Based on interview, record review and document review, the facility failed to ensure an effective Governing Body was responsible for the conduct of the hospital and failed to: -Meet the Condition of Participation of Quality Assurance and Performance Improvement. (Cross-Reference Tag A 0263). -Ensure administrative leadership in Quality Assurance and Risk and Patient Safety maintained a program to identify, investigate, analyze and implement preventive actions regarding an incident affecting patient safety. (Cross-Reference Tag A 0286). -Ensure a Physician dictated operative reports in a timely manner and repeatedly failed to ensure its Medical Record Analysts identified the missed operative reports via auditing processes. (Cross-Reference Tag A 0959). The cumulative effect of this systematic practice resulted in the failure of the facility to deliver statutory-mandated care to patients.
Based on record review, document review and interview, the facility failed to implement and maintain an effective ongoing, hospital wide, data driven quality assessment and performance improvement plan (QAPI) regarding an adverse event. Specifically, the hospital failed to analyze and implement preventive actions following a patient adverse event which a Quality Manager was informed of and failed to document for follow-up (See Tag A 0286). The effect of these systemic practices resulted in the failure to ensure an effective ongoing, hospital wide, data driven quality assessment and performance improvement plan implementation in the delivery of care to patients.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview, record review, and document review, the hospital failed to track and analyze a patient adverse event in a timely manner for one of 30 sampled patients (Patient #1). Findings: Patient #1 Patient #1 was admitted on [DATE] with diagnoses including abdominal pain and perforated appendix. On 10/22/2020 at 9:52 AM the Pulmonologist revealed on 01/23/2020, Patient #1 was in the Intensive Care Unit. The patient had developed an acute kidney injury secondary to low perfusion from a deep vein thrombosis (DVT) and a pulmonary embolism. The patient required dialysis for decreasing urinary output. On 01/23/2020, the Pulmonologist placed a hemodialysis catheter (a type of central venous catheter with a thick diameter). The Pulmonologist explained the catheter was to be placed in the right internal jugular vein in the neck, and then threaded through the venous circulation to its final position in the superior Vena Cava (a large vein in the chest near the heart). The Pulmonologist reported no further contact with the patient after the procedure. In April 2020, another physician made the Pulmonologist aware of the issue of the venous catheter being inserted into the carotid artery. The Pulmonologist reported the hospital had placed no restrictions on the provider's hospital privileges. On 10/21/2020 at 11:47 AM, the Cardiovascular Thoracic surgeon recalled being consulted for Patient #1 on 01/29/2020. The patient had developed left-sided deficits with ischemic strokes, and a Computerized Tomography (CT) scan revealed a central venous catheter was positioned inside the patient's right carotid artery. The Cardiovascular Thoracic surgeon explained a venous catheter should never be in an artery. The Cardiovascular Thoracic surgeon performed the surgery to remove the central venous catheter from the artery on Patient #1. The surgeon explained the artery was cleanly cannulated (the insertion of a tube into a vessel) and we pulled the item out intact. The depth from the skin to the artery was about 8 - 10 centimeters (cm). The catheter had two lumens (channels). The surgeon verbalized blood clots probably came off the tip of the catheter which could have caused the stroke. The surgeon explained the insertion of the central venous catheter into the carotid artery was a serious and uncommon medical error. The surgeon did not know if Patient #1's incorrectly placed dialysis catheter was reported to the Medical Executive Committee (MEC) or if an investigation had been done completed. On 10/23/2020 at 8:59 AM, the Associate Chief Medical Officer indicated the hospital process for adverse events involved an initial report to Risk/Quality managers, followed by a formal review with the Medical Executive Committee (MEC), the Patient Safety Committee, and the Board of Trustees. Adverse events would be referred to the Patient Safety Committee for development of a Root Cause Analysis (RCA) and a process improvement plan. This plan would involve a Serious Event Analysis and actions to take regarding a serious event, and what actions to take to prevent reoccurrence. The final Root Cause Analysis (RCA) must be completed within 45 days after the incident. The action plan was then would be monitored for four months. The involved practitioner would be subject to peer review by other physicians. Sanctions or limitation could be placed on a physician based on what the event is and how much of the event was related to the physician's actions. The MEC could limit privileges, remove privileges, or take a physician off of the staff. On 10/23/2020 in the morning, the Vice President of Quality verified medical staff including a Radiologist and the Cardiovascular Thoracic surgeon, had become aware of Patient #1's incorrectly placed dialysis catheter. The radiologist detected the incorrect catheter placement on a CT scan on 01/28/2020. The Cardio-Thoracic surgeon became aware on 01/29/2020 when Patient #1 underwent surgery to remove the dialysis catheter.
On 10/23/2020 in the morning, the Vice President of Quality verbalized the Quality/Risk managers were first made aware of the incident on 09/24/2020, when the hospital received a letter from an external party. On 01/15/2021 at 11:00 AM, a Registered Nurse verbalized the process of adverse event reporting included an entry in Meditech (electronic documentation system) and following the chain of command to report the event. Adverse events were reported when someone was either directly involved in the incident or when the person was functioning as a charge nurse. The first person aware of an adverse event should report it. On 01/15/2021 at 11:20 AM, an Intensive Care Unit Physician (ICUP) indicated being asked to inform the Pulmonologist of the missing dictation following the placement of the dialysis catheter. The ICUP could not recall exactly who asked or when but verbalized usually it would be someone from the Quality department. On 01/15/2021 at 3:50 PM, a Radiologist who documented the dialysis catheter was within the right common carotid artery at 5:10 PM on 01/28/2020 verbalized the adverse event was verbally reported (no more than a week afterward) to the Quality Manager assigned to the radiology department at the time of the incident. On 01/15/2021 at 4:45 PM, the Director of Quality Management (DQM) explained an initial adverse event report did not necessarily require escalation for a full review if there were no paths for improvement. The Quality Management (QM) Module (computer module for reporting) method of initially reviewing adverse events did not necessarily result in the event to be escalated or formally documented. The DQM indicated the Quality Manager referred to by the Radiologist had retired in May of 2020. Pages 3-4 of the Medical Staff Professional Practice Evaluation document read as follows: C. All cases requiring single case review will be entered into the Quality Management (QM) Module and will be tracked and trended by Provider and indicator. G. All cases requiring single case review will have the final conclusions, recommendations, and case or event Code recorded in the QM Module. The Director of Quality Management acknowledged the policy contradicted not having to document the lowest level, single case review. On 01/15/2021 at 11:38 AM, the Vice President of Quality verbalized physicians were trained during orientation to report adverse patient events verbally to a Quality Manager. Physicians were not provided access to the electronic incident reporting system and did not enter incident reports into the system. Physicians were not provided access to the incident report system because they were not hospital employees. On 01/15/2021 in the afternoon, the Vice President of Quality explained Patient #1's dialysis catheter was inserted on 01/23/2020 and was detected by a radiologist on 01/28/2020 to have been incorrectly placed (in the artery versus the vein). The hospital Quality program initiated an investigation of the incident on 09/24/2020. The investigation of the incident was completed and was submitted to Patient Safety Committee on 11/23/2020. An Event Analysis was completed, and the conclusion was submitted to the Patient Safety Committee on 12/09/2020. The conclusion went to the Medical Executive Committee and to the Board of Trustees on 12/17/2020. The Vice President of Quality verbalized not knowing why the Quality Program did not become aware of the incident until approximately seven months after it was detected and reported by the Radiologist. The Vice President of Quality acknowledged incidents should be investigated by the hospital starting within five days of detection. The Facility Event and Close Call Reporting policy, last approved 05/2019, documented: A. Policy is intended to minimize risk to patients, non-patients, visitors, and employees through the development and implementation of an event and close call reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report events and close calls to the Risk Manager, Patient Safety Director, or to his or her designee.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review, policy review and interview, the facility failed to ensure a continuous Heparin infusion was titrated in a timely manner and lab draws were spaced out according to policy for 1 of 30 sampled patients (Patient #1). Findings include: Patient #1 was admitted on [DATE], with diagnoses including abdominal pain and perforated appendix. A physician ordered dated 01/21/2020 at 10:22 AM, documented Heparin infusion for deep vein thrombosis/ pulmonary embolism protocol. The electronic medical record showed the order was in effect until 1:30 AM on 1/25/2020. On 01/22/2020 at 11:33 AM, a partial thromboplastin time (PTT) blood draw revealed a critical test result of 118. At 12:39 PM, the result was verbally verified with a Registered Nurse. The Adult Continuous Infusion Heparin Protocol revealed for a PTT result greater than 112: Call Provider. HOLD for 60 minutes. Decrease by 200 units/hour. The Adult Critical Care Flowsheet documented the patient continued with the same infusion rate until the 5:00 PM. The infusion was stopped for an hour and restarted at 6:00 PM, decreasing the infusion rate by 200 units. The medical record lacked documented evidence a nurse contacted a physician according to the protocol and was told to wait over 4 hours before stopping the infusion. From 12:39 PM to 5:00 PM, roughly 4 hours and 21 minutes elapsed before a nurse adjusted the rate in relation to the critical PTT result. Another rate change occurred after the 11:30 PM result on 01/22/2020. According to the Heparin protocol, monitoring included obtaining another PTT every 6-hours after an infusion rate change. The medical record showed there was no PTT lab drawn until 11:55 AM on 01/23/2020, twelve plus hours after the 11:30 PM result on 01/22/2020. On 01/23/2020 at 11:55 AM, a PTT blood draw revealed a test result of 47. At 12:20 PM, the lab entered the result for nurses to assess for rate adjustment. The Adult Continuous Infusion Heparin Protocol revealed for a PTT result of 47 the nurse should have increased the infusion rate by 100 units. The Adult Critical Care Flowsheet documented the patient continued to receive the same infusion rate until the 2:30 PM, 2 hours beyond the availability of the result to adjust the rate. On 01/24/2020 to 01/25/2020 during the night shift, the Adult Critical Care Flow Sheet documented the Heparin was discontinued per order at 1:30 AM. The lab continued to draw PTT labs on 01/25/2020 at 5:33 AM and again at 10:02 AM. The order was not entered as canceled until 4:00 PM on 01/25/2020. On 10/22/2020 from 11:30 AM to Noon, the facility designated a Registered Nurse/Charge Nurse from its Intensive Care Burn Unit to answer questions regarding the Adult Continuous Infusion Heparin Protocol. The Registered Nurse explained the Heparin protocol, which was ordered for Patient #1. The Registered Nurse focused on the lab values and the protocol ranges for rate adjustment rather than on the time frame for the blood draws and the infusion rate changes. In response to what was reasonable lag time to adjust the rate, the Registered Nurse continued to focus on the lab value and the correctness of the infusion rate in the protocol range for infusion rate adjustment. The Registered Nurse failed to respond to what was a reasonable time for nurses to adjust the infusion rate. On 10/23/2020 at 8:30 AM, a Lab Manager acknowledged the times when Patient #1's PTT results were available to nurses. On 10/23/2020 at 10:30 AM, the Chief Nursing Officer indicated nurses would be expected to titrate the new rate within an hour of the lab result being finalized and entered into the computer system or within an hour of the results being called to the floor.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, record review, and document review the facility failed to ensure the medical records contained the reasons and narrative explanation for the patient's refusal and non-application of physician ordered intermittent pneumatic compression device (sequential compression device/SCD) for 6 of 30 sampled patients (Patient #10, #5, #6, #12, #18, and #20); and a physician's order for the application of intermittent pneumatic compression-thigh and foot pump for 1 of 30 sampled patients (Patient #10). Findings include: The facility's policy titled Evidence Based Clinical Documentation (EBCD) Provision of Care approved in May 2020, indicated documentation in the electronic health record (EHR) was focused on patient care activities, clinical decisions, and patient response to care. Key elements of the patient centered EHR included assessment and care activities. Patient Notes were used in a limited capacity to document unusual assessments or events which were not addressed in the standardized documentation. Patient #10 (P10) P10 was admitted on [DATE] and discharged on [DATE], with a diagnosis of left lower extremity deep venous thrombosis (DVT). The physician's order dated 10/02/2020 at 7:07 PM, documented intermittent pneumatic compression device. The placement/length was knee high bilaterally. P10's medical record documented the placement of intermittent pneumatic compression device and foot pump, None for non-application of intermittent pneumatic compression device, and Refused on the following dates and times: - 10/02/2020 at 10:54 PM, None - 10/03/2020 at 8:13 PM, None - 10/06/2020 at 9:41 AM, Intermittent pneumatic compression - thigh - 10/11/2020 at 8:08 AM, Refused - 10/11/2020 at 8:00 PM, Refused - 10/12/2020 at 8:58 AM, Refused - 10/13/2020 at 7:45 PM, Refused - 10/14/2020 at 9:19 AM, Foot pump - 10/14/2020 at 7:27 PM, Refused - 10/15/2020 at 8:37 AM, None The patient's medical record lacked documented evidence of a physician's order for intermittent pneumatic compression-thigh and foot pump, reason for the non-application of intermittent pneumatic compression device, and interventions when the patient refused intermittent pneumatic compression device as ordered. On 10/22/2020 at 9:01 AM, a Registered Nurse (RN) confirmed the findings and explained a mechanical prophylaxis such as intermittent pneumatic compression device or foot pump should have been applied within the next two hours from the time the intervention was ordered, unless specified in the physician's order. The nurses documented the placement/length of intermittent pneumatic compression device and other mechanical prophylaxis such as foot pump in the Nursing Assessment portion of the electronic charting at least every shift. The physician's order specified the placement/length of intermittent pneumatic compression device such as thigh high bilaterally, thigh high left leg only, thigh high right leg only, knee high bilaterally, knee high left leg only and right leg only. The order could have also specified foot pumps on both feet, left foot, or right foot. The nurses should have applied and documented the correct mechanical prophylaxis and placement/length of intermittent pneumatic compression device as ordered. The RN revealed the nurses would have documented None if the patient had no intermittent pneumatic compression device in place or Refused. A narrative nurse's notes should have been documented on the reason why the intermittent pneumatic compression device was not applied. Nursing interventions such as health teachings should have been documented when the patient refused the application of intermittent pneumatic compression device as ordered. On 10/23/2020 at 9:42 AM, a Performance Improvement Coordinator confirmed there was no physician's order for P10's intermittent pneumatic compression-thigh and foot pump. The physician's order contained in the patient's medical record was intermittent pneumatic compression-knee high bilaterally. Patient #5 (P5) P5 was admitted on [DATE], with a diagnosis of left knee infection. The physician's order dated 10/08/2020, documented intermittent pneumatic compression device. The placement/length was knee high bilaterally. P5's medical record documented None for non-application of intermittent pneumatic compression device and Refused on the following dates and times: - 10/09/2020 at 8:30 PM, None - 10/10/2020 at 8:00 PM, None - 10/17/2020 at 7:34 PM, Refused - 10/20/2020 at 8:00 PM, None The patient's medical record lacked documented evidence on the rationale for the non-application of intermittent pneumatic compression device and patient's refusal. Patient #6 (P6) P6 was admitted on [DATE], with diagnosis including positive COVID-19 and pneumonia. The physician's order dated 10/06/2020, documented intermittent pneumatic compression device. The placement/length was knee high bilaterally. P6's medical record documented None for non-application of intermittent pneumatic compression device and Refused on the following dates and times: - 10/08/2020 at 8:00 PM, None - 10/11/2020 at 8:00 PM, Refused - 10/12/2020 at 8:00 AM, Refused - 10/12/2020 at 7:45 PM Refused - 10/13/2020 at 8:00 AM, None - 10/13/2020 at 8:30 PM, Refused - 10/14/2020 at 7:45 PM, Refused - 10/15/2020 at 8:00 PM, None - 10/17/2020 at 8:00 AM, None - 10/18/2020 at 7:57 AM, None The patient's medical record lacked documented evidence on the rationale for the non-application of intermittent pneumatic compression device and patient's refusal. Patient #12 (P12) P12 was admitted on [DATE], with a diagnosis of cardiac arrest. The physician's order dated 10/17/2020 at 3:51 PM, documented intermittent pneumatic compression device. The placement/length was knee high bilaterally. P12's medical record documented None for non-application of intermittent pneumatic compression device on the following dates and times: - 10/17/2020 at 8:30 PM, None - 10/18/2020 at 12:00 AM, None The patient's medical record lacked documented evidence on the rationale for the non-application of intermittent pneumatic compression device. On 10/23/2020 at 10:01 AM, the Chief Nursing Officer (CNO) explained the nurses were expected to apply foot pump or intermittent pneumatic compression device as soon as possible when ordered by a physician. The physician's order on the type of mechanical prophylaxis such as foot pump or intermittent pneumatic compression device including placement/length should have been followed. The nurses should have documentation in the patient's medical record if there was a deviation from the order. A narrative explanation should have been documented for patient's refusal, non-application of intermittent pneumatic compression device, and application of different placement/length of intermittent pneumatic compression device from the one ordered by the physician. A patient's medical record should have contained the physician's order for the intermittent pneumatic compression device applied to the patient. On 10/23/2020 at 10:31 AM, a Performance Improvement Coordinator confirmed there was no documentation in the medical records of P10, P5, P6, and P12 on the rationale for the refusal and non-application of intermittent pneumatic compression device.
The facility policy titled Thrombosis Prevention Guidelines last reviewed 01/2018, documented the following data will be documented in the daily care intervention in Meditech (an electronic charting system used by the facility) or the relevant section of the medical record: The application and removal times each shift of all compression devices, skin and neurovascular inspections, size of stockings as applicable, cleaning of stocking and pneumatic devices. Patient #18 (P18) P18 was admitted on [DATE] with diagnoses including end stage renal failure and uncontrolled blood pressure during hemodialysis. A physician order dated 04/04/2020, documented intermittent pneumatic compression device. Placement: knee high bilateral. Review of the daily care intervention documentation from Meditech titled Evidence Based Clinical Documentation (ECBD) Mechanical Prophylaxis Group from 10/01/2020 to 10/21/2020 revealed daily entries at 8:00 AM and 8:00 PM was recorded as None or as Refused. The medical record lacked documented evidence as to why the patient did not had the device applied to the lower extremities and the rationale for the refusal. On 10/20/2020 at 3:15 PM, a Charge Nurse indicated application of an intermittent pneumatic compression device was a shared duty between the nurses and the Patient Care Technicians. The Charge Nurse indicated the nurse caring for the patient was responsible for the documentation of the application of the device. The Charge Nurse confirmed if a patient had refused an application of the device the expectation was to document the rationale as to why the device was not applied. On 10/22/2020 at 1:55 PM, P18 was observed in the room with no intermittent pneumatic compression device applied to the lower extremities. There was no device noted inside the room. On 10/22/2020 at 2:00 PM, a Registered Nurse (RN) caring for P18 indicated the patient had been continuously refusing the application of the device for months. The RN confirmed there was an active physician order for the application of the intermittent pneumatic compression device and the physician should have been notified for the continuous refusal and the order should have been discontinued. The RN verbalized a narrative should have been entered into Meditech for every None or Refused entry. Patient #20 (P20) P20 was admitted on [DATE] with diagnoses including end stage renal failure and diabetic foot ulcer. A physician order dated 09/01/2020, documented Intermittent Pneumatic Compression Device. Placement: knee high bilateral. Review of the daily care intervention documentation from Meditech titled Evidence Based Clinical Documentation (ECBD) Mechanical Prophylaxis Group from 10/04/2020 to 10/21/2020 revealed daily entries at 8:00 AM and 8:00 PM recorded as None or as Refused. The medical record lacked documented evidence as to why the patient did not have the device applied to the lower extremities and the rationale for the refusal. On 10/20/2020 at 3:15 PM, a Charge Nurse indicated application of an intermittent pneumatic compression device was a shared duty between the nurses and the Patient Care Technicians. The Charge Nurse indicated the nurse caring for the patient was responsible for the documentation of the application of the device. The Charge Nurse confirmed if a patient had refused an application of the device the expectation was to document the rationale as to why the device was not applied. On 10/22/2020 at 9:45 AM, the Performance Improvement Coordinator indicated an entry of None reflected the patient did not have any device applied to the lower extremity for the shift and Refused reflected the patient had refused the application of the device. On 10/23/2020 at 9:20 AM, the Chief Nursing Officer (CNO) indicated the expectation was for the nurses to enter a narrative every time a patient refused or the nonapplication of an Intermittent Pneumatic Compression Device. The CNO confirmed if the entry was None and a physician order was active, the physician's order was not followed.
Based on record review, document review and interview, the facility failed to ensure a physician completed dictation of operative reports within 72 hours for 4 of 4 sampled patients (Patient #1, #2, #3, and #4). Findings include: Patient #1 On 01/17/2020, Patient #1 was admitted with appendicitis and subsequent appendectomy via laparoscopy. On 01/23/2020, Physician #1 placed a hemodialysis catheter in the right internal jugular vein. The medical record showed Physician #1 failed to dictate the operative report until 03/31/2020. The authenticated dictation, dated 04/02/2020, revealed a statement left unclarified within the operative report: The catheter was packed and (blank space) were placed. The Medical Staff General Rules and Regulations regarding Physician Entries documented all blanks left in dictated reports must be filled in by the dictating physician at the time the report is authenticated. Patient #2 On 08/29/2020, Patient #2 was admitted with severe sepsis, hypoxia, Covid pneumonia and fluid overload. On 09/02/2020, Physician #1 placed a hemodialysis catheter in the right internal jugular vein. The medical record showed Physician #1 failed to dictate the operative report until 09/08/2020. Patient #3 On 07/27/2020, Patient #3 was admitted with pneumonia, respiratory failure and hypoxemia. On 08/03/2020, Physician #1 intubated Patient #3 and placed an arterial line in the right femoral vein. The medical record showed Physician #1 failed to dictate the operative reports until 08/13/2020. Patient #4 On 09/03/2020, Patient #4 was admitted with compromised airway. On 09/04/2020, Physician #1intubated Patient #4. The medical record showed Physician #1failed to dictate the operative report until 09/08/2020. The authenticated dictation, dated 09/09/2020, revealed statements left unclarified within the operative report: Unfortunately, the tube ended up in esophagus and therefore I pulled it out, (blank space) the patient again until the oxygen saturation was about 90% to 95% again...A chest x-ray was ordered as well as placing her back on the same setting (blank space) FiO2 of 100% temporarily. The Medical Staff General Rules and Regulations regarding Physician Entries documented all blanks left in dictated reports must be filled in by the dictating physician at the time the report is authenticated. On 10/22/2020 at 10:00 AM, Physician #1 acknowledged dictation was required to be completed within 72 hours and blank information completed. The Physician acknowledged being approached months after the missing operative report for Patient #1. The Physician was unaware of the electronic template the facility required physicians to use to document the brief operative note prior to the dictated version. The Medical Staff General Rules and Regulations regarding Operative Reports documented: 2.4.1 A dictated operative report must be completed immediately following surgery for outpatients as well as inpatients. Any physician with undictated operative reports within seventy-two (72) hours following the day of the operation shall be subject to temporary limitation of privileges, pursuant to Section 2.14 of these Rules and Regulations. A brief operative note must be entered into the medical record immediately after surgery and include pertinent information that is necessary for any care provider who will be attending the patient. Immediately after surgery is defined as upon completion of surgery. The written postoperative note must include at least the following elements: A. Primary surgeon and assistant(s) B. Pre and postoperative diagnosis(es) C. Name and description of specific surgical procedure(s) performed D. Description of the findings E. Tissues removed or altered F. Estimated blood loss On 10/21/2020 at 1:37 PM, the Director of Medical Records acknowledged the following operative reports were expected to be dictated within 72 hours.
Based on the findings at A2401 the facility failed to ensure compliance with CFR 489.24.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on document and interview, the facility failed to ensure CMS (Center for Medicare and Medicaid Services) or the State Agency were notified of a possible inappropriate transfer/referral of a patient from another facility for 1 of 33 sampled patients (Patient #15). Findings include: Patient # 15 Patient #15 presented to the Emergency Department (ED) on 9/8/12 at 3:20 PM with complaints of worsening flank pain and dribbling of urine. The initial nurse triage note documented Patient #15's pain level was 10/10, and the patient appeared to be in pain. Documentation in the Physician's Notes indicated Patient #15 had been seen in the ER of Hospital #2 on the same day. The notes also documented Hospital #2 diagnosed the patient with possible kidney stone and left sided [DIAGNOSES REDACTED]. Patient #15 received additional workup including laboratoy testing and an ultrasound of the abdomen. The patient received pain medication with relief documented. Patient #15's medical record at Hospital #1 included a discharge instruction sheet from Hospital #2 dated 9/8/12 13:55 (1:55 PM), which documented: Follow up with: Go to Sunrise hospital as soon as you are able, as you need urgent urology evaluation for stenting of your left ureter. When: Within 1 to 3 days Review of the On Call Specialist log documented there was no urology on-call on 9/8/13. The ED physician indicated Patient #15 did need a urology consult. The patient was then transferred to Hospital #3. On 5/6/13 at the Director of Emergency Serviceas and Trauma (DEST) and the Director of Regulatory Compliance (DRC) were interviewed. The Director of Emergency Services was asked if a patient was discharged from this ED and required services that this ED could not provide, would the patient be told to go to another hospital to receive the service. The employee responded - No, that may be considered an EMTALA (Emergency Medical Treatment and Labor Act) violation. The employee was then asked to review the file of Patient #15 and to determine if she thought this was an appropriate referral from another facility. She responded, No. The Director of Regulatory Compliance verbalized - at the time of Patient #15's admission, it had been identified as problem by QI (Quality Improvement). The employee added the COO (Chief Operating Officer) of this hospital had tried to contact the COO of Hospital #2 by telephone to obtain additional information regarding this transfer. The COO of this hospital was never able to connect with the COO of Hospital #2. The issue was then dropped. The DEST and DRC were asked if they were familiar with the EMTALA reporting requirements. Both staff indicated they were aware of the requirements. The DEST indicated this incident had not been reported to CMS or the state as a possible EMTALA violation. The hospital's policy titled EMTALA Transfer last reviewed 4/20/12, documented 7. a. Receiving Hospitals. Receiving hospitals have a duty to report any inappropriate transfer received from a transferring institution. A hospital that suspects it may have received an improperly transferred individual (transfer of an unstable individual with an EMC (Emergency Medical Condition) who has not provided an appropriate transfer according to Section 489.24(e)(2)), is required to promptly repoort the incident to the Centers for Medicare and Medicaid Services or the state agency within 72 hours of the occurrence.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interviews, medical record and policy review, the facility failed to ensure two patients had completed and stabilized psychiatric (#22) and medical treatment (#35) before their disposition. Patient #22 The Clinical Report- Nurses for Patient #22 indicated the patient arrived by ambulance on 6/4/12 at 10:50 PM and was triaged at 11:09 PM at an acuity level 2. The Clinical Report-Nurses for Patient #22 dated at 11:18 PM, documented,...The patient exhibited bizarre behavior. Patient #22 was found at (name of casino) and called 911. The patient indicated someone was trying to kidnap her and her daughter... The notes indicated Patient #22 pulled the fire alarm at the casino. Patient #22 then ran from the police with her six year old daughter. The notes documented Patient #22 told the EMS (Emergency Medical Services) her daughter was poisoned by the child's grandfather. The Clinical Report-Nurses for Patient #22 dated 6/4/12 at 11:18 PM revealed the following: - ...EMS unable to obtain vital, IV (intravenous) BS (blood sugar ?) due to patient paranoia. - Abuse history: patient reports, physical abuse by significant other and parent against patient and patient's daughter ED (emergency room ) physician notified and police. - Security at bedside for 4 point restraints. Nurse took belongings away from patient and put at nurses station. Patient was changed into blue scrubs. - 23:25 (11:25 PM) - INTERVENTIONS ID (identification) and allergy band on patient. To treatment room. - PHYSICAL ASSESSMENT 23:26 (11:26 PM) 06/04/2012. To room via stretcher. Alert. Affect appears normal. Patient appeared calm and cooperative. Patient appears well-nourished and unkempt. Respirations not labored. Breath sound within normal limits. Abdomen soft and nontender. Bowel sounds within normal limits. Capillary refill less than 2 seconds. Skin warm and dry skin within normal limits. - NURSE PROGRESS NOTES 23:27 (11:27 PM) 06/04/2012. Patient identifiers checked. The initial plan of care for this patient had been created. Pulse oximeter and NIBP monitor placed on patient; monitor alarms on. (PATIENT IN FOUR POINT RESTRAINTS BY SECURITY). Call light in reach. Side rails up x (times) 2. Bed placed in lowest position. Breaks of bed on. - 23:39 (11:39 PM) IV (intravenous) access: site #1 left antecubital space, 18g (gauge) angiocath (catheter), with aseptic technique and good blood return; one attempt. Blood drawn. Labeled in presence of patient and sent to lab (laboratory). Lock flushed with 10 ml (milliliters) of saline (child protective services at bedside). - 00:14 (12:14 AM) 6/5/2012 (Patient removed restraints, nurse went to get medications for patient and patient left the ED)... A Nurses Note dated 6/5/12 at 12:19 AM documented, Missing from room 23 seen running out of the fire exit a few minutes earlier by a visitor. An Initial Order Form (first 24 hours) Non-Violent/Non-Self Destructive Restraint Order dated 6/4/12 at 11:09 PM, for Patient #22 was written and signed by a physician. The restraint justification box on the form documented, ...Impulsive or unpredictable behavior i.e. traumatic brain injury... The restraint limit was for 24 hours. The restraint devices included full siderails. In the box that indicated check which device in use the box on the form checked was, bilateral wrist restraints... On 6/4/12 at 23:12 (11:12 PM), The Clinical Report-Physicians/Mid levels for Patient #22 indicated the following: ...Arrived by ambulance. Historian patient and EMS personnel. - History of present illness-Chief Complaint-BEHAVIOR CHANGE. This started today. - The patient has exhibited a behavioral change. (Pt. (patient) called 911 at (name of casino) and presented bizarre behavior trying to run from police and stating people are after her and her daughter. Pt. states her father hired an assassin to kill her). She has anxiety. Has exhibited unusual behavior and been paranoid. The patient has had persecution delusions. No suicidal attempts. - The symptoms are described as moderate. No injury present. - Similar symptoms previously: none. - Past History-See nurses notes unknown. Unobtainable due to patient's uncooperativeness. - Social history-Smoker current status unknown. - Physical exam: Psych/Neuro (psychiatric/neurology) Oriented x 3 Appears to have persecution delusions. Denies suicidal thoughts. The patient does not feel treatment is necessary. No motor deficit. No sensory deficit. - PROGRESS AND PROCEDURES Course of care: BP (blood pressure) 136/82 lying down r (right) arm auto. (automatic) HR: (heart rate) 119. RR: (respiratory rate) 20. Temp (temperature) 98.0 oral. 02 (oxygen) saturation on room air 100%. - 00:14 (12:14 AM) Ativan IV 2 mg. (milligram) Haldol IV 5 mg. Benadryl IV 50 mg - 1:02 AM- Patient removed 4-pt. (point) restraints (restraints on wrists and ankles) and eloped from the ED. - pt. delusional, abnormal thought pattern. Seems very nervous as well. Will uphold L2K (Legal 2000-The State of Nevada's legal civil commitment). - pt. eloped prior to being able to fill out L2K. - Transfer orders written. - Disposition: Transfer to DOU (Discharge Observation Unit for psychiatric patients awaiting completion of mental health assessments). Condition stable CLINICAL IMPRESSION Acute psychosis with paranoia... The Toxicology lab results of Patient #22 collected at 6/4/2012 at 23:37 (11:37 PM) and message received as final results on 6/5/12 at 2:05 AM indicated, positive for Amphetamine/Methamphetamine and Cannabinoids. The T-System Order Summary-Order Sheet for Patient #22 dated 6/4/12 at 22:31 (11:31 PM) documented the patient was placed on suicide precautions. Patient #22's Suicide Risk Factor Scale and Observation Intensity Trigger dated 6/4/12 at 23:09 (11:09 PM) was assessed at an 11 (4-11 moderate risk precautions) which required hourly welfare checks. The form was incomplete, not all the risk factors were filled out. The Precaution Monitoring Flow Sheet (11 PM-7 AM) dated 6/4/12 to 6/5/12, for Patient #22 indicated the following: Visual Appearance: Behavior 2315 (11:15 PM) WORRIED ANXIOUS 2330 (11:30 PM) WORRIED ANXIOUS 2345 (11:45 PM) WORRIED ANXIOUS 0000 (12:00 AM) WORRIED ANXIOUS 0015 (12:15 AM) WORRIED ANXIOUS Patient #22 was listed as being in room 23. The Registered Nurse signed her initials after each entry in the visual appearance/anxious boxes. On 6/21/12, review of the ED log dated 6/4/12, indicated Patient #22 was placed in the mini DOU. On 6/21/12 in the afternoon, the Manager of Emergency Services indicated the mini DOU was an area in the ED with six beds where psychiatric patients were placed when there was no room in the DOU. There was one Registered Nurse (RN) for four patients and a RN and a Certified Nurses Assistant for six patients. The expectations for observation of the patients were the same as the DOU. which included continuous monitoring. On 6/22/12 in the afternoon, the Director of the ED indicated Patient #22 was on a gurney located on Hall 10 (in the ED hallway between room 39 and the ED anteroom). They were waiting to move the patient into a room. Patient #22 had changed into blue scrubs ( colors used for psychiatric patients) and hospital socks. The Director of the ED indicated Patient #22 was transferred to Room 23 due to the DOU and the mini DOU were filled on 6/4/12. The Director of the ED indicated there was no policy for the mini DOU. The Director of the ED indicated Patient #22 was not on a one on one. The Director of the ED indicated Patient #22 was on every 15 minute checks and visual checks. Room 23 was observed on 6/22/12 in the afternoon, the room consisted of one bed. There were approximately 27 steps from room 23 to the fire exit which led out to the area where the ambulances parked. The fire door was on a delayed alarm. On 6/22/12 in the afternoon, The Manager of Public Safety explained the procedure when a patient who was unstable eloped. When an adult patient eloped a call was placed to security to inform them a patient was missing. A copy of the facesheet was given to security in order to assess if the patient's family knows the whereabouts of the patient. If security was unable to find the patient the police department was notified and it was broadcast to the police officers to see if they were able to find the patient. The Manager of Public Safety indicated if a patient eloped with AMS (altered mental status or was on an L2K, then they would call a Code Walker. This would be announced over the call system of the facility and the Public Safety department would give a description to all employees who had the responsibility to look for the patient. On 6/22/12 in the afternoon the Manager of Public Safety indicated an adult elopement procedure was followed in order to find Patient #22. The Manager of Public Safety indicated Patient #22 was not found. The patient's six year old daughter who was placed in the pediatric ED was removed by Child Protective Services on 6/5/12. On 6/22/12 in the afternoon, Security Officer #1 indicated he placed the four point soft restraints on Patient #22. The Officer indicated Patient #22 was a thin small person who weighed about 90 pounds. The officer indicated he did not want to put the restraints on too tight, he could understand how Patient #22 might have removed them. He indicated Patient #22 was more worried about her computer that was confiscated than anything else. Policy #EDADM11-EMERGENCY DEPARTMENT-THE DIFFICULT PATIENT ...Purpose To provide guidelines for the management of the patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems. Scope Adult Emergency Department Policy A. Patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems will be treated with care and dignity in a safe secure environment. 1. A suicide risk assessment and a 15 minute checklist are required at the time of arrival to the Emergency Department (ED). B. All patients will be triaged and assigned a room in accordance with patient care requirements and established policy. C. Should restraints be necessary, they will be applied by the Public Safety staff and in accordance with the hospital policy, using the least restrictive method of restraint to maintain safety of the patient and others with stretcher/gurney siderails raised. F. Patients who are placed on legal hold status (aka L2K) may have specialized care to maintain their safety and dignity: 1. All patient belongings are secured and stored by Public Safety staff unit. 2. after the patient is deemed medically stable by the attending physician, the patient may be held in a separate locked discharged observation unit pending completion of a mental health assessment. In summary: -On 6/4/12 at 10:50 PM Patient #22 arrived by ambulance to the Emergency Department, the patient was triaged at 11:09 PM and given an acuity level of 2. -Patient #22 was seen by the Emergency Department physician at 11:12 PM and diagnosed with [DIAGNOSES REDACTED] -The DOU and mini DOU were full and Patient #22 was first placed in a hall bed, then transferred to room 23 in the ED. -Patient #22 was placed on a monitor with alarms, a pulse oximeter and an IV was started. Patient #22 was placed on four point restraints by security. -Patient #22 was given a suicide risk assessment and scored an 11 (moderate risk) and was placed on suicide risk. -Patient #22 had an order for Ativan IV 2 mg. (milligram) Haldol IV 5 mg. Benadryl IV 50 mg. The medication was not given. -Patient #22 removed the four point restraints and eloped while the nurse went to get the medications. -There was no documentation whether Patient #22 took out the IV before she eloped. -- -Patient #22 left in blue paper scrubs and hospital socks. -The physician was unable to complete the papers for the L2K since the patient eloped. -Patient #22's toxicology report came back positive for Amphetamine/Methamphetamine and Cannabinoids. -The facility did follow the adult elopement procedure to find Patient #22. The patient was not found. -Patient #22 eloped without a psychiatric stabilization screening. Patient #35 Patient #35 was triaged in the ED on 6/2/12 at 20:57 (8:57 PM) at an acuity level of 3. Patient #35's chief complaint was abdominal pain and nausea. The patient's vital signs were taken and a sepsis screen was performed and was negative. Patient #35 had a documented pain level at 10/10. The Clinical Report-Nurses dated 6/2/12 at 8:57 PM documented, ...History onset x 3 hours. PAST MEDICAL HX (history) negative. SURGICAL HX: No history of previous surgery. ADDITIONAL PROBLEMS: No known problems. INTERVENTIONS: ID allergy band on patient. Fall risk assessment completed per protocol. Risk factors identified include severe pain. Fall interventions initiated. Patient identified as a fall risk by ID band. To treatment room--21:03 (9:03 PM). Nursing Progress Notes IV start unsuccessful, site #1 left hand 20 gauge angiocath (catheter), using a topical anesthetic, with aseptic technique; one attempt. Blood drawn: rainbow set. Labeled in presence of of the patient and sent to lab. Lock flushed with 10 millimeters normal saline.--21:10 (9:10 PM). (given specimen cup to provide urine specimen states cannot give urine at this time)--21:12 (9:12 PM). 21:48 (9:48 PM) 6/2/12. (FAMILY CAME TO WINDOW, STATES PT. IN A LOT OF PAIN, FAMILY ADV (advised) WILL GET ROOM AS SOON AS POSSIBLE, NOT TOO LONG OF A WAIT. FAMILY CAME TO WINDOW A SECOND TIME STATING, I NEED HELP MY HUSBAND IS IN A LOT OF PAIN ADV SOON AS POSSIBLE. PT. SEEN LEANING ON FAMILY WALKING TOWARDS ER DOOR, TRIAGE RNS ADV PT IS LEAVING AND HAS IV IN HIS HAND. (Licensed Nurse #1) WENT OUTSIDE TO REMOVE PT'S IV AS PT GETTING INTO CAR, PT DID NOT HAVE A LONG WAIT BUT LEFT ANYWAY--21:57 (9:57 PM) (RECEIVED RESULT OF CT (Computerized Tomography) SCAN AT 21:54 (9:54 PM). FAMILY LEFT WITHOUT PATIENT NOTIFYING NURSES. SEE ABOVE NOTE. ATTEMPTED TO CALL PT WITH NUMBER LISTED ON FACESHEET. NO ANSWER.--22:02 (10:02 PM) DISPOSITION/DISCHARGE 01:21 (1:21 AM) 6/3/12. BP not taken due to pt not present:0 HR:0 RR:0 temp:0..02 saturation:0 Condition at departure: unchanged and critical. Patient reports a pain level on departure at 10/10. The goals identified in the patient's plan of care were partially met. The following issues were addressed: language and cultural issues, psychosocial issues and educational issues. All aspect of the patient's plan of care were not met because the patient left the emergency department against advice accompanied by a family member. The patient appears to be alert, oriented x 4 and coherent. The patient appears to be in distress. The patient did not notify the ED staff prior to leaving the department.. Notified ED physician and charge nurse of departure. Pt. left without signing form prior to leaving. The patient left the Emergency department carried and via private vehicle. (PT'S FAMILY WALKED PT OUT, ONE ON EACH SIDE WITH PT'S ARMS OVER SHOULDERS). Departure time: 2150 (9:50 PM) June 02 2012... The CT scan performed on Patient #35 on 6/2/12 revealed the patient had acute appendicitis with perforation. No abscess and a small shrunken non functioning left kidney. Patient #35's lab work revealed a white blood cell count of 17.49 (normal 3.91-9.68). On 6/22/12 at 2:45 PM, Licensed Nurse (LN) #1 indicated during a telephone conversation it was early evening when the Security Guard (did not remember his name) told LN #1, Patient #35 was in the driveway and still had the IV. The family of Patient #35 said they were taking him somewhere else. LN #1 indicated the family said the ED was not doing anything for the patient. The family indicated they had been up to the window two or three times. LN #1 indicated she removed the IV and placed a bandage on Patient #35 while he sat in the car. On 6/22/12 in the afternoon, the Director of the ED indicated Patient #35 was in the waiting room then went to imaging and had the CT scan performed. The Director of ED indicated she was aware Patient #35 went AMA (Against Medical Advice). The Director of the ED indicated she personally called the number on the facesheet of Patient #35. The Director indicated a female answered the telephone and the Director told the female Patient #35 needed to go to the hospital. On 6/22/12 in the afternoon, the ED Manager, indicated the Nurse Practitioner (NP) did a RME (Rapid Medical Examine) at 21:03 (9:03 PM). The Manager indicated the NP did not order pain medication. The Manager indicated the patient could have asked for something for pain when Patient #35 went back into the waiting room. The Manager indicated pain was subjective, sometimes a 10 was a 3. On 6/22/12 in the morning, the telephone number on facesheet of Patient #35 was called. A female answered the telephone and indicated she did not speak English. The female put a young boy on the telephone. He interpreted what the female said. He indicated the family of Patient #35 took him right to Hospital B. The boy indicated Patient #35 had surgery at Hospital B and was doing fine. Emergency Departmetn Pain Management Policy dated 05/2011 (#EDEMS04) documented the following: ...Purpose: This policy will assure that all patients presenting to the (name of hospital) Emergency Department will be objectively evaluated and appropriately treated for pain while minimizing hte potential for divesion and bsue of narcotic pain medications... Principles: A. Pain is the primary reason patients come to the emergency department. Many medical and traumatic conditions cause pain. The role of the health care provider is to assess the pain, determine the cause, and provide appropriate treatment... B. Patient presenting to the (name of hospital) Emergency Department will be evaluated for pain using one of the following objective scoring systems: 1. Nurmerical Score (0-10) and 2. Visual Analog Score... C. Following triage, all patients will receive a Rapid Medical Evaluation (RME) and appropriate pain management will be provided based upon the practitioner's assessment... Assessing Pain: pain is a subjective complaint. However, it can be objectively evaluated with various pain scoring systems. At (name of hospital) we use the 0-10 scoring system where 0 represents the patient being pain free and 10 being the worst pain possible. The policy included a, Wong -Baker Faces Pain Rating Scale and pain at a rating of 10 had a face crying with hurts worst underneath the face. This was a visual analog score for those with limited communication skills. The policy indicated for severe pain the drugs of choice were Morphine 5 mg IM (intramuscularly) or IV; Hydromorphone 1 mg IM/IV or Fentanyl 100 mcg (micrograms) IM/IV. Nursing Standing Orders 1. Registered nurses as approved by (name of facility), may administer analgesic therapy who present to the emergency room in acute pain. 2. The nurse will: a. Assess pain and determine whether the pain is considered mild, moderate or severe. b. determine whether the patient has any medication allergies and select the most appropriate analgesic to which the patient is not allergic. c. may administer an initial dose of medication as indicated in (name of facility) pain management table if a physician is not readily available... d. will monitor the patient for any beneficial or untoward effects that result from medication administration. 3. The medication will be considered a verbal order from the Emergency Department physician who is ultimately responsible for the patient's care. 4. Subsequent doses of narcotics will not be administered without physician evaluation and order... Review of the ED records for Patient #35 from Hospital B dated 6/2/12 revealed the following: -Patient #35 arrived at the ED via wheelchair at 10:40 PM. -The patient was triaged at 10:40 PM and given Dilaudid 1 mg. IV push (P) and Zofran (for nausea) 4mg. IVP. At 12:20 PM the patient was administered Zosyn (an antibiotic) 4.5 grams every 8 hours IV piggy back. -Patient #35 had a laboratory work-up, a CT scan of the abdomen and pelvis and an electrocardiogram (EKG) on 6/2/12. -The CT completed on 6/2/12 for Patient #35 reported acute appendicitis with peritoneal abscess. -Patient #35 underwent surgery on 6/3/12 at 2:58 PM. -Patient #35 was diagnosed on [DATE] at 12:22 AM with acute appendicitis and [DIAGNOSES REDACTED]. In summary -Patient #35 arrived at the ED of Hospital A on 6/2/12 at 8:57 PM with complaints of abdominal pain and nausea. The patient was given an acuity level of 3 -Patient #35's pain was assessed at a 10/10 during the nurses assessment. -Patient #35 had a RME by the Nurse Practitioner. however, the patient did not have a complete medical screening. -Patient #35 had lab work and a CT scan completed. -Patient #35 was sent to the waiting room after the CT scan was performed. -Patient #35's family member complained to the triage nurse that the patient needed something for pain several times. The family indicated Hospital A was not doing anything for the patient and left the ED -A Security Officer notified the nurse Patient #35 was in the parking lot with his IV still in place. The nurse removed the IV and Patient #35 left the ED by car. -The documentation on disposition indicated Patient #35 was in distress, had a pain level of 10/10 and the CT scan reported Patient #35 had an acute appendix with perforation. -Patient #35 was taken to Hospital B. There patient arrived at 10:40 PM was assessed and given pain medication and medication for nausea at 10:40 PM. -Patient #35 had lab work a CT scan and an EKG on 6/2/12. -The CT scan reported acute appendicitis with peritoneal abscess. -Patient #35 was admitted to inpatient on 6/2/12 at 12:20 AM -The patient underwent surgery on 6/3/12 for ruptured appendicitis. -Patient #35 was discharged from Hospital B on 6/8/12. Based on observation, interviews, medical record and policy review, the facility failed to ensure two patients had completed and stabilized psychiatric (#22) and medical treatment (#35) before their disposition. Patient #22 The Clinical Report- Nurses for Patient #22 indicated the patient arrived by ambulance on 6/4/12 at 10:50 PM and was triaged at 11:09 PM at an acuity level 2. The Clinical Report-Nurses for Patient #22 dated at 11:18 PM, documented,...The patient exhibited bizarre behavior. Patient #22 was found at (name of casino) and called 911. The patient indicated someone was trying to kidnap her and her daughter... The notes indicated Patient #22 pulled the fire alarm at the casino. Patient #22 then ran from the police with her six year old daughter. The notes documented Patient #22 told the EMS (Emergency Medical Services) her daughter was poisoned by the child's grandfather. The Clinical Report-Nurses for Patient #22 dated 6/4/12 at 11:18 PM revealed the following: - ...EMS unable to obtain vital, IV (intravenous) BS (blood sugar ?) due to patient paranoia. - Abuse history: patient reports, physical abuse by significant other and parent against patient and patient's daughter ED (emergency room ) physician notified and police. - Security at bedside for 4 point restraints. Nurse took belongings away from patient and put at nurses station. Patient was changed into blue scrubs. - 23:25 (11:25 PM) - INTERVENTIONS ID (identification) and allergy band on patient. To treatment room. - PHYSICAL ASSESSMENT 23:26 (11:26 PM) 06/04/2012. To room via stretcher. Alert. Affect appears normal. Patient appeared calm and cooperative. Patient appears well-nourished and unkempt. Respirations not labored. Breath sound within normal limits. Abdomen soft and nontender. Bowel sounds within normal limits. Capillary refill less than 2 seconds. Skin warm and dry skin within normal limits. - NURSE PROGRESS NOTES 23:27 (11:27 PM) 06/04/2012. Patient identifiers checked. The initial plan of care for this patient had been created. Pulse oximeter and NIBP monitor placed on patient; monitor alarms on. (PATIENT IN FOUR POINT RESTRAINTS BY SECURITY). Call light in reach. Side rails up x (times) 2. Bed placed in lowest position. Breaks of bed on. - 23:39 (11:39 PM) IV (intravenous) access: site #1 left antecubital space, 18g (gauge) angiocath (catheter), with aseptic technique and good blood return; one attempt. Blood drawn. Labeled in presence of patient and sent to lab (laboratory). Lock flushed with 10 ml (milliliters) of saline (child protective services at bedside). - 00:14 (12:14 AM) 6/5/2012 (Patient removed restraints, nurse went to get medications for patient and patient left the ED)... A Nurses Note dated 6/5/12 at 12:19 AM documented, Missing from room 23 seen running out of the fire exit a few minutes earlier by a visitor. An Initial Order Form (first 24 hours) Non-Violent/Non-Self Destructive Restraint Order dated 6/4/12 at 11:09 PM, for Patient #22 was written and signed by a physician. The restraint justification box on the form documented, ...Impulsive or unpredictable behavior i.e. traumatic brain injury... The restraint limit was for 24 hours. The restraint devices included full siderails. In the box that indicated check which device in use the box on the form checked was, bilateral wrist restraints... On 6/4/12 at 23:12 (11:12 PM), The Clinical Report-Physicians/Mid levels for Patient #22 indicated the following: ...Arrived by ambulance. Historian patient and EMS personnel. - History of present illness-Chief Complaint-BEHAVIOR CHANGE. This started today. - The patient has exhibited a behavioral change. (Pt. (patient) called 911 at (name of casino) and presented bizarre behavior trying to run from police and stating people are after her and her daughter. Pt. states her father hired an assassin to kill her). She has anxiety. Has exhibited unusual behavior and been paranoid. The patient has had persecution delusions. No suicidal attempts. - The symptoms are described as moderate. No injury present. - Similar symptoms previously: none. - Past History-See nurses notes unknown. Unobtainable due to patient's uncooperativeness. - Social history-Smoker current status unknown. - Physical exam: Psych/Neuro (psychiatric/neurology) Oriented x 3 Appears to have persecution delusions. Denies suicidal thoughts. The patient does not feel treatment is necessary. No motor deficit. No sensory deficit. - PROGRESS AND PROCEDURES Course of care: BP (blood pressure) 136/82 lying down r (right) arm auto. (automatic) HR: (heart rate) 119. RR: (respiratory rate) 20. Temp (temperature) 98.0 oral. 02 (oxygen) saturation on room air 100%. - 00:14 (12:14 AM) Ativan IV 2 mg. (milligram) Haldol IV 5 mg. Benadryl IV 50 mg - 1:02 AM- Patient removed 4-pt. (point) restraints (restraints on wrists and ankles) and eloped from the ED. - pt. delusional, abnormal thought pattern. Seems very nervous as well. Will uphold L2K (Legal 2000-The State of Nevada's legal civil commitment). - pt. eloped prior to being able to fill out L2K. - Transfer orders written. - Disposition: Transfer to DOU (Discharge Observation Unit for psychiatric patients awaiting completion of mental health assessments). Condition stable CLINICAL IMPRESSION Acute psychosis with paranoia... The Toxicology lab results of Patient #22 collected at 6/4/2012 at 23:37 (11:37 PM) and message received as final results on 6/5/12 at 2:05 AM indicated, positive for Amphetamine/Methamphetamine and Cannabinoids. The T-System Order Summary-Order Sheet for Patient #22 dated 6/4/12 at 22:31 (11:31 PM) documented the patient was placed on suicide precautions. Patient #22's Suicide Risk Factor Scale and Observation Intensity Trigger dated 6/4/12 at 23:09 (11:09 PM) was assessed at an 11 (4-11 moderate risk precautions) which required hourly welfare checks. The form was incomplete, not all the risk factors were filled out. The Precaution Monitoring Flow Sheet (11 PM-7 AM) dated 6/4/12 to 6/5/12, for Patient #22 indicated the following: Visual Appearance: Behavior 2315 (11:15 PM) WORRIED ANXIOUS 2330 (11:30 PM) WORRIED ANXIOUS 2345 (11:45 PM) WORRIED ANXIOUS 0000 (12:00 AM) WORRIED ANXIOUS 0015 (12:15 AM) WORRIED ANXIOUS Patient #22 was listed as being in room 23. The Registered Nurse signed her initials after each entry in the visual appearance/anxious boxes. On 6/21/12, review of the ED log dated 6/4/12, indicated Patient #22 was placed in the mini DOU. On 6/21/12 in the afternoon, the Manager of Emergency Services indicated the mini DOU was an area in the ED with six beds where psychiatric patients were placed when there was no room in the DOU. There was one Registered Nurse (RN) for four patients and a RN and a Certified Nurses Assistant for six patients. The expectations for observation of the patients were the same as the DOU. which included continuous monitoring. On 6/22/12 in the afternoon, the Director of the ED indicated Patient #22 was on a gurney located on Hall 10 (in the ED hallway between room 39 and the ED anteroom). They were waiting to move the patient into a room. Patient #22 had changed into blue scrubs ( colors used for psychiatric patients) and hospital socks. The Director of the ED indicated Patient #22 was transferred to Room 23 due to the DOU and the mini DOU were filled on 6/4/12. The Director of the ED indicated there was no policy for the mini DOU. The Director of the ED indicated Patient #22 was not on a one on one. The Director of the ED indicated Patient #22 was on every 15 minute checks and visual checks. Room 23 was observed on 6/22/12 in the afternoon, the room consisted of one bed. There were approximately 27 steps from room 23 to the fire exit which led out to the area where the ambulances parked. The fire door was on a delayed alarm. On 6/22/12 in the afternoon, The Manager of Public Safety explained the procedure when a patient who was unstable eloped. When an adult patient eloped a call was placed to security to inform them a patient was missing. A copy of the facesheet was given to security in order to assess if the patient's family knows the whereabouts of the patient. If security was unable to find the patient the police department was notified and it was broadcast to the police officers to see if they were able to find the patient. The Manager of Public Safety indicated if a patient eloped with AMS (altered mental status or was on an L2K, then they would call a Code Walker. This would be announced over the call system of the facility and the Public Safety department would give a description to all employees who had the responsibility to look for the patient. On 6/22/12 in the afternoon the Manager of Public Safety indicated an adult elopement procedure was followed in order to find Patient #22. The Manager of Public Safety indicated Patient #22 was not found. The patient's six year old daughter who was placed in the pediatric ED was removed by Child Protective Services on 6/5/12. On 6/22/12 in the afternoon, Security Officer #1 indicated he placed the four point soft restraints on Patient #22. The Officer indicated Patient #22 was a thin small person who weighed about 90 pounds. The officer indicated he did not want to put the restraints on too tight, he could understand how Patient #22 might have removed them. He indicated Patient #22 was more worried about her computer that was confiscated than anything else. Policy #EDADM11-EMERGENCY DEPARTMENT-THE DIFFICULT PATIENT ...Purpose To provide guidelines for the management of the patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems. Scope Adult Emergency Department Policy A. Patients who may be manifesting behaviors due to the influence of alcohol, drugs or emotional problems will be treated with care and dignity in a safe secure environment. 1. A suicide risk assessment and a 15 minute checklist are required at the time of arrival to the Emergency Department (ED). B. All patients will be triaged and assigned a room in accordance with patient care requirements and established policy. C. Should restraints be necessary, they will be applied by the Public Safety staff and in accordance with the hospital policy, using the least restrictive method of restraint to maintain safety of the patient and others with stretcher/gurney siderails raised. F. Patients who are placed on legal hold status (aka L2K) may have specialized care to maintain their safety and dignity: 1. All patient belongings are secured and stored
Based on the findings at A2404 and 2406 the facility failed to ensure compliance with CFR 489.24.
Based on record review, interview and document review, the facility failed to ensure the physician on-call list accurately reflected coverage for ENT (Ear, Nose, and Throat) services which resulted in an inappropriate transfer for 1 of 32 sampled patients (Patient #8). Findings include: Record Review Hospital A Review of Patient #8's medical record on 1/25/12, revealed the patient presented to the emergency room (ER) on 11/8/11 at 14:13 (2:13 PM) with complaints of a severe headache (10/10 pain level). The patient's history indicated the patient had a CSF (Cerebral Spinal Fluid) leak for several months and had seen Physician #2 (ENT) on an outpatient basis. On admission to the ER, Patient #8's vital signs were recorded as temperature - 99.4 degrees. At 17:30 (5:30 PM), the patient's temperature was noted to be 102.2 degrees orally. Laboratory results were drawn and revealed the Patient's WBC (White Blood Count) was elevated to 16.03 (Normal value 3.91 - 9.68). Documentation in Patient #8's physician notes dated 11/8/11 documented: - 15:43 (3:43 PM) No ENT on call. Will transfer to Hospital B. - 17:56 (5:56 PM) DW (Discussed with) Physician #3 (ENT), ABX (Antibiotics) appropriate for CSF leak. Calls placed to health care provider Physician #2, ENT. Multiple messages left; calls not returned. Consult obtained with Physician #3, ENT at 16:36 (4:36 PM). Wants to transfer pt (patient) to Hospital B. Phone consult only.... Patient #8's record revealed the patient was transferred to Hospital B at 1905 (7:05 PM). Interview with Physician #1 (ER) On 1/25/12 at 4:30 PM, an interview with Physician #1 revealed he was the ER physician who treated Patient #8 on 11/8/11. The ER physician indicated: based on a) the presenting symtoms of the patient, which included a severe headache & CSF leak from the nares; b) results of the laboratory tests which showed an elevated WBC; and c) the patient's elevated temperature; the patient required an evaluation from an ENT physician to treat the CSF leak. The ER physician indicated based on all the presenting symptoms, he believed Patient #8 could possibly have meningitis. The ER physician verbalized since Patient #8 was being seen as an outpatient by Physician #2 (ENT), the ER physician attempted to contact the ENT multiple times, but was not successful. Since there was no Otolaryngeal (ENT) Physician On-Call on 11/8/11, according to the posted schedule, Physician #1 then contacted Physician #3, ENT, for a telephone consultation to discuss the appropriate antibiotics for the patient's CSF leak. Physician #1 decided to transfer Patient #8 to Hospital B for an ENT consultation since he believed the patient needed to be seen quickly by an ENT physician to have the CSF leak repaired. Physician #1 was asked why he did not admit the patient to Hospital A to be treated for the meningitis by an Internist, Infectious Disease physician, and an ENT physician (Physician #2), he indicated he was not aware Physician #2 had privileges at Hospital A, and he believed an ENT evaluation needed to be done right away to correct the CSF leak. Physician #1 verbalized he did not speak to the accepting physician at Hospital B. The Physician added all transfer arrangements were made by the intake coordinator. Interview with Physician #2 On 1/26/12 at 2:25 PM, Physician #2 (ENT) was interviewed by telephone. The physician indicated he had been treating Patient #8 as an outpatient. Physician #2 verbalized he had a conversation with Physician #1 (ER) on 11/8/11 when Patient #8 presented to the ER. Physician #2 verbalized he communicated to the ER physician that the patient did not require an ENT evaluation at that time. Physician #2 believed the patient should be evaluated for the headache, should be admitted , and have an Infectious Disease Physician follow her as an inpatient. Physician #2 added, he would not perform any nasal procedures on Patient #8 until the symptoms of the infection were cleared. Interview with Physician #3 On 1/26/12 at 3:10 PM, an interview with Physician #3 by telephone revealed he had been called by Physician #1 for a telephone consultation only, regarding the appropriate antibiotics to administer to Patient #8, for a CSF leak. Physician #3 added he was not on call in the ER at the time he received the telephone call. Physician #3 revealed he had been out of town doing surgery when he first received the call from Physician #1. The physician added he gave Physician #1 several alternatives to treat Patient #8 including: transferring the patient to Hospital B, if Physician #1 believed the patient needed ENT consult and treatment immediately; contact the physician treating Patient #8 on an outpatient basis, and have the patient admitted and evaluated by Infectious Disease; or, the ER physician could admit the patient until the patient could be seen by an ENT physician. Physician #3 verbalized he did take call on 11/8/11, since he came in to see several patients at Hospital A. The physician added he was not sure of the time he placed himself on call for 11/8/11. Physician #3 added, on 11/9/11, he notified the scheduler to retroactively add him on call for 11/8/11. Interview with Vice President of Quality and Medical Staff On 1/25/12, in the afternoon, the Vice President of Quality and Medical Staff verbalized the facility did not provide on-call services for Otolaryngology (ENT). Physician #3 did take call at times based on his schedule. However, the services were not always available. When a patient in the ER required an ENT consult and there was no ENT physician on call, the patient was transferred to another facility for the service. On 1/26/12, in the afternoon, the VPQMS revealed the original Otolarygology Physician On - Call List did not indicate any physician on call for 11/8/11. The VPQMS verbalized Physician #3 had added himself to the call schedule after he had received the telephone call regarding Patient #8. The VPQMS added Physician #3 notified the scheduler on 11/9/11, to retroactively place him on call for 11/8/11. The on-call list was updated on 11/9/11 to reflect the change. On 1/27/12 in the morning, the VPQMS indicated Physician #3 had notified the ER staff at 6:00 PM on 11/8/11, that he would assume call at that time. Then on 11/9/11, the physician notified the scheduler in medical staff to update the call log to indicate he was on call for 11/08/11. The VPQMS added Infectioius Disease physicians did not take call in the ER. They only saw patients once they have been admitted to the facility. Document review Review of the physician credentialing files revealed both Physician #2 and Physician #3 had ENT privileges at Hospital A. Information provided by the Regulatory Compliance Coordinator revealed Physician #3 was the only Otolaryngologist who had signed a professional services agreement to provide ENT call coverage for Hospital A. The facility's policy titled Emerency Department On-Call Schedules last review date 7/2011, indicated Policy - I. General ...The Medical Staff Office (the MSO), in collaboration with the clinical department/division chairpersons and/or trauma medical directors, coordinated and publishes on-call rotation schedules on a monthly basis for the following clinical practice areas: Adult Services: - Cardiology - Medicine (hospitalist service) - Medical Intensive Care (critical care) - Neurology (adult) - Obstetrics/Gynecology Hospitalist - General Orthopedic Surgery (includes separate pelvic call) - Primary Care Outpatient Referral - Spine Surgery - Urological Surgery Combined Adult and Pediatric Services: - Trauma Anesthesia - CVT (Cardiovascular Thoracic) Surgery - Hand Surgery - Neurosurgery - Oral/Maxillofacial Surgery - Plastic Surgery - General Trauma Surgery - Opthalmology... Panels Without 24/7 Availability - Otolaryngology (ENT) (pediatric and adult)... II Medical Staff Department Responsibilities A. ...2. Unless otherwise noted on a particular schedule, the call assignments are for a 24-hour period from 7:00 a.m. to 7:00 a.m.... B. Schedule changes - Any changes requested to be made to a published call schedule must be submitted to the MSO no less than 24 hours prior to the scheduled assignment. Any call changes must be submitted on the prescribed Emergency Department Call Change Form... C. After MSO Business hours - After regular business hours (7:30 am to 4:00 pm Monday through Friday), on weekends or holidays, call changes should be submitted by the on-call provider to the Emergency Department. The Emergency Department HUC (Head Unit Clerk) is responsible for completing the Physician ER Call Daily Change Log (Attachment B) communicating any changes to the call schedule(s) to the MSO within 24 hours of the change. This form is to be faxed by the night shift ED HUC to the MSO at 6:00 a.m. daily. The ED HUC will also be responsible to immediately call any assignment changes to the Intake Coordinator.... The Medical Staff General Rules and Regulations, approved on 7/21/11, section 3.13 Response to Call indicated: - 3.13.8 When an on-call physician is contacted by the Emergency Department and requested to respond, the physician must do so within a reasonable time period. The following guidelines have been established for responding by phone to a call from the emergency department or any nursing unit: A. Stat calls : twenty (20) minutes B. Routine Calls: one (1) hour - 3.13.9 The Emergency Department physician, in consultation with the on-call physician, shall determine whether the patient's condition requires the on-call physician to see the patient immediately. The determination of the Emergency Physician shall be controlling in this regard. On 1/25/12, the Vice President of Quality/ Medical Staff (VPQMS) provided several versions of the Otolaryngology On Call schedule dated 11/8/11. Review of the original Otolaryngology (ENT) Physician Call Schedule dated 11/8/11, revealed Physician #3 was on call every day in November except 11/8 - 11/10, 11/15 - 11/16, and 11/29 - 11/30. The ENT Physician Call Schedule dated 11/8/11, indicated there was no ENT physician on call for 11/8/11. The Otolaryngology Call schedule revised 11/9/11 at 1145, indicated - Physician #3 was on call on 11/8/11, and documented Change called in after the call (telephone call regarding Patient #8) was taken per Doctor (Physician #3). There was no documented evidence Physician #3 completed a change in call schedule form for 11/8/11. There was no documented evidence of the time Physician #3 officially placed himself on call on 11/8/11. Patient #8's record revealed the patient was transferred to Hospital #B at 1905 (7:05 PM). There was no documented evidence Patient #8 was seen by an ENT physician while she was in the ER of Hospital A, although Physician #3 was placed on call at approximately 6:00 PM. Since Patient #8 had a CSF leak and several options were proposed regarding treatment of the patient, all physician on-call schedules were reviewed to determine if other specialties were available to evaluate and treat the patient. The On-Call logs indicated Internal Medicine, Neurology, Spine Surgery, and Neurosurgeon specialists were all available for ER Call, if requested. In summary: - Patient #8 was seen in the ER at Hospital A with a severe headache, CSF, elevated temperature and elevated WBC; - Possible diagnoses was meningitis (as per the interview with Physician #1); - Conflicting opinions were obtained regarding the course of treatment; - The Otolaryngology Call Schedule was not accurate; - The ENT physician provided a telephone consultation regarding Patient #8, then placed himself on call later in the same day; - Patient #8 was still in the ER at the time Physician #3 placed himself on call. - Patient #8 could have been admitted to Hospital A and treated for the meningitis by an internist, Infectious Disease physician, and ENT if needed. - The services could have been provided at Hospital A (Complaint #NV 239)
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review, the facility failed to ensure an appropriate medical screening examination was conducted for 2 of 32 sampled patients (Patient #8, #32). Findings include: Patient #8 Patient #8 arrived by private vehicle to Hospital A on 11/8/2011, with complaint of a headache. The patient was diagnosed with [DIAGNOSES REDACTED] Record review Patient #8's Clinical Report-Nurses form indicated Patient #8 was triaged on 11/8/2011 at 14:00 (2:00 PM). The form documented the following: ...Chief complaint: (HA (headache) NEUROLOGIST DX'D (diagnosed ) CSF LEAKAGE). 14:13 (2:13 PM). BP (blood pressure) R (right) arm sitting 150/84 HR (heart rate): 95 RR (respiratory rate): 18 (unlabored) Temp (temperature) 99.1 oral. O2 (oxygen) SATURATION: 100% air. Alert. No acute distress. ...History-This started today. Onset (6 hours ago) Pain level now:10/10... ...PHYSICAL ASSESSMENT 14:38 (2:38 PM) Appears in pain, anxious and in distress. Pupils equal, round and reactive to light. No facial asymmetry noted. Respirations not labored. breath sound within normal limits. Normal sinus rhythm noted. abdomen soft and nontender. Pulses within normal limits. Mucous membranes are pink. Skin is warm and dry... ...14:25 (2:25 PM) O2 saturation: 93% room air PLACED AT MOUTH (CSF LEAKAGE THRU NOSE). O2 started via nasal cannula at 3 liters/minute. RN (Registered Nurse) notified... ...14:50 (2:50 PM) BP: 142/69 HR: 98 O2 saturation -95 percent on nasal cannula at 4 liter/minute... ...17:30 (5:30 PM) late entry-. Temp 102.2 oral... ...18:04 (6:04 PM) TYLENOL 975 mg (milligrams) PR (per rectum)... ...18:58 (6:58 PM) Temp 98.7 oral... ...DISPOSITION/DISCHARGE 16:51 (4:51 PM) BP: 132/64. HR: 107. RR: 15. Temp: 102.2. ...departure time: 19:50 [DATE]... Patient #8's EMTALA (Emergency Medical Treatment and Labor Act) MEMORANDUM OF TRANSFER dated 11/08/2011 documented the following: RISKS AND BENEFIT FOR TRANSFER: Obtain level of care/service unavailable at this facility service: ENT (ear, nose and throat) Consult... ...Time of transfer: 19:05 (7:05 PM). date: 11/8/11. Vital Signs Just Prior to Transfer: Temp 98.7 Pulse 107 R 14 BP 132/68 Time: 1644 (4:44 PM)... Patient #8's Clinical Report-Physicians form (by Physician #1) indicated the patient was seen on 11/08/2011 at 14:19 (2:19 PM). The form documented the following: ...Arrived by private vehicle. Historian patient and family... ...HISTORY OF PRESENT ILLNESS-Chief Complaint: HEADACHE. This started today 6 hours ago. It was gradual in onset and has been constant. Onset during rest. Is still present and now worse. It is described as pain. described as a global headache. No neck pain. At its maximum severity described as moderate. Modifying factors: relieved by nothing. Not worsened by anything. She has nausea and vomiting. No numbness... ...Similar symptoms previously: she had previous symptoms (intermittent for the last three months). These were worse... ...Recent medical care: The patient was seen recently by a health care provider (seen by (Physician #2) and sent here for CSF leakage). (ENT (ear, nose and throat) Physician #2)... ...REVIEW OF SYSTEMS No fever, ear pain, sore throat, head injury or difficulty breathing. No cough, abdominal pain, diarrhea or enlarged lymph nodes. All systems otherwise negative, except as recorded above... ...PAST HISTORY See nurses notes. Diabetes mellitus. History of chronic headaches. No history of heart disease or hypertension... CT (computerized tomography) of sinuses Scan dated 10/27/11 ...FINDINGS: there is suggestion of small miningocele/[DIAGNOSES REDACTED] along the roof of the right nasal passage. No significant contrast is appreciated within the nasal passage itself. There is a dense air-fluid level within the left maxillary sinus which could potentially represent a small amount of contrast within the left maxillary sinus although it is unusual that no contrast is seen elsewhere within the paranasal sinuses... ...There is asymmetric appearance of the pituitary gland in the right sella with the relative paucity of pituitary tissue in the left sella. No definite evidence of postop change... CT of head dated 11/8/11 ...IMPRESSION: Findings suggesting a small [DIAGNOSES REDACTED]/[DIAGNOSES REDACTED] at the roof of the right nasal passage. High resolution on coronal T2 MRI (magnetic resonance imaging) would also be helpful evaluation as clinically warranted... ...Abnormal appearance of the pituitary gland as described above. Consider MRI correlation... ...Findings discussed with Physician #2 on October 27, 2011. Facial CT performed with contrast...(CT scan done at outpatient facility on 10/27/2011). ...IMPRESSION: No acute hemorrhage or evidence of mass lesion or acute infarction. Head CT performed without contrast... (CT scan done in Hospital A on 11/8/11). ...Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process... ...PROGRESS AND PROCEDURES Course of Care: BP R arm sitting 150/84. HR: 95 RR: 18 (unlabored) Temp: 99.1 oral. O2 (oxygen) saturation 100 %... ...14:21 (2:21 PM) Dilaudid IV (intravenous) 1 mg (milligram) Zofran IV 8 mg Reglan IV 10 mg ...15:28 (3:28 PM) Clindamycin IV 900 mg... ...15:39 (3:39 PM) Droperidol IV 1.25 m (sic) ...15:43 (3:43 PM) No ENT on call will transfer to Hospital B... ...16:33 (4:33 PM) Spoke with family, pt (patient) has been having CSF leak for 3 months and today's headache was the worst. Pt. has no meningsmus. Neck is supple. ...17:56 (5:56 PM) vancomycin IV 1 gm (gram) DW (Discussed with) DR. (Physician #3), ABX (antibiotic treatment) APPROPRIATE FOR CSF LEAK.. Calls placed to health care provider (Physician #2), ENT. Multiple messages left; calls not returned. Consult obtained from ENT. (Physician #3) at 16:36 (4:36 PM) Wants to transfer pt to Hospital B. Case discussed. Phone consult only. Agree with treatment plan. Patient counseled in person regarding the patient's test results and diagnosis. Old ED (emergency department) records reviewed (last seen on 6/8/08 by (physician's name). dx: (diagnosis) Acute mental status change with confusion. Controlled type II diabetes Transfer orders written. Disposition: Transfer to Hospital B. Condition stable: stable CLINICAL IMPRESSION Headache. CSF leak... Patient #8's laboratory results dated [DATE], at 14:26 (2:26 PM) reported a white blood count of 16.03 (normal 3.91-9.68) and the Hematology Differential dated 11/08/11 at 14:26 (2:26 PM), documented, ...Bandemia is present... Interview with Physician #1 On 1/25/2011 at 4:30 PM, Physician #1 indicated Patient #8 came in to the ER on 11/8/11 with complaints of a persistent headache. Patient #8 was known to have a history of a cerebral spinal fluid leak. The patient brought in a CT scan she had performed previously. Physician #1 indicated he tried to contact the ENT physician (Physician #2) who had been treating the patient for months and knew about the patient's CSF leak. Physician #1 indicated he was unable to reach Physician #2 who was at a conference. Physician #1 called Physician #3 who was also an ENT physician. Physician #1 indicated Physician #3 was in Bullhead City doing surgery. Physician #1 asked Physician #3's advice on what antibiotic to give the patient. Physician #3 indicated vancomycin was the antibiotic of choice for a CSF leak. Physician #1 indicated a lumbar puncture was not necessary to perform on Patient #8, since there was an obvious source of the CSF leak (Patient #8's nasal passage). Physician #1 indicated the CSF leak needed to be fixed by an ENT physician regardless of the infection. When asked why Patient #8 was transferred if Physician #2 had privileges, Physician #1 indicated he was not aware Physician #2 had privileges, and Physician #2 wanted the patient transferred. Also, Physician #3 recommended the patient be transferred. Physician #1 indicated there were different ENTs who were specialized in surgery to repair a CFS leak such as Patient #8 had. Physician #1 indicated Patient #8 was not running a temperature when he first examined her. Physican #1 did not feel the patient's white blood cell count of 16,000 was a cause for concern. Physician #1 indicated Physician #2 wanted the patient transferred (Physician #1 indicated he did speak to Physician #2 later in the day). Physician #1 indicated Physician #2 was pretty, nonchalant about the transfer. Physician #1 indicated he felt very uncomfortable leaving the patient at Hospital A, since there was no ENT on call at Hospital A. Physician #1 indicated he did not speak to a physician at Hospital B, he indicated the intake coordinator made the arrangements with the receiving hospital. Interview with Physician #2 On 1/26/11 at 2:25 PM, Physician #2 indicated by telephone that Patient #8 was referred by another ENT physician who felt the patient had a CSF leak. Physician #2 indicated the first time he examined Patient #8 was on 9/29/11. Physician #2 indicated Patient #8 had a work-up for the CSF leak about 12 months ago. The patient had an episode 5 years prior at Hospital A and they could not find the source of the leak. Physician #2 indicated Patient #8 had a CT scan as an outpatient in which dye was injected into the CSF to make sure no part of her brain was poking out. Physician #2 indicated the patient needed a 2nd study but did not get the 2nd study and showed up at Hospital A. Physician #2 indicated he did not direct Patient #8 to go to Hospital A. Physician #2 indicated someone did call him from the ER at Hospital A (did not remember physician's name). Physician #2 indicated he told the physician who called him, if the patient had meningitis she needed to be treated. Physician #2 felt that a lumbar puncture should have been done on Patient #8 at Hospital A. Physician #2 also indicated an MRI should have been done on Patient #8 to make sure no brain tissue was poking out. If indeed there was brain tissue, a neurosurgeon would need to get involved. Physician #2 indicated he thought Patient #8 was being treated at Hospital A for meningitis. Physician #2 indicated you would not need intervention by an ENT physician on someone who was infected. Physician #2 indicated he thought he made it very clear that the infection needed to be treated by a physician specializing in infectious disease or an internist with a neurology background. Physician #2 indicated a lumbar puncture should have been done on Patient #8 so cultures taken from the CSF leak would determine the appropriate antibiotic therapy. Physician #2 indicated he did not expect the patient to show up at hospital B. Physician #2 indicated he thought Patient #8 was being treated for the infection at Hospital A. Physician #2 indicated he would expect the patient to have a craniotomy when she recovered from the infection. Interview with Physician #3 On 1/26/11 at 3:07 PM, Physician #3 indicated by telephone he vaguely remembered the case. Physician #3 said he remembered the conversation he had with Physician #1 concerning Patient #8. Physician #3 indicated he was not on call on the morning of 11/8/11; Physician #3 indicated he was doing surgery in Bullhead City. Physician #3 indicated he advised Physician #1 to call a physician who specialized in infectious disease or the doctor who was treating the patient. Physician #3 indicated a lumbar puncture was feasible on possible meningitis; however, Physician #3 indicated a CSF leak could be caused by several things other than meningitis. Physician #3 indicated that vancomycin was the normal choice of antibiotic for a CSF leak. Physician #3 indicated he was quite sure he suggested an infectious disease physician be called for Patient #8 Physician #3 indicated he informed Physician #1 to get in touch with Physician #2. Physician #3 indicated he was going by what Physician #1 told him on the telephone. Physician #3 indicated, one would think if Patient #8 needed an ENT physician, the patient needed to be transferred to a hospital who had an ENT physician on call. Physician #3 indicated, a physician could not wait for the patient to get better to go in and repair the leak. Surgery would be required to fix the leak. Physician #3 indicated that he was pretty sure he explained to Physician #1 that he was out of town. Physician #3 indicated, the best case scenario was to transfer the patient and have an ENT physician treat her. The second best scenario was to have the physician who treated Patient #8 (Physician #2) see the patient at Hospital A. The third scenario was to have Physician #1 admit Patient #8 to Hospital A. Physician #3 indicated he came back in the evening from Bullhead City. Physician #3 indicated he did take on call later in the evening on 11/8/11 because he came in to see several patients at Hospital A. Physician #3 indicated Patient #8 needed to see an ENT physician. Physician #3 indicated if the patient saw a neurosurgeon, the surgeon would perform a craniotomy to repair the leak. A trained ENT physician could go through the patient's nose to do a repair on the CSF leak. Physician #3 indicated he recalled never hearing about that phone call again. Physician #3 indicated he was put on the schedule on 11/8/11, which made it seem like he was on call the whole day. Physician #3 indicated he did not get back into Las Vegas until about 6:00 PM. In summary: On 11/8/11 at 2:00 PM, Patient #8 was admitted to the emergency room at Hospital A with complaint of headache. - Patient #8 was seen by the emergency room physician who diagnosed the patient with a global headache and CSF leakage. -After consulting with an ENT physician by telephone he made the decision to transfer the patient to Hospital B, since there was no ENT physician on call. - The patient's temperature reached 102.2 Fahrenheit and white blood count 16,000. -It is unclear if there was an ENT physician on call. The on call schedule for 11/8/11 was changed several times to reflect when Physician #3 was actually on call by an administrative assistant. -Hospital A did not address the patient's meningitis and the need for a lumbar puncture. The patient's medical screening was incomplete and the cause of the headache was not treated. (Complaint #NV 239) Patient #32 Patient #32 signed in to the emergency room on [DATE] at 8:06 PM with complaints of abdominal cramps and vaginal bleeding. The triage note dated 9/23/11 documented the time the patient was triaged at 22:10 (10:10 PM) at a level 2 (emergent). These times were confirmed with the Director of Compliance on 1/27/11. The emergency room chart of Patient #32 lacked documentation as to why there was a delay in triage of the patient. A review of the Triage Policy: #EDADM12 last review date 3/2008 documented the following: ...PROCEDURE D. 2. A2 Emergent (EM) priority should be assigned to those patients who require a treatment room for definitive care to be rendered and for whom under optimal circumstances a delay of 15 to 60 minutes will not significantly affect the patient outcome. Patient should be informed that some delay may be experienced and a brief explanation should be given. Examples of patients who may receive a 2: Emergent priority are those who present with: j. Bleeding with abnormal vital signs... (Patient #32 had low blood pressure 103/59) Patient #32 had a medical screening and pelvic exam performed on 9/24/11 at 1:30 AM. The NURSES PROGRESS NOTES indicated Patient #32 had light amount of bright red. The PHYSICIAN CLINICAL REPORT dated 9/23/11 indicated time seen 1:23 AM 9/23/11. ...The patient had abnormal bleeding described as lighter than normal and passing clots... ...Patient has been having vaginal bleeding. She had a US (ultra sound) done 2 weeks ago that showed a live IUP (in utero pregnancy). US done last Friday showed no fetal heart tones. She should be 9 weeks pregnant. US shows no evidence of IUP. I discussed the result with the patient. She is given OB (obstetric) follow-up. I stressed the importance of following up... ...DISPOSITION: Condition stable. discharged in good condition... ...CLINICAL IMPRESSION Spontaneous abortion Missed abortion ...Follow up in two days even if well. Call for an appointment. Or your OB/GYN (gynecologist). Understanding of the discharge instructions verbalized by patient... The disposition of the patient was documented as 9/24/11 at 3:19 AM.
Based on findings at A2404, A2406, A2407, and A2409, the facility failed to ensure compliance with CFR 489.24.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on physician and staff interviews, record review, and document review, the hospital failed to maintain a list of physicians who were on call for duty to provide further evaluation and /or treatment necessary to stabilize an emergency medical condition for 1 of 33 patients (Patient#15). Findings include: Patient #15 Medical Record Review Patient #15 was a [AGE] year old who was seen in the ER of Hospital A (transferring Hospital) on 12/21/10 at 11:47 PM with complaints of right testicular pain, accompanied by vomiting, swelling and redness. Patient #21's history included a right hydrocele repair on 12/21/10 at Hospital A. Hospital A contacted Hospital B (receiving hospital) at 1:00 AM on 12/22/10, and requested Patient #15 be transferred due to the need for continued medical treatment by a Urologist. Hospital B accepted the transfer of Patient #15. Patient #15 was then transferred by ground transport, due to weather conditions, and arrived at Hospital B at 4:30 AM, as documented on the triage form. The ER physician's history indicated an Ultrasound (U/S) of the right testicle was performed at Hospital A which showed no blood flow to the right testicle. A repeat U/S was completed at Hospital B which indicated heterogeneous right testicle. No arterial blood flow identified compatable (sic) for torsion. There is however, some venous flow. Right scrotal fluid collection. The left testicle is unremarkable. Documentation on the Intake Coordinator Transfer Flow Sheet on 12/22/10 at 6:40 AM indicated Urology refused to see pt (patient). Peds (Pediatric) ED called (Dr. Name). (ED Dr. Name) even trying general surgery. Called Hospital C (2nd Receiving Hospital). Spoke to AOD ...She will accept patient. Consent was obtained for transfer of Patient #15 and the patient was transferred to Hospital C at 7:10 AM for follow up by a Pediatric Urologist. Document Review Review of Hospital B's Specialist Call Schedule for December 2010, revealed there were no pediatric urologists on-call for the month. There was documented evidence a urologist was on call for the adult ED (Emergency Department) and for trauma on 12/22/10. Hospital B's Transfer Checklist had no documented evidence the ER Physician #1 had accepted Patient #15 since the section for PCP (Primary Care Physician) acceptance was left blank. Interviews - On 2/18/11 at 3:50 PM, the Vice President of Quality and Medical Staff, (VP of Q&MS) indicated that a call was placed to the adult on-call urologist on 2/18/11. The adult urologist indicated to the VP of Q&MS he remembered the call on 12/22/10, and indicated he was not on-call for pediatrics and only on-call for adults and trauma. The VP of Q&MS verbalized a review of the urologist's contract did not specify a specific age group the urologist would or would not treat. The VP of Q&MS also indicated research was done to review the cases the on-call adult urologist had performed during the 2010 calendar year. The VP of Q&MS indicated there was an elective case done by the On-Call Adult urologist on 9/16/10, which involved an orchiectomy on a [AGE] year-old patient. - On 2/18/11, the Intake Coordinator (IC) and Chief Operating Officer (COO) of the Children ' s Hospital (Hospital B) were interviewed to obtain additional information about the Intake Coordinator Transfer Flow Sheet. The IC indicated that during the intake process for accepting transfers from another facility, the intake nurse would have called the ED physician for approval. Documentation on Patient #15's Intake form revealed the registered nurse (RN) in the pediatric ED accepted Patient #15. The IC further acknowledged that the Night Shift Intake Coordinator, who was on duty for Patient #15's transfer, does know that there were no pediatric urologists on-call at that time of the transfer. The COO indicated that from the documentation on the transfer flow sheet, we were not sure if a pediatric urologist was available at the time of the referral. The COO indicated that pediatric urologists were called, however one was sick, another was out-of-the country and a third had scheduled cases during the morning of 12/22/10. The COO indicated none of the three pediatric urologists called were contracted for scheduled on-call services in the pediatric ED and revealed that in the past, pediatric urologists on staff at Hospital B would consult and/or accept patients from the ED. - On 2/24/11 at 2:44 PM, the ED physician at Hospital B, indicated he did not verbally accept Patient #15 and denied ever talking to the ED physician from Hospital A requesting the transfer. The ED physician indicated he reminded staff that there were no pediatric urologists on-call in the ED and didn't hear anything for hours. The ED physician then indicated Patient #15 showed up and an assessment was completed. With no urologist available to assess and treat Patient #15, the patient needed to be transferred again. The ED physician further indicated that attempts were made to get a pediatric urologist, but one had cases in the morning, one was very sick and the third was in Sri Lanka. The ED physician indicated the Urologist on call for the adult ED refused to assess Patient #15 because the testicular torsion was not due to trauma and the patient was a minor. The ED Physician added the case was even mentioned to a general surgeon passing through the ED. He finished by mentioning he had to harp on the charge nurse about not having pediatric urologists on-call. - On 2/28/11 at 5:00 PM, the Night Shift Intake Coordinator (NSIC) indicated she received a call from Hospital A's ED staff, asking for a transfer. The employee indicated once she received the call, she felt the case should go to the pediatric ED. The NSIC indicated at that time she called the pediatric ED and informed the nurse of the possible transfer, then transferred the call and hung up. The NSIC indicated at that time she was finished with the case, other than faxing the patient's facesheet to the ED. The NSIC further indicated Hospital B had pediatric urologists at one time. The employee did not decline the transfer because there was a possibility to get a urologist. She stated, I wanted to be sure we can help, so I transferred the call. The NSIC verbalized it was unknown what happened after the call was transferred. She stated, there must have been a communication breakdown. I heard the ED Physician at this hospital did not talk with the ED physician from Hospital A. The NSIC also mentioned she doesn't recall talking to the ED Physician at any time during the transfer process of Patient #15. Based on document review and interviews, the facility failed to ensure the specialist on-call schedule was accurate and staff informed of the current availability of all specialists available for ED Call.
Based on interview and record review, the facility failed to ensure an appropriate medical screening examination was conducted to rule out a psychiatric emergency prior to discharge for 1 of 33 patients (#11). Findings include:
Patient #11 Patient #11 was transferred to the emergency room by ambulance on 12/27/2010, for suicidal/homicidal ideations. The patient was diagnosed with alcohol intoxication and substance abuse (marijuana). Patient #11's Medic West Patient Care Record form indicated an ambulance treated Patient #11 on 12/27/2010. The form documented: -...Chief Complaint (Nature of the Emergency/Transfer) Suicidal/Homicidal Idealion(sic)... -...Clinical Impression: r/o (rule out) acute psychosis vs. ingestional behavior... -...Course PTA: pt (patient) found sleeping in park by park police, pt awake stating his wife kicked him out, exibiting suicidal/homicidal statements... Patient #11's Clinical Report - Nurses form indicated the patient was triaged on 12/27/2010, at 11:42 AM. The form documented: -...Chief Complaint: BIZARRE BEHAVIOR and (SUICIDAL/HOMICIDAL(THREATENED HIS WIFE---)... -...NURSING PROGRESS NOTES 11:50 AM...Suicide precautions initiated:q (every) 15 min checks performed. See restraint documentation (placed into 4 point restraints by Security). (examined by (physician name))... Patient #11's Physician Clinical Report form dated 12/27/2010, indicated the patient was examined by the physician at 11:48 AM. The form documented: -...HISTORY OF PRESENT ILLNESS Chief Complaint - BEHAVIOR CHANGE and AGITATED, ANGRY and AGGRESSIVE. This started today. He has experienced situational problems related to significant other. The patient exhibited a behavior change. He has been angry and aggressive. Recent alcohol consumption. Last drink was less than 24 hours ago. The patient was not found wandering. Has been very angry. Has exhibited unusual behavior but been eating or sleeping. No self-injury inflicted. The systems are described as moderate. No injury is present. pt denies SI/HI (suicidal/homicidal ideations), states that he was sleeping in the park, and metro awoke him... -...REVIEW OF SYSTEMS The patient has had altered mental status: hostile and combative... -...PHYSICAL EXAM Appearance : Alert. Appearance is normal. The patient is restless and appears hostile and agitated. He shows no apparent trauma but is not ill appearing or toxic appearing or uncooperative... Patient #11's ADULT ED LEGAL HOLD (2000) ORDERS form was signed and dated by the physician on 12/27/2010, at 1415. The physician ordered for Benadryl, Haldol, and Ativan to be given as needed. The form had a check mark in the box that read: -...Safe discharge when alert, oriented, able to safely ambulate without assistance and tolerate oral intake... Patient #11's Adult ED (emergency department) Suicide Risk Factor Scale and Observation Intensity Trigger form was not dated or signed. The form was initiated but was not completed. The risk factors and points in each column were not completed. There was no total score completed to determine what risk level the patient rated. On 2/18/2011, in the afternoon, the Adult Emergency Department Nurse Manager indicated the Adult ED Suicide Risk Factor Scale and Observation Intensity Trigger form was not complete. Patient #11's Toxicology report documented Alcohol Blood for the patient was 248 mg/dL (milligrams/deciliter) (D) on 12/27/2010, at 1245 PM. The form documented: -...(D) Plasma ethanol levels are 10 - 35% greater than whole blood alcohol levels. A plasma ethanol level of 10-110 mg/dL approximates the >0.08% which legally defines sobriety. Coma may occur when plasma ethanol reaches 300 mg/dL, and death may result when levels exceed 400 mg/dL... Patient #11 had a urine toxicology screen completed on 12/27/2010 on 1440 (2:10 PM). The screen was positive for Cannabinoids. Patient #11's Monitor for Use of Restraint - DOWNTIME form dated 12/27/2010 indicated at 1200, 1300 (1:00 PM), and 1500 (3:00 PM) the patient was combative. The restraints were removed sometime after 4:00 PM. On 12/27/2010, at 1811 (6:11 PM), Patient #11 was transferred to the DOU (discharge observation unit). The DOU area was located away from the emergency department area and was a locked unit to hold patients. In the unit there were small rooms. Each room was not enclosed but surrounded by 3 walls. The opening to the room had no door and led into a long corridor. One security staff member was always on the unit. There were individual cameras for every room in which the monitor was always observed by the staff. Patient #11's Clinical Report - Nurses form dated 12/27/2010, documented at 21:11 (9:11 PM): -...The patient was discharged home and unaccompanied at the time of discharge. The patient left the Emergency Department ambulatory and via (WILL WALK)... There was no documented evidence the patient was reassessed for suicidal/homicidal ideations after his restraints were taken off, after he became calm and cooperative, and before being discharged to go home. On 2/18/2011, in the afternoon, the Adult Emergency Department Nurse Manager indicated that the physical medical issues should be resolved first before reassessing the psychological status of the patient. The manager indicated Patient #11 was diagnosed with Alcohol Intoxication and Substance Abuse. The Manager indicated Patient #11's psychological status should have been reassessed when the resident had calmed down and was not highly intoxicated. On 2/18/2011, in the afternoon, the Adult Emergency Department Nurse Manager indicated there was no documented evidence that the patient was psychologically reassessed before his discharge. There was no documented evidence the resident was asked if he continued to have suicidal/homicidal ideations prior to his discharge. In summary: On 12/27/2010, at 11:21 AM, Patient #11 was transferred by ambulance to the hospital for possible suicidal/homicidal ideations. - The Patient was triaged by the nurse and assessed by the emergency room physician. The nursing notes indicated the patient was combative and placed in restraints. - The physician assessment, completed at 11:48 AM, indicated the patient was not suicidal or homicidal but he also indicated the patient was hostile and agitated. - The patient's alcohol level obtained at 12:45 PM, was elevated above 0.08% and also had a positive toxicology screen for cannabinoids at 2:40 PM. - The patient was diagnosed with alcohol intoxication and substance abuse. - Physician orders written at 2:15 PM, indicated to safely discharge the patient when the patient was alert, oriented, and was able to safely ambulate without assistance. - The nurse's notes indicated the patient continued to be restrained and combative until 4:00 PM. - There was no documented evidence that the patient was reassessed by the physician or nurse and asked if he had any suicidal or homicidal ideations after the restraints were discontinued and when he became calm and cooperative.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to provide continuation of treatment to stabilize an emergency medical condition for 1 of 33 sampled patients (#15). Findings include: Patient #15 Medical Record Review Patient #15 was a [AGE] year old who was seen in the ER of Hospital A (transferring Hospital) on 12/21/10 at 11:47 PM with complaints of right testicular pain, accompanied by vomiting, swelling and redness. Patient #21's history included a right hydrocele repair on 12/21/10 at Hospital A. Hospital A contacted Hospital B (receiving hospital) at 1:00 AM and requested Patient #15 be transferred due to the need for continued medical treatment by a Urologist. Hospital B accepted the transfer of Patient #15. Patient #15 was then transferred by ground transport, due to weather conditions, and arrived at Hospital B at 4:30 AM, as documented on the triage form. The ER physician's history indicated an Ultrasound (U/S) of the right testicle done at Hospital A, showed no blood flow to the right testicle. A repeat U/S was completed at Hospital B which indicated heterogeneous right testicle. No arterial blood flow identified compatable (sic) for torsion. There is however, some venous flow. Right scrotal fluid collection. The left testicle is unremarkable. Documentation on the Intake Coordinator Transfer Flow Sheet on 12/22/10 at 6:40 AM indicated Urology refused to see pt (patient). Peds (Pediatric) ED called (Dr. Name). (ED Dr. Name) even trying general surgery. Called Hospital C (2nd Receiving Hospital). Spoke to AOD ...She will accept patient. Consent was obtained for transfer of Patient #15 and the patient was transferred to Hospital C at 7:10 AM for follow up by a Pediatric Urologist. Document Review Review of Hospital B's Specialist Call Schedule for December 2010, revealed there were no pediatric urologists on-call for the month. There was documented evidence a urologist was on call for the adult ED (Emergency Department) and for trauma on 12/22/10. Hospital B's Transfer Checklist had no documented evidence the ER Physician #1 had accepted Patient #15 since the section for PCP (Primary Care Physician) acceptance was left blank. Interviews - On 2/18/11 at 3:50 PM, the Vice President of Quality and Medical Staff, (VP of Q&MS) indicated that a call was placed to the adult on-call urologist on 2/18/11. The adult urologist indicated to the VP of Q&MS he remembered the call on 12/22/10, and indicated he was not on-call for pediatrics and only on-call for adults and trauma. The VP of Q&MS verbalized a review of the urologist's contract did not specify a specific age group the urologist would or would not treat. The VP of Q& MS also indicated research was done to review the cases the on-call adult urologist had performed during the 2010 calendar year. She indicated there was an elective case done by the On-Call Adult urologist on 9/16/10, which involved an orchiectomy on a [AGE] year-old patient. - On 2/18/11, the Intake Coordinator (IC) and Chief Operating Officer (COO) of the Children's Hospital (Hospital B) were interviewed to obtain additional information about the Intake Coordinator Transfer Flow Sheet. The IC indicated that during the intake process for accepting transfers from another facility, the intake nurse would have called the ED physician for approval. Documentation on Patient #15's Intake form revealed the registered nurse (RN) in the pediatric ED accepted Patient #15. The IC further acknowledged that the Night Shift Intake Coordinator, who was on duty for Patient #15's transfer, does know that there were no pediatric urologists on-call at that time of the transfer. The COO indicated that from the documentation on the transfer flow sheet, we were not sure if a pediatric urologist was available at the time of the referral. The COO indicated that pediatric urologists were called, however one was sick, another was out-of-the country and a third had scheduled cases during the morning of 12/22/10. The COO indicated none of the three pediatric urologists called were contracted for scheduled on-call services in the pediatric ED and revealed that in the past, pediatric urologists on staff at Hospital B would consult and/or accept patients form the ED. - On 2/24/11 at 2:44 PM, the ED physician indicated he did not verbally accept Patient #15 and denied ever talking to the ED physician from Hospital A requesting the transfer. The ED physician indicated he reminded staff that there were no pediatric urologists on-call in the ED and didn't hear anything for hours. The ED physician indicated Patient #15 showed up and an assessment was completed. With no urologist available to assess and treat Patient #15, the patient needed to be transferred again. The ED physician further indicated attempts were made to get a pediatric urologist, but one had cases in the morning, one was very sick and the third was in Sri Lanka. The Ed physician indicated the Urologist on call for the adult ED refused to assess Patient #15 because the testicular torsion was not due to trauma and the patient was a minor. The ED Physician added the case was even mentioned to a general surgeon passing through the ED. He finished by mentioning he had to harp on the charge nurse about not having pediatric urologists on-call. - On 2/28/11 at 5:00 PM, the Night Shift Intake Coordinator (NSIC) indicated she received a call from Hospital A's ED staff, asking for a transfer. The employee indicated once she received the call, she felt the case should go to the pediatric ED. The NSIC indicated at that time she called the pediatric ED, and informed the nurse of the possible transfer, then transferred the call and hung up. The NSIC indicated at that time she was finished with the case, other than faxing the patient's facesheet to the ED. The NSIC further indicated Hospital B had pediatric urologists at one time. The employee did not decline the transfer because there was a possibility to get a urologist. She stated, I wanted to be sure we can help, so I transferred the call. The NSIC verbalized it was unknown what happened after the call was transferred. She stated, there must have been a communication breakdown. I heard the ED Physician at this hospital did not talk with the ED physician from Hospital A. The NSIC also mentioned she doesn't recall talking to the ED Physician at any time during the transfer process of Patient #15. Evidence through record review, document review and interviews, revealed Hospital B failed to provide continuation of treatment for Patient #15, with a diagnosis of testicular torsion. There were no pediatric urologists under contract for scheduled on-call services for the pediatric ED at the time of the transfer. The scheduled on-call urologist for the adult ED refused to accept Patient #15 due to the urologist's determination the testicle torsion was not due to trauma and the patient was a minor. Patient #15 had to be transferred for a second time to Hospital C to receive continued treatment which caused a delay in medical treatment for Patient #15.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on record review and interview, the facility failed to ensure the appropriate transfer forms were completed and medical records forwarded to the receiving facility for the transfer of 1 of 33 patients (Patient #17). Findings include: Patient #17 Patient #17 was an [AGE] year-old who (MDS) dated [DATE], with diagnoses of a left hip dislocation. Documentation in the physician's History and Physical (H&P) revealed the patient had hip surgery, Reduction of Slipped Capital Femoral Epiphysis and removal of 3 screws, three weeks prior to admission. The note indicated, Today, the patient was in school, standing outside on her crutches. A ball hit the patient's crutches causing her to fall on her left hip causing the hip dislocation. Documentation in the physician's progress notes indicated the ER physician did not call the pediatric orthopedic doctor on call but called the orthopedic doctor who performed the original surgery. The orthopedic doctor came in to see the patient, although he did not have privileges at this facility. The orthopedic doctor recommended the patient be transferred to another facility, where the doctor had privileges, and could re-perform the hip surgery. Based on the orthopedic surgeon's recommendation, Patient #7 was transferred to Hospital C. Documentation in the ER physician's History and Physical indicated the ER physician at Hospital B called the ER doctor at Hospital C, and the patient was accepted by the facility. There was no documented evidence in the medical record the transfer form was completed which indicated the patient was stable for transfer to the receiving facility, and the benefits of transfer outweighed the risk of transfer. There was no documented evidence the medical record was copied and sent with the patient to the receiving facility. Documentation in the nurse's notes indicated 19:50 (7:50 PM) Report was given to a nurse via a phone call... There was no documentation of the nurse's name at the receiving facility who received the report. On 2/18/11 at 1:00 PM, the Director of Regulatory Compliance confirmed there was no EMTALA transfer form completed.
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