HospitalInspections.org

Based on interview and record review the facility failed to stabilize and implement an appropriate transfer when a patient, while receiving Cardiopulmonary resuscitation (CPR), was loaded onto an ambulance, and sent to another acute care hospital; the patient was unable to be revived and time of death was called at the receiving hospital. The failure to stabilize the patient, prior to transport, placed the patient at risk of ineffective CPR while in the back of a moving ambulance with limited personnel and resources. (Patient #14)

Finding include:

Review of the facility provided policy titled "Patient Transfers" (approved 01/07/2014) reflected,
"Prior to patient transfers
l) All patient transfers will be entirely predicated upon medical necessity. All patients will have the right to equal treatment and the right to request a transfer into the care of a physician and hospital of their choosing regardless of race, religion, national origin, age, sex, insurance status, and/or ability pay.

2) All patients requiring transfer will have been evaluated by the ER Physician upon arrival at Signature Care Emergency Center and personally examined and evaluated by the ER Physician before an attempt to transfer is made.

3) Emergency Medical Conditions will be stabilized prior to transfer unless:
a) Stabilization of the patient's vital signs is not possible because the facility does not have the appropriate equipment or personnel to correct the underlying process.
b) The patient (or a legally responsible person acting on the patient's behalf), after being informed of the facility's obligation to stabilize and treat prior to transfer, and the risk of transfer, request a transfer in writing indicating reason for transfer and that they are aware of risks and benefits of transfer.
c) The ER Physician has signed a certification (memorandum of transfer: MOT) including a summary of the risk and benefits, which, based on information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at a hospital outweighs the increased risk to the patient or
patient/unborn child in the case of labor...

Transferring a Patient
Signature Care Emergency Center has relationships with ambulance services and outside physicians with admitting privileges at local hospitals to directly admit Signature Care Emergency Center patients who require a higher level of care. Some geographic regions may have additional partnerships with hospitals/systems that allow for a transfer line to be utilized for the coordination of physicians and transportation. The transfer line should be used where applicable, as this service is well documented and time-stamped, even providing audio recordings of all phone communication.

When a treating ER Physician decides a patient needs to be admitted to the hospital, the ER Nurse or ER Physician will contact an admitting physician and/or Signature Care transfer center representative.
2. Signature Care transfer center representative will notify the appropriate EMS service of transport and obtain ETA from the dispatcher. In the event of an emergent/time sensitive transfer, the treating ER Physician may authorize a 9l1 transport. However, proper procedures will be followed including appropriate treatment, stabilization, and documentation.

3. When the admitting physician calls back, the treating ER Physician will speak with her/him regarding the patient's status and acceptance of responsibility for the patient's medical care and hospital treatment, as a doctor-to-doctor report.

4. Either the physician or nursing supervisor will call back with a bed number. The Signature Care Emergency Center RN/ Signature Care transfer center representative will document the bed assignment, name of the nurse receiving report on the patient, and the time of acceptance, as a nurse-to-nurse report.

5. The Signature Care transfer center representative Emergency Center RN will contact the nursing supervisor transfer center at the admitting hospital with the patient's registration and clinical information.

6. The Signature Care Emergency Center RN will complete the Memorandum of Transfer (MOT). It will be signed by the transferring physician or a SCER staff member acting under the order of the Physician. Once the admit process is completed, Signature Care Emergency Center personnel will report any issues regarding direct admits via email to the Facility Medical Director."

During an interview on 12/20/22 at 9:20 am in the admin conference room, Staff #7, Facility Manager stated, "When Patient #14 arrived, she was nonresponsive, we immediately started CPR. We were able to reach ROSC (return of spontaneous circulation). She was intubated and central line was placed."
When asked if the facility had contacted the other facility prior to the transfer, Staff #7 stated, "No, we called 911 for an emergency transfer; the ambulance will determine where to take the patient. We don't fill out an MOT if 911 is called."

During an interview on 12/20/22 at 11:20 am in the admin conference room, when asked who made the decision to transfer Patient #14 while CPR was in progress, Staff #8, Director of Nursing, stated in part, "I'm not sure. It is our policy to stabilize the patient prior to transferring ...Patient #14 had been resuscitated and was requiring a higher level of care, we called 911 for an emergency transfer. Before the ambulance arrived, Patient #14 coded and CPR was started; when EMS arrived, they took over the care ...Patient #14 should have been stabilized before transferring ...I told the staff, patients do die in emergency rooms."