transfer: Patient left the department at 11/27/13 06:45 [AM]...Transfer was initiated for: Specialized Care - Orthopedic...Transferred to [name of Hospital #3]...Patient was transferred by Ground EMS [emergency medical services]..."

Review of the "Patient Transfer Form" dated 11/27/13 and not timed revealed the following:
In the area under Section 1 where it was asking, "Appropriate medical records of the examination and treatment of the patient provided to the receiving facility at the time of transfer", the area was left blank.
In the area #2 for the "Equipment Needs During Transfer", the area was left blank.
In the area "Personnel Needed During Transfer", the area was left blank.
In the area "Mode of Transfer", the area was left blank.
In the area "Transfer of the patient to a hospital with additional capacity and/or capacities is medically indicated, or had been requested by the patient or the patient's legal guardian", the area was left blank.
In the area "PHYSICIAN CERTIFICATION", "EMERGENCY MEDICINE PHYSICIAN TO COMPLETE", "Expected Benefits of Transfer", the area was left blank.
In the area "Specific Risks of Transfer', the area was left blank.
In the area for the patient's name, date, time, facility and department, the area was left blank.

4. Review of the medical record for Patient #5 at Hospital #1 dated 11/28/13 revealed the patient presented to the DED with a complaint of chest pain.

Review of the "Physician Documentation" dated 11/28/13 at 1:06 AM documented, "...CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS...[name of Patient #5] is a 51 year old F that presented to the Emergency Department...Pain: 8 chest...Symptoms began at 21:00 [9:00 PM on 11/27/13]. Symptoms came on gradually...Pain began during normal activities of daily living...Symptoms are present now. Symptoms are intermittent...Symptoms located in the entire precordium...Patient describes quality of symptoms as pressure, squeezing...Patient states symptoms are of moderate intensity...Symptoms relieved by nothing...51 ... with h/o HTN [hypertension], SLE [systemic lupus erythematosus] and chronic pain syndrome to ED with CP [chest pain] on and off x 3 weeks. Worse last night starting at 2100 hrs...Crushing, Cramping...non radiating pain of mod [moderate] severity (8/10)...Remote cardiology visit (6 yrs ago - [name of Physician #6]...for CAD [coronary artery disease]...DIAGNOSTIC TEST RESULTS...EKG [electrocardiogram]...Sinus tachycardia with heart rate = 125 beats per minute...DISPOSITION...CONSULTATION & CRITICAL THINKING...Case discussed with [name of Physician #6]. S/He agrees to accept patient in transfer...Certified Med Emerg: Patient's condition represents a certified medical emergency..."

Review of the "Nurse Documentation" dated 11/28/13 at 2:30 AM documented, "...Disposition...Transfer: Patient left the department at 11/28/2013 02:30 [2:30 AM]...Transfer was initiated for: Specialized Care - Cardiac...The patient was transferred for cardiac services...Transferred to [name of Hospital #2]...Patient was transferred by Ground EMS..."

Review of the "Patient Transfer Form" dated 11/28/13 at 2:20 AM revealed the following:
In the area under Section 1, " Appropriate medical records of the examination and treatment of the patient provided to the receiving facility at the time of transfer (CHECK ALL THAT APPLY), the area was left blank.
In the area "Full Name of Person Accepting Transfer", "Title", "Time", "Time Accepted", the area was left blank.
In the area "Personnel Needed During Transfer", the area was left blank.
In the area "PHYSICIAN CERTIFICATION", "EMERGENCY MEDICINE PHYSICIAN TO COMPLETE", "Expected Benefits of Transfer", and "Specific Risks of Transfer", the areas were left blank.

5. Review of the medical record for Patient #17 at Hospital #1 dated 12/12/13 revealed the patient presented to the DED with a complaint of nausea and vomiting, admitted as an observation patient and brought back to the DED with a complaint of chest pain.

Review of the "Physician Documentation" dated 12/12/13 at 5:06 AM documented, "...CHIEF COMPLAINT/HISTORY OF PRESENT ILLNESS...a 33 year old F [female] that presented to the Emergency Department...Pain: 9 chest...Onset of symptoms was 12 hour(s) ago. Symptoms came on gradually...Symptoms are intermittent...Symptoms located in the entire periumbilical region region of the abdomen, chest...Symptoms exacerbated by anxiety...positive Chest Pain, positive dyspnea on exertion, positive Palpitations...Positive Abdominal Pain, positive diarrhea, positive nausea, positive vomiting...positive syncope...PAST MEDICAL AND SURGICAL HISTORY...positive 1st Trimester Gestation...HIGH RISK PREGNANCY IN FL [Florida]...Treatment & Reevaluation...[name of Physician #7]...ACCEPTS TO [name of Hospital #4] PER CHOICE...AWAITING TRANSFER...CONSULTATION & CRITICAL THINKING...Case discussed with [name of Physician #7] IN SURGERY...S/He agrees to accept patient in transfer. Receiving Facility: [name of Hospital #4]...Certified Med Emerg: Patient's condition was emergent..."

Review of the "Nurse Documentation" dated 12/12/13 documented, "...Disposition...Transfer: Patient left the department at 12/12/2013 12:55 [PM]...Transfer was initiated for: Specialized Care - Cardiac...The patient was transferred for cardiac services...Transferred to [name of Hospital #4]...Patient was transferred by Ground EMS..."

Review of the "Patient Transfer Form" dated 12/12/13 at 12:40 PM revealed the following:
In the area for patient/patient 's legal guardian to acknowledge the risks related to transfer, "...SECTION B...PATIENT OR PATIENT'S LEGAL GUARDIAN TO COMPLETE...Risks related to transfer acknowledgement..." there was no documentation the patient/legal guardian signed acknowledging the risks.
In the area under SECTION B, "...Physician Initiated transfer - Acceptance...I have been informed by the physician that the medical benefits of transfer outweigh the risks...", the area was not signed by patient/legal guardian.

6. Medical record revealed Patient #18 presented to Hospital #1's DED on 12/12/13 at 3:52 AM per ambulance with altered mental status. The patient was found at home eating soap and telling the she lives with baby Jesus. The patient exhibited behaviors of being agitated and tearful. The patient's speech was slurred, appeared to be delusional, having auditory hallucinations, flight of ideas and uncooperative. The patient was found in the bathtub fully clothed with 4 layers of clothing and eating soap. The patient had behaviors and was put 1:1 and was later restrained. The area mental health crisis center was notified for a patient consult.

Review of the "Physician Documentation" dated 12/12/13 documented the patient was a 55 year old female with a history of Anxiety/Depression. MD #2 documented the patient was "...found at house "eating soap", in agitated state, answering inappropriately [inappropriately], rambling and apparently unable to care for self...Pt has required physician restraint in ED...ED COURSE AND TREATMENT...Will recommend Crisis Team Evaluation..."

Review of the 12/12/13 "Crisis Assessment" documented, "...Seemed psychotic...lives alone...PTSD [post traumatic stress disorder]..." The crisis worker determined the patient was at risk and required an involuntary admission to a Regional Mental Health Institute and completed the involuntary admission paperwork.

The 12/12/13 "Physician Documentation" revealed MD #2 documented at 11:48 AM the patient was reassessed and awaiting transfer to a Regional Mental Health Institute. The crisis worker determined the patient was to be transferred per law enforcement.
MD #2 documented the patient had a "...Psychotic Episode...History of Depression...Major Depression, Acute Exacerbation..." The patient would be transferred to Hospital #5. "...Patient's condition was emergent..."

Review of the 12/12/13 "Nurse Documentation" revealed the patient was discharged into the care of "Police" at 12:15 PM to transport the patient to a local Regional Mental Health Institute for involuntary admission.

There was no documentation the MD completed a "Patient Transfer Form" for this patient's transfer in accordance with the facility's policy.

During an interview in the Chief Executive Officer's office on 1/23/14 at 12:45 PM, the Chief Nursing Officer stated the emergency department did not complete transfer forms on any patients transferred to a mental health facility with an involuntary admission.