HospitalInspections.org

Based on medical record review and interview, it was determined that in 1 (P#1) of 50 records reviewed of patients who presented to the Hospital requesting emergency services, the facility failed to ensure compliance with 489.24 in that the facility failed to perform an appropriate transfer.

Findings included:
1. Please see findings cited at 489.24 (a) 2409.

Based on medical record (MR) review and interview, the facility (Facility #1) failed to provide an appropriate transfer for 1 patient with an emergency medical condition (EMC) - (P#1) - out of 50 medical records reviewed.

Findings included:
A. Medical record review of P#1 at Facility #1:
1. Emergency Department (ED) records indicated that P#1 went to Facility #1's ED on 2-25-10 with complaint of jaw pain and swelling. Initial nursing assessment documented "constant jaw pain aggravated by movement" and "patient states cannot open mouth." Per the Physician's Treatment Notes, diagnoses were "jaw pain secondary to periodontal disease" and "mild pharyngitis without edema."
2. Per Hospitalist Admission Order set, P#1 was admitted to a medical-surgical Observation unit. Diagnoses: "difficulty swallowing" and "extensive periodontal disease with trismus." An order was written for an ENT (ear, nose, and throat) consult "re: difficulty swallowing."
3. Per the ENT (A#3's) Consultation Note: "I was asked to consult on the patient because of the dysphagia, trismus, and significant cervical swelling that the patient developed."Also, "the patient did have some wincing with swallowing." Under Review of Systems, "the patient notes difficulty swallowing and some difficulty opening the mouth as well as left-sided greater than right-sided neck pain." HEENT exam included "patient has a broken off tooth on the right and left mandible...very tender to touch..floor of the mouth is boggy and edematous." Neck exam included "cervical exam is remarkable for severe submental and submandibular swelling." Assessment and Plan included "I recommend that we see how he/she responds to the (IV) antibiotic over the next 12-24 hrs....I did discuss the possibility of the need for tracheotomy if his/her condition were to worsen."
4. Per the Short Stay Summary, A#4 documented, under Assessment and Plan, "Severe dental infection with possible abscess. The patient is currently with trismus." Under Hospital Course, A#4 documented he/she advised P#1 that he/she did have "significant dental infection and abscess" requiring IV antibiotics and needed to have an oral surgeon involved. A#4 attempted to page an oral surgeon on call, but none were available. He/she then contacted the only dental physician on call at Facility #2 that had privileges at Facility #1. That dental physician advised A#4 that the best option was to release P#1 from Facility #1 and send him/her to the ED at Facility #2 for detailed assessment and further management by an oral surgeon. A#4 documented "...the options were given to P#1 of staying in the hospital (Facility #1) and getting IV antibiotics until the infection resolved or the swelling improved and then seeing an oral surgeon as an outpatient as opposed to having him/her go to the ED at Facility #2, where he/she could be seen and evaluated by an oral surgeon that same day. The patient "refused the next dose of IV antibiotic, got dressed and walked out to the hallway and eventually walked out of the hospital." This occurred on 2-25-10 at 1530.
5. The medical record from Facility #1 lacked a written order for P#1 to be discharged or transferred.

B. Medical record review of P#1 from Facility #2
1. Per Emergency Department (ED) Chart, P#1 arrived at Facility #2 by private car at 1559, 29 minutes after leaving Facility #1. Nursing assessment at 1617 included "...the pt. is spitting into a cup, states cannot swallow...speech clear...unusual drooling noted, broken left tooth...states was seen at (Facility #1) and told to come here...told we have an oral surgeon who could 'pull bad tooth before throat closes'." A#20, Physician Assistant (PA) Progress Notes included "Patient admitted to (Facility #1) today. A#4 then discharged the patient and instructed him/her to come to (Facility #2) ED for evaluation by an oral surgeon. This was an unstable patient that was discharged from a medical floor at (Facility #1) without consult from A#4 to a physician at (Facility #2). On presentation to the ED the patient was in obvious distress, having difficulty handling secretions...sitting forward with difficulty with his/her airway."
2. Per H&P by A#15, "A#4's explanation to the patient was that he/she needed an oral surgeon and they had none available at their facility. However, A#4 made no attempt to contact anybody at (Facility #2) to set up a transfer, he/she simply discharged the patient from their facility and suggested that he/she come immediately to (Facility #2) ED." Diagnostic Impression: " Ludwig's angina with progression and airway distress and the origin most probably the dental abscess. The patient went to the operating room and underwent successful transnasal flexible fiberoptic intubation...teeth extracted...abscess cleaned...to be left intubated overnight or until edema resolved."
3. Per the Operative Report, P#1 was taken to surgery on 2-25-10 at 1714, nasally intubated, two teeth were extracted, and an abscess was irrigated. Pre- and post- operative diagnosis was Ludwig's angina.
4. The patient was extubated on 2-26-10 and discharged approximately two hours later.

C. Per staff interview at Facility #2
1. A#13, ED Triage nurse and A#14, ED charge nurse, stated that P#1 told them he/she was "instructed to come directly to their ED" and had no paperwork from Facility #1. A#13 stated that P#1 "was leaning forward...unable to handle secretions...had a basin to spit into."
2. A#10, Director of Risk Management, spoke with A#19, Facility #2's Medical Chief of Staff, who voiced concern that P#1 had come by private car, no transfer information/paperwork was received from Facility #1, P#1 couldn't swallow secretions, and his/her airway was compromised to the point that the ED physician considered performing a tracheotomy.

D. Facility #1 did not effectuate an appropriate transfer of a patient with an emergency medical condition (EMC) that was not stabilized (P#1). Indications of the EMC not being stabilized included the patient being unable to tolerate his/her own secretions (drooling and spitting in a cup), severe submental swelling, trismus, and the ENT physician (A#3) indicating the patient might need a trach if their condition worsened (meaning there was a reasonable probability that the patient's condition could deteriorate and require surgical management if not treated). Also, A#4 at Facility #1 did not indicate that the patient could be discharged home, which means the EMC was still unresolved and not stable. The ENT physician at Facility #1 felt that P#1 needed to be observed for 12-24 hrs. for his/her response to the IV antibiotic. This also suggests an unstable EMC.