Based on observation, policy review and Life Safety Code (LSC) complaint investigation findings (ASPEN #HIFN21, KS 994) the hospital failed to meet the applicable provisions of the current LSC by failing to implement a fire watch when the sprinkler system was impaired in two of two construction areas (the Prep/Recovery and EP (electrophysiology) Lab projects. This deficient practice placed all patients, visitors, and staff at risk for fire or smoke spreading to other areas of the building. The facility had a census of at the time of survey. Findings Include: 1. On 08/27/19 the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% inspection on the prep/recovery and EP Lab projects. It is observed at 9:00 AM that the ceiling tiles and grid have been removed from the prep/recovery suite undergoing construction. Multiple walls have been rearranged creating areas without sprinkler protection. Throughout the suite there are approximately 8 feet between the sprinkler head deflector and the ceiling deck. Many of the sprinkler heads are on flex piping and have been laid over without support and are positioned parallel with the floor. Cylinders used for hot work and large amounts of combustible storage are observed throughout the space. This work zone is not separated from the occupied portion of the hospital by 1 hour fire rated construction. The temporary partition wall between the corridor and the partition wall separating the occupied pre/post of patient area are constructed of one layer of + inch drywall with exposed studs on the construction side. A non ducted supply airline is running through the construction zone and into the occupied corridor through a grate that does not have a fire damper. 2. On 08/27/19 at 9:20 AM the inspection progressed to the EP Lab portion of the project. The ceiling grid is observed removed throughout the space. This creates an approximate 8 foot gap between the sprinkler deflectors and the ceiling deck. In the two procedure rooms, with drywall ceilings, the sprinklers are observed with the protective caps stills covering the sprinkler heads. There are not proper 1 hour fire rated walls separating the construction from the occupied portion of the building. Many of the previous corridor door openings have had the doors removed and one layer of + inch drywall has been placed over the openings. No fire rated door frame is provided at the door to enter/exit the construction zone from the corridor, and there are two non ducted air supply vents running to the corridor from the work zone. 3. On 08/27/19 at 9:30 AM the Fire Prevention Supervisor was called, and the findings were reported. The Fire Prevention Supervisor arrived at the hospital at 10:20 AM. The supervisor confirmed the findings, and the facility was placed into immediate jeopardy status at 10:40 AM. The facility immediately removed the immediate jeopardy when they began a fire watch at 11:00 AM. The facility plans to remain in fire watch until the sprinkler system can be corrected and is no longer impaired. 4. During interview and policy review on 8/27/19 at 11:00 AM, and 1:00 PM, it is revealed that the facility's written policy for implementing a fire watch for sprinkler system impairment is to have taken affect anytime the sprinkler system is out of service for more than 10 hours. The policy states under the purpose heading, During periods of maintenance, construction, or renovation the fire alarm or fire suppression system may be taken out of service for short periods of time. The purpose of this process is to allow OPRMC to determine when the fire watch will be required and for what duration. The policy also states under the scope heading, Actions must be taken prior to taking the fire alarm or fire suppression system out of service and the recommendations are identified in the scope. This process must be placed in effect if one of the two following conditions are scheduled or unscheduled: 1. Where a required fire alarm system is out of service for more than 4 hours in a 24 hour period. 2. Where a required fire protection system is out of service for more than 10 hours in a 24 hour period. Under the hospitals fire watch worksheet point 1 states, A fire watch must be in place anytime a fire protection system is impaired. However, at the time of the 50% inspection, a portion of the sprinkler system had been significantly impaired for approximately 30 days, and walls had been rearranged creating areas without sprinkler protection without a fire watch being performed. Refer to A-0709 for further details. Refer to LSC complaint survey findings (ASPEN #HIFN21, KS 994) for additional information.
Based on observation, policy review and Life Safety Code (LSC) complaint investigation findings (ASPEN #HIFN21, KS 994) the hospital failed to meet the applicable provisions of the current LSC by failing to implement a fire watch when the sprinkler system was impaired in two of two construction areas (the Prep/Recovery and EP (electrophysiology) Lab projects. This deficient practice placed all patients, visitors, and staff at risk for fire or smoke spreading to other areas of the building. Findings Include: 1. On 08/27/19 the Office of the State Fire Marshal's Fire Protection Specialist performed a 50% inspection on the prep/recovery and EP Lab projects. It is observed at 9:00 AM that the ceiling tiles and grid have been removed from the prep/recovery suite undergoing construction. Multiple walls have been rearranged creating areas without sprinkler protection. Throughout the suite there are approximately 8 feet between the sprinkler head deflector and the ceiling deck. Many of the sprinkler heads are on flex piping and have been laid over without support and are positioned parallel with the floor. Cylinders used for hot work and large amounts of combustible storage are observed throughout the space. This work zone is not separated from the occupied portion of the hospital by 1 hour fire rated construction. The temporary partition wall between the corridor and the partition wall separating the occupied pre/post of patient area are constructed of one layer of + inch drywall with exposed studs on the construction side. A non ducted supply airline is running through the construction zone and into the occupied corridor through a grate that does not have a fire damper. 2. On 08/27/19 at 9:20 AM the inspection progressed to the EP Lab portion of the project. The ceiling grid is observed removed throughout the space. This creates an approximate 8 foot gap between the sprinkler deflectors and the ceiling deck. In the two procedure rooms, with drywall ceilings, the sprinklers are observed with the protective caps stills covering the sprinkler heads. There are not proper 1 hour fire rated walls separating the construction from the occupied portion of the building. Many of the previous corridor door openings have had the doors removed and one layer of + inch drywall has been placed over the openings. No fire rated door frame is provided at the door to enter/exit the construction zone from the corridor, and there are two non ducted air supply vents running to the corridor from the work zone. 3. On 08/27/19 at 9:30 AM the Fire Prevention Supervisor was called, and the findings were reported. The Fire Prevention Supervisor arrived at the hospital at 10:20 AM. The supervisor confirmed the findings, and the facility was placed into immediate jeopardy status at 10:40 AM. The facility immediately removed the immediate jeopardy when they began a fire watch at 11:00 AM. The facility plans to remain in fire watch until the sprinkler system can be corrected and is no longer impaired. 4. During interview and policy review on 8/27/19 at 11:00 AM, and 1:00 PM, it is revealed that the facility's written policy for implementing a fire watch for sprinkler system impairment is to have taken affect anytime the sprinkler system is out of service for more than 10 hours. The policy states under the purpose heading, During periods of maintenance, construction, or renovation the fire alarm or fire suppression system may be taken out of service for short periods of time. The purpose of this process is to allow OPRMC to determine when the fire watch will be required and for what duration. The policy also states under the scope heading, Actions must be taken prior to taking the fire alarm or fire suppression system out of service and the recommendations are identified in the scope. This process must be placed in effect if one of the two following conditions are scheduled or unscheduled: 1. Where a required fire alarm system is out of service for more than 4 hours in a 24 hour period. 2. Where a required fire protection system is out of service for more than 10 hours in a 24 hour period. Under the hospitals fire watch worksheet point 1 states, A fire watch must be in place anytime a fire protection system is impaired. However, at the time of the 50% inspection, a portion of the sprinkler system had been significantly impaired for approximately 30 days, and walls had been rearranged creating areas without sprinkler protection without a fire watch being performed. 5. Construction personnel and hospital EHS staff were present and acknowledged the findings and state that this situation has been in place for approximately 4 weeks, starting in late July. 6. NFPA (National Fire Protection Association) Standard: Buildings shall be permitted to be occupied during construction, repair, alterations, or additions only when required means of egress and required fire protection features are in place and continuously maintained for the portion occupied or where alternative life safety measures acceptable to the AHJ are in place. 2012 NFPA 101, 4.6.10.1 NFPA Standard: Corridor walls shall be continuous from the floor to the underside of the floor or roof deck above; through any concealed spaces, such as those above suspended ceilings; and through interstitial structural and mechanical spaces, unless otherwise permitted by 19.3.6.2.4 through 19.3.6.2.8. Corridor walls shall have a minimum 1?2 hour fire resistance rating. Corridor walls shall form a barrier to limit the transfer of smoke. In smoke compartments protected throughout by an approved, supervised automatic sprinkler system in accordance with 19.3.5.7, a corridor shall be permitted to be separated from all other areas by non fire rated partitions and shall be permitted to terminate at the ceiling where the ceiling is constructed to limit the transfer of smoke. 2012 NFPA 101, 19.3.6.2.1, 19.3.6.2.2, 19.3.6.2.3, 19.3.6.2.4 Review of the following NFPA Standard revealed: Sprinkler System Impairments. Sprinkler impairment procedures shall comply with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water Based Fire Protection Systems. 2012 NFPA 101, 9.7.6 Review of the following NFPA Standard revealed: All preplanned impairments shall be authorized by the impairment coordinator. 2011 NFPA 25, 15.5.1 Review of the following NFPA Standard revealed: Before authorization is given, the impairment coordinator shall be responsible for verifying that the following procedures have been implemented: (1) The extent and expected duration of the impairment have been determined. (2) The areas or buildings involved have been inspected and the increased risks determined. (3) Recommendations have been submitted to management or the property owner or designated representative. (4) Where a required fire protection system is out of service for more than 10 hours in a 24 hour period, the impairment coordinator shall arrange for one of the following: (a) Evacuation of the building or portion of the building affected by the system out of service (b) An approved fire watch (c) Establishment of a temporary water supply (5) The fire department has been notified. (6) The insurance carrier, the alarm company, property owner or designated representative, and other authorities having jurisdiction have been notified. (7) The supervisors in the areas to be affected have been notified. (8) A tag impairment system has been implemented. (See Section 15.3.) (9) All necessary tools and materials have been assembled on the impairment site. 2011 NFPA 25, 15.5.2 Review of the following NFPA Standard revealed: Emergency impairments shall include, but are not limited to, system leakage, interruption of water supply, frozen or ruptured piping, and equipment failure. When emergency impairments occur, emergency action shall be taken to minimize potential injury and damage. The coordinator shall implement the steps outlined in Section 15.5. 2011 NFPA 25, 15.6.1, 15.6.2 & 15.6.3 Review of the following NFPA Standard revealed: Restoring Systems to Service. When all impaired equipment is restored to normal working order, the impairment coordinator shall verify that the following procedures have been implemented: (1) Any necessary inspections and tests have been conducted to verify that affected systems are operational. The appropriate chapter of this standard shall be consulted for guidance on the type of inspection and test required. (2) Supervisors have been advised that protection is restored. (3) The fire department has been advised that protection is restored. (4) The property owner or designated Establishment and implementation of an approved program to eliminate potential ignition sources and limit the amount of fuel available to the fire representative, insurance carrier, alarm company, and other authorities having jurisdiction have been advised that protection is restored. (5) The impairment tag has been removed 2011 NFPA 25, 15.7
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review the hospital failed to ensure the privacy of patient information for one of four patients reviewed for confidentiality, Patient 5. The hospital failed to ensure the property of Patient 5, labeled with patient confidential information, was not released to the wrong patient. Findings Include: Patient 1 and 2 were both patients at Overland Park Regional Medical Center. Patient 2 was admitted from 11/01/18 to 11/05/18, and her son, Patient 1, was in the Neonatal Intensive Care Unit (NICU) from 11/01/18 to 11/25/18. Patient 2 was pumping and storing her breast milk in the hospital's freezer until she returned home. The 11/01/18 Admission Summary for Patient 1 identified he was admitted on [DATE] immediately following delivery. He was delivered after mother presented with vaginal bleeding and admitted to the NICU for prematurity. Review of the 11/25/18 Discharge Summary for Patient 1 diagnosis included: 24 day old with feeding problems, jaundice in preterm infant, breech presentation, large for gestational age, and [DIAGNOSES REDACTED]. Review of the 12/20/18 Patient Event Record completed by the Director NICU and reported by Patient 2 identified the following information: Patient 1 was admitted on [DATE], Event Code: Wrong medication; wrong breast milk went. Event date: 11/25/18, time: 1200. Event location: NICU Neonatal Intensive Care Unit; Exact location: Babies [baby's] home. Description of event: Mother discovered breast milk with another babies [baby's] name on the bottles. Mother had already fed the milk. She discovered 16 other bottles of another patient [patient's milk] in her freezer. Pt [patient]/Family notified: Patient 2 on 12/20/18 at 8:37 AM, and Patient 5 on 12/20/18 at 8:38 AM by phone from the Director, NICU. Breakdown in process: did not follow process to double check milk. On 02/19/19 at 12:05 PM observation of the NICU refrigerators and freezers that are used for storage of breast milk were found to have labels on the breast milk containers that included a scan bar, baby's name, pump date, time; and breast milk containers located in the freezer also included the thaw date. The front of plastic bins containing breast milk containers were labeled with the patient's name. Observed RN A administer breast milk, as described on the hospital procedures for EMAR Labeling of Breast Milk. On 02/19/19 at 12:10 PM interview with the Director NICU RN A revealed if not paying attention, breast milk containers can accidentally be put in the wrong bin; that is why scanning is very important. Scan every time they give milk; that is what they are supposed to do. During a telephone conversation with Patient 2 on 02/19/19 at 1:55 PM, she revealed that on 12/19/18 when she went to make Patient 1 a bottle of breast milk and found the label was for another woman's breast milk. She did not notice the label on the bottle until her son had completed the bottle. Patient 2 had counted 16 bottles of another person's breast milk that the hospital gave her by mistake when she left the hospital. All the breast milk bottles were labeled with another woman's name and her confidential information. On 02/19/19 at 2:00 PM interview with Director Risk Management (RM) regarding the mother that went home with the wrong breast milk revealed, we acknowledged the error; identified both mothers; mother was tested ; rendered test results to the mother; and notified her by phone and in writing. She had a conversation with the Manager NICU; wanted us to release PHI [Protected Health Information]; we only release what pertained to testing. She wanted additional testing, healthcare history and background from the other mom. We could not provide ... because of HIPAA violations. The nurse was gathering the breast milk and preparing the patient (Patient 1) for discharge. She pulled out the wrong batch of breast milk and that was how the mistake happened. The double verification process in place was not adhered to, hence the mistake. On 02/19/19 at 2:40 PM interview and record review with the Director NICU, revealed systems and documents that were put in place since the event. Since we had a mistake, we don't want it to happen again. On 02/19/19 at 4:00 PM interview with the Manager of Infection Prevention (IP) revealed that she had conversations with Patient 2 to include we did the appropriate blood work and informed that the blood work was negative; she (Patient 2) received a letter that stated the lab work was negative. She wanted us to take the breast milk that was in her home and test it. I told her that it was out of our custody and there was no way we could test it. We follow the CDC [Center for Disease Control and Prevention] guidelines with input from our physician. On 02/20/19 at 10:00 AM during an interview with the Social Worker and Director NICU regarding patient rights and infection control, the Director NICU stated we had yearly competency (training); nurses are to double check milk. Before, there was no written proof (ensuring accuracy of the name on the breast milk container matched the respective mother/baby), something we taught nurses to do. I don't know why she didn't double check. Procedures for EMAR [Electronic Medication Administration Record] Labeling of Breastmilk (no date) included on the Purpose: To implement EMAR labeling of expressed breast milk (EBM) at the time that it is pumped by the infant's mother, and to identify the process of scanning EBM at the bedside prior to administration to an infant. Guidelines for Storing and Defrosting Breastmilk (no date) included procedures for the collection, storage, handling, and documentation; verification of the infant's name and medical record number on the container label and infant band by two personnel or electronic medication scanning system before preparation or administration of human milk.
Based on medical record review, interview, and policy review, the hospital failed to provide State Agency contact information for 20 of 20 medical records reviewed (Patients #1-20). Failure to inform patients of all contact information for grievance reporting placed patients at risk for not having a place to voice concerns about their care. Findings include: - Patient #1's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #2's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #3's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #4's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #5's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #6's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #7's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance.. - Patient #8's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance.. - Patient #9's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #10's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #11's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #12's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #13's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #14's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #15's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #16's closed medical review on 3/7/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #17's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #18's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance.. - Patient #19's closed medical review on 3/6/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. - Patient #20's closed medical review on 3/8/2017 revealed signed documentation that the patient received the Patient Bill of Rights pamphlet at admission. Review of the document received by the patient lacked evidence of contact information for the Kansas Department of Health and Environment to be used if the patient wanted to file a grievance. Quality Vice President Staff C interviewed on 3/8//2017 at 9:45 am confirmed the Hospital patient's rights handbook that is provided to all patients does not include contact information for the Kansas Department of Health and Environment (KDHE). Policy review of Patient Complaint and Grievance Process on 2/8/2017 directed ...In addition to the internal process, patients receive information on lodging external complaints which includes the Kansas Department of Health and Environment (KDHE) and the Quality Improvement Organization (QIO) if they have a complaint regarding quality of care, insurance coverage, or a premature discharge...
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, document review, and patient and staff interviews, the hospital failed to provide without delay, further examination and treatment to patients # 1, 3, and 5 and arranged to transfer the patients when the benefits did not outweigh the risks after determining the three patients had out of network (OON) insurance. The hospital's practice of initiating discussions regarding insurance and payment with the three patients delayed further examination and stabilizing treatment of their emergency medical conditions out of 22 records sampled from May to July 2016. This practice had the potential to delay the care and stabilizing treatment of any individual with emergency medical condition who presented to the ED seeking care. Findings include: Review of the hospital ' s Policy/Procedure titled EMTALA and Stabilization Policy dated 2/1/16 reads in part: 5. No Delay in Medical Screening or Examination a. Reasonable Registration Process. An MSE, stabilizing treatment, or appropriate transfer will not be delayed to inquire about the individual's method of payment or insurance status, or conditioned on an individual's completion of a financial responsibility form, an advance beneficiary notification form, or payment of a co-payment for any services rendered ... Reasonable registration processes may include asking whether the individual is insured, and if so, what that insurance is, as long as these procedures do not delay screening or treatment or unduly discourage individuals from remaining for further evaluation ... f. Financial Inquiries. If the MSE determines that the individual does not have an emergency medical condition ... the individual may be informed of the risk and benefits of his/her treatment options. The individual may: Accept further treatment at the DED (Dedicated Emergency Department) and financial liability ... Review of a three page document provided by Overland Park Regional Medical Center (OPRMC) during the survey and titled OUT OF NETWORK INSURANCE (OON) is inconsistent with the hospital's No Delay ... policy described above. The OUT OF NETWORK INSURANCE document reads in part, 1. Go to oprmc.com website. Scroll to bottom of page and under Company Transparency click on Accepted Insurance. This will tell you what insurance companies we are contracted and not contracted with. ... 2. Once you discover that the patient's insurance is out of network circle the insurance on the face sheet and write in red or yellow out of network and give to the ED staff (Unit Secretary, if not available then the provider). ... 4. You will then go into the room and educate the patient that they are OON for our facility and will incur a higher cost due to this. ... 5. You may have to call the insurance company to find out where the patient can be transferred that would be in network. If for some reason you cannot reach the insurance other options would be to pull insurance up on line or call the other hospitals to see if they are in network. In an interview on 8/2/16 at 1:45 pm, the Patient Access Manager was asked about the admission process at OPRMC. The Patient Access Manager stated that registration staff go in to the patient's area and obtain insurance information from the patient or a family member and check it with the insurance company. The Patient Access Manager stated that if the patient's insurance is OON, the registration staff inform the ED staff and physician. In an interview on 8/2/16 at 11:30 am, the Director of the Emergency Department stated that out of network should be documented as a patient request not OON. The Director stated that the OPRMC has had multiple grievances related to billing. The hospital tries to be more proactive in letting patient's know that their insurance will or won't cover costs. Review of Patient #1's medical record revealed she presented to the emergency department (ED) on 07/09/16 at 9:51 am and was diagnosed with acute appendicitis, an emergency medical condition. At 12:10 pm, PA A documented a decision to transfer patient # 1. Further documentation by PA A indicated The hospital is out of network for her. In light of this, she is requesting transfer to [Hospital B]. At 12:40 pm Hospital B accepted PA A's transfer request. Review of the transfer form indicated the reason for transfer was Patient Requested, but patient # 1 did not sign the form indicating she had requested the transfer. The medical risks and benefits noted for transfer indicated insurance reasons per PA A's handwriting and Deterioration of condition in route per check mark. The medical benefits of transfer did not outweigh the risks to the patient's health and well-being. PA A signed the transfer form on 7/9/16 at 1:15 pm. At 2:10 pm, the ED nurse noted patient # 1 Departed, approximately 4 1/2 hours after arriving at OPRMC requesting care for an emergency medical condition. Review of Hospital B's medical record showed that patient # 1 arrived at its hospital at 2:45 pm. Two hours and 15 minutes later, patient # 1 was taken to Hospital B's operating room for an emergent appendectomy which concluded at 6:28 pm, nearly 8 1/2 hours after initially presenting to OPRMC with acute appendicitis. In an interview on 8/3/16 at 10:30 am, PA A stated that patient # 1 presented with abdominal pain and was diagnosed with appendicitis. The admission/registration clerk informed PA A that [patient # 1] was OON. PA A stated that the patient didn't know why the appendectomy could not be performed at OPRMC. Review of patient # 5 ' s medical record showed the patient (MDS) dated [DATE] at 11:17 am complaining of chest pain, shortness of breath and jaw pain. At 1:15 pm, the ED physician documented I discussed with the patient admission to the hospital for her chest pain with further evaluation with the cardiologist. Patient agrees to admission however her insurance does not cover her admission to this hospital, patient request transfer to [Hospital B] for further treatment and inpatient care. At 3:59 pm approximately 4 + hours after arrival, patient # 5 was transferred to another hospital in an ambulance equipped with advanced cardiac life support. The reason for the transfer noted on the OPRMC transfer form was in the opinion of the physician responsible for my care the benefits of transfer outweighed the risks of transfer. The medical risks of transfer included Deterioration of condition in route, Risk of traffic delay/accident resulting in condition deterioration or death, and Other with no explanation documented. The box on the transfer form indicating the patient requested the transfer including the statement I make this request upon my own suggestion and not that of the hospital, physician or anyone associated with the hospital was not checked and the space for the patient to document the reason(s) they requested the transfer was blank. The evidence in the medical record indicated patient # 5 had chest pain that could have been cardiac in nature requiring further cardiac evaluation, and that transfer to another hospital un-necessarily delayed receipt of stabilizing treatment for the patient's emergency medical condition. OPRMC was fully equipped to provide patient # 5 with cardiac consultation and testing including but not limited to 12 operating rooms, 4 cardiac catheterization procedure rooms, cardiac catheterization laboratory, cardio-thoracic surgery, and diagnostic and therapeutic radiology services. In an interview on 8/3/16 at 2:30 pm, patient # 5 stated that while in the ED on 7/10/16, the hospital notified me that my insurance would not cover hospitalization at OPRMC. Patient # 5 stated she could not afford the out-of-pocket costs and agreed to be transferred to another hospital for care where the insurance would cover costs. Review of the medical record revealed Patient #3 (MDS) dated [DATE] at 4:06 pm complaining of abdominal pain which began yesterday morning. At 5:30 pm, the radiologist notified ED physician F of a critical result, pneumobilia (abnormal accumulation of air around the liver, gallbladder and pancreas from a puncture or perforation) and a gallstone ileus (obstruction of the bowel due to one or more gallstones). ED physician F documented that According to patient's insurance patient is out of network for this hospital so patient will be transferred to Hospital C at his request. This is what significantly delayed his disposition. At 6:30 pm, ED physician F documented the patient's disposition decision was Transfer, reason out of network here. Review of the transfer form indicated the medical benefits of transfer were Insurance related purposes. The medical risks of transfer were Deterioration of condition in route and Risk of traffic delay/accident resulting in condition deterioration or death. The section of the transfer form indicating patient consent for transfer including the statements I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer and I have been informed of the risks and benefits of this transfer was checked. The box on the transfer form indicating the patient requested the transfer including the statement I make this request upon my own suggestion and not that of the hospital, physician or anyone associated with the hospital was not checked and the space for the patient to document the reason(s) they requested the transfer was blank. At 9:56 pm, a delay of 6 hours after patient # 3 presented to the ED with an emergency medical condition, the patient was transferred to Hospital C for stabilizing treatment due to insurance, when the medical benefits of transfer did not outweigh the risks. Please refer to tag A2408 for further details.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on medical record review, document review, and patient and staff interviews, the hospital failed to provide without delay, further examination and treatment to patients # 1, 3, and 5 and arranged to transfer the patients when the benefits did not outweigh the risks after determining the three patients had out of network insurance. The hospital's practice of initiating discussions regarding insurance and payment with the three patients delayed further examination and stabilizing treatment of their emergency medical conditions out of 22 records sampled from May to July 2016. This practice had the potential to delay the care and stabilizing treatment of any individual with an emergency medical condition who presented to the ED seeking care. Findings include: OPRMC staff updated the Medicare Hospital/Critical Access Hospital Database worksheet on 8/1/16 revealing the hospital offered the following services: 12 Operating Rooms, 4 Cardiac Catheterization Procedure Rooms, Anesthesia Service, Cardiac Catheterization Laboratory, Cardiac-Thoracic Surgery, CT Scanner, Dedicated Emergency Department, Cardiac, Medical/Surgical, Surgical Intensive Care Units, Magnetic Resonance Imaging (MRI), Neurosurgery Services, Nuclear Medicine Services, Orthopedic Surgery, Post-operative Recovery Rooms, Diagnostic and Therapeutic Radiology Services, Respiratory Care Services, and Inpatient and Outpatient Surgery Surgical Services. The Multi-Specialty Emergency on-Call Schedule for July - September 2016 revealed the week of July 4 -July 11, 2016 Surgeon Staff L was listed as first call for the General Surgery service, Surgeon Staff M on second call for General Surgery, Physician Staff Q on call for Cardiology and Physician Staff R on call for Interventional Cardiology. The week of July 18-25, 2016 Surgeon Staff P was first call for General Surgery and Surgeon Staff M on second call for General Surgery. Review of Patient #1's medical record revealed she presented to the emergency department (ED) on 07/09/16 at 9:51 am complaining of sharp right lower quadrant abdominal pain that started two days prior with nausea, vomiting, and diarrhea. Physician Assistant (PA) A documented the patient's abdomen was exquisitely tender in the right lower quadrant. At 9:58 am lab tests showed patient # 1's white blood cell count (blood cells that fight infection) was elevated to 23.8 (normal is 4.1 - 11.1). At 10:30 am patient # 1 received intravenous (IV) medication for pain control and IV fluids for hydration. At 11:15 am a CT scan (special type of x-ray) of the patient's abdomen showed findings consistent with acute appendicitis (the appendix is a small appendage of the colon and when blocked with stool, bacteria invade and infection develops. If untreated, the appendix can rupture and cause a life threatening infection). At 12:10 pm, PA A documented a decision to transfer patient # 1. Further documentation by PA A indicated The hospital is out of network for her. In light of this, she is requesting transfer to [Hospital B]. At 12:40 pm the surgeon at Hospital B accepted PA A's transfer request. At 1:00 pm, patient # 1 received an IV antibiotic and the ED nurse documented Ready to Transfer. Review of the transfer form indicated patient # 1 had an emergency medical condition Acute appendicitis. The reason for transfer per documentation on the transfer form was Patient Requested, but patient # 1 did not sign the form indicating she had requested the transfer. The medical risks and benefits noted for transfer indicated insurance reasons per PA A's handwritting and Deterioration of condition in route per check mark. The medical benefits of transfer did not outweigh the risks to the patient's health and well being. The mode of transport noted was Advanced Life Support ambulance per check mark. PA A signed the transfer form on 7/9/16 at 1:15 pm. At 2:10 pm, the ED nurse noted patient # 1 Departed, approximately 4 1/2 hours after arriving at OPRMC requesting care for an emergency medical condition. Review of Hospital B's medical record showed that patient # 1 arrived at its hospital at 2:45 pm. Two hours and 15 minutes later, patient # 1 was taken to Hospital B's operating room for an emergent appendectomy which concluded at 6:28 pm, nearly 8 1/2 hours after initially presenting to OPRMC with acute appendicitis, a surgical emergency medical condition. In an interview at 10:05 am on 8/2/16, OPRMC Physician C stated Patient access informed patient # 1 she was out-of-network. Physician C confirmed he had received education on EMTALA. When asked if OPRMC had the capability to provide care to patient # 1, he stated other than insurance issues we were capable of caring for her here. In a document provided by Hospital B on 8/3/16, the transfer nurse was told by a representative from the call center at OPRMC that patient # 1 was told her ED visit would be covered but not the surgery because OPRM was out-of-network (OON) and that was why the patient agreed to be transferred. The document indicated PA A stated that the patient did not want to be transferred but only agreed because of the fact that she is OON at OPRMC and was told that surgery would not be covered. In an interview on 8/2/2016 at 1:45 p.m., the Patient Access Manager was asked about the admission process at OPRMC. The Patient Access Manager stated that Registration Staff go in to the patient's area and obtain insurance information from the patient or the patient's family member and they check it with the insurance company. If the insurance is out of network they inform the ED staff and physician. In an interview on 8/2/16 at 11:30 am, the Director of the Emergency Department stated that out of network should be documented as a patient request not OON. The Director stated that the OPRMC has had multiple grievances related to billing. The hospital tries to be more proactive in letting patient's know that their insurance will or won't cover costs. In an interview on 8/2/16 at 1:30 pm OPRMC Physician F stated there had been numerous conversations regarding this matter of 'out of network' insurance for patients. If the patient requires admission and is out of network we tell them we will admit and treat, or transfer and find a hospital in network and let them choose. In an interview on at 11:55 am, ED registered nurse D stated she thought patient # 1 was going to stay. The patient asked for assistance from staff about whether to stay or transfer to another hospital. Registration was sent back in to talk with the patient to make a transfer decision. In an interview on 8/3/16 at 10:30 am, PA A stated that patient # 1 presented with abdominal pain and was diagnosed with appendicitis. The admission/registration clerk informed PA A that [patient # 1] was OON. PA A stated that the patient didn't know why the appendectomy could not be performed at OPRMC. PA A stated, since this happened, I saw an e-mail, we as providers, we will not talk to patients (about their insurance status), the registration staff will handle these issues. Review of the medical record revealed patient # 5, a [AGE] year old female (MDS) dated [DATE] at 11:17 am complaining of chest tightness, shortness of breath, sweating, and jaw pain (warning signs of a heart attack) that began at 10:00 am on 7/10/16. Documentation by Advanced Practice Registered Nurse (APRN) O indicated the patient reported she is having 'a little bit of chest pain currently'. At 11:50 am, lab testing showed the patient had a normal Troponin level (troponins are proteins in the blood released when the heart muscle has been damaged and are measured by blood testing that is repeated two more times over the next 6 to 24 hours following signs of a heart attack). At 12:06 pm, patient # 5 received nitroglycerin and aspirin. At 1:15 pm, APRN O documented that I discussed with the patient admission to the hospital for her chest pain with further evaluation with the cardiologist. Patient agrees to admission however her insurance does not cover her admission to this hospital, patient requests transfer to [Hospital B] for further treatment and inpatient care. At 1:40 pm the OPRMC transfer center contacted Hospital B. At 2:33 pm, the physician at Hospital B accepted APRN O's transfer request. Review of the transfer form indicated Patient # 5's emergency medical condition (EMC) Diagnosis was Chest Pain. The Medical Benefits of transfer was check marked Other and in handwriting patient request. The Medical Risks boxes checked were Deterioration of condition in route, Risk of trafffic delay/accident resulting in condition deterioration or death and Other without any written explanation. The section of the transfer form indicating the patient's consent to transfer was check marked and read I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risks and benefits of this transfer. The box indicating the patient requested the transfer was not checked and the reason the patient requested transfer was blank. Documentation by the ED nurse indicated patient # 5 left the hospital by an ambulance equipped with advanced life support at 3:59 pm. The evidence in patient # 5's medical record does not support the medical benefits of transfer outweighed the risks. The hospital's capabilities included an on-call cardiologist and additional testing of the patient's troponin levels. Nearly 4 1/2 hours after presenting to the ED at 11:17 am, the hospital transferred patient # 5 delaying further examinaton and stabilizing treatment based on Patient # 5's insurance. During a phone interview on 8/3/2016 at 2:30 pm, patient # 5 stated the hospital notified me that my insurance would not cover hospitalization at this hospital. Patient #5 stated she could not afford the out of pocket costs and agreed to be transferred to another hospital for care where the insurance would cover costs. Review of the medical record revealed Patient #3 (MDS) dated [DATE] at 4:06 pm complaining of abdominal pain which began yesterday morning, 7/20/16. Documentation in the medical record indicated patient # 3 stated his pain was located in the right upper part of his abdomen. Further documentation showed his pain worsened with food and drink. Pain is dull and mild but constant. The patient did have some nausea and vomiting and mild constipation. At 4:18 pm, lab testing revealed patient # 3 had an elevated white blood cell count of 18.7 (normal is 4.1 - 11.1), and an elevated bilirubin level 2.2 (normal is 0.0 - 1.0), (bilirubin testing is part of a group of tests to check the health of the liver). At 5:05 pm, a CT scan (special type of x-ray) of patient # 3's abdomen/pelvis revealed multiple dilated small bowel loops with evidence of at least a partial distal small bowel obstruction (condition in which digested material is prevented from passing normally through the bowel), related...likely to a stone within the distal ileum. At 5:30 pm, the radiologist notified ED physician F of a critical result, pneumobilia (abnormal accumulation of air around the liver, gallbladder and pancreas from a puncture or perforation) and a gallstone ileus (obstruction of the bowel due to one or more gallstones). ED physician F documented that According to patient's insurance patient is out of network for this hospital so patient will be transferred to Hospital C at his request. This is what significantly delayed his disposition. At 6:30 pm, ED physician F documented the patient's disposition decision was Transfer, reason out of network here. Review of the transfer form indicated the medical benefits of transfer were Insurance related purposes. The medical risks of transfer were Deterioration of condition in route and Risk of traffic delay/accident resulting in condition deterioration or death. The section of the transfer form indicating patient consent for transfer read as indicated by a check mark I understand that it is the opinion of the physician responsible for my care that the benefits of transfer outweigh the risks of transfer. I have been informed of the risks and benefits of this transfer. The box on the transfer form indicating the patient requested the transfer including the statement I make this request upon my own suggestion and not that of the hospital, physician or anyone associated with the hospital was not checked. The space on the transfer form for the patient to document the reason(s) they requested the transfer was blank. At 9:56 pm, a delay of 6 hours after patient # 3 presented to the ED with an emergency medical condition, the patient was transferred to Hospital C for stabilizing treatment when the medical benefits of transfer did not outweigh the risks.
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