Cape Fear Valley Hoke Hospital

“BLOOD TRANSFUSIONS AND IV MEDICATIONS CFR(s): Blood transfusions and intravenous medications must be administered in accordance with State law and approved medical staff policies and procedures. This Standard is not met as evidenced by: 26622 Based on hospital policy reviews, medical record reviews and interviews, the hospital staff failed to document blood transfusion vital signs per hospital policy for 2 of 2 sampled emergency department patients that received a blood transfusion (Patient #3 and #13). The findings include: Review on 10/09/2024 of the hospital policy titled “Blood and Blood Products Transfusion - Adult” effective date 07/03/2024 revealed “... Documentation: ...Routine Transfusion - Document vital signs at baseline, 15 minutes after the start, 55-65 minutes after the start (if applicable), and at completion/termination of the transfusion.” Review on 10/09/2024 of the hospital policy titled “Adult Nursing Admission Assessment and Reassessment...” effective 06/17/2023 revealed “... Vital signs include temperature, pulse, respirations, blood pressure and pulse oximetry...” 1. Review on 10/08/2024 of the medical record for Patient #3 revealed a 64-year-old female that presented to the Emergency Department on 09/29/2024 at 1536 with a chief complaint of shortness of breath. Review of the physician orders documented on 09/29/2024 at 1642 revealed an order to transfuse one (1) unit of PRBC (packed red blood cells). Review of the nursing flowsheet revealed the blood transfusion was started at 1830. The nursing flowsheet indicated that a complete set of vital signs were documented at baseline, 15 minutes after the start and at completion. Review of the nursing flowsheet revealed that a temperature and blood pressure were documented 55-65 minutes after the start. The record review failed to reveal documentation of a heart rate (pulse), respiratory rate (respirations) and pulse oximetry (level of oxygen in the blood) 55-65 minutes after the start of the blood transfusion. Interview on 10/09/2024 at 1455 with RN #1 revealed the staff were expected to document a full set of vital signs to include temperature, heart rate, respiratory rate, blood pressure and pulse oximetry during a blood transfusion. The expectation was for staff to document vital signs at baseline, 15 minutes after start, 1 hour after start and at completion of blood transfusion. Interview revealed the staff failed to follow the hospital policy. Interview on 10/09/2024 at 1625 with RN #2 revealed that a complete set of vital signs included a temperature, heart rate, respiratory rate, blood pressure and pulse oximetry. RN #2 indicated that a complete set of vital signs should be obtained during a blood transfusion at baseline, 15 minutes after start, 1 hour after start and at completion. 2. Review on 10/09/2024 of the medical record for Patient #13 revealed a 69-year-old male that presented to the Emergency Department on 09/29/2024 at 1952 with a chief complaint of shortness of breath. Review of the physician orders documented on 09/29/2024 at 2103 revealed an order to transfuse one (1) unit of PRBC (packed red blood cells). Review of the nursing flowsheet revealed the blood transfusion was started at 0218 on 09/30/2024. The nursing flowsheet indicated that a complete set of vital signs were documented at baseline, 55-65 minutes after the start and at completion. Review of the nursing flowsheet revealed that a temperature and blood pressure were documented 15 minutes after the start. The record review failed to reveal documentation of a heart rate (pulse), respiratory rate (respirations) and pulse oximetry (level of oxygen in the blood) 15 minutes after the start of the blood transfusion. Interview on 10/09/2024 at 1455 with RN #1 revealed the staff were expected to document a full set of vital signs to include temperature, heart rate, respiratory rate, blood pressure and pulse oximetry during a blood transfusion. The expectation was for staff to document vital signs at baseline, 15 minutes after start, 1 hour after start and at completion of blood transfusion. Interview revealed the staff failed to follow the hospital policy. Interview on 10/09/2024 at 1625 with RN #2 revealed that a complete set of vital signs included a temperature, heart rate, respiratory rate, blood pressure and pulse oximetry. RN #2 indicated that a complete set of vital signs should be obtained during a blood transfusion at baseline, 15 minutes after start, 1 hour after start and at completion. NC00183531, NC00191329, NC00201118”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 33790 Based on policy review, medical record review, and staff interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24. The findings included: 1. The hospital failed to provide a thorough medical screening examination within the capability of the hospital’s Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for one (1) of 37 sampled patients who presented to the DED. (Patient #3). ~cross refer to 489.24 (a) & 489.24 (c), Medical Screening Exam - Tag A2406 2. The hospital failed to provide an appropriate transfer for one (1) of 5 sampled patients transferred to other acute care hospitals. (Patient #29) ~cross refer to 489.24 (e)(1)-(2), Appropriate Transfer - Tag A2409”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 33790 Based on policy review, medical record review, and physician and staff interviews, the hospital failed to provide a thorough medical screening examination within the capability of the hospital’s Dedicated Emergency Department (DED), including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition existed for one (1) of 37 sampled patients who presented to the DED (Patient #3). The findings included: Review of hospital policy titled “Medical Screening”, effective date 01/02/2023, revealed “...3. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition.... exists. The exam includes appropriate resources routinely available or accessible to (Hospital system name). ...” DED medical record review, on 02/13/2024, revealed Patient #3 arrived via private vehicle on 02/20/2023 at 2010 hours with a chief complaint of “Dizziness.” Patient #3 was triaged at 2018 hours. The Triage Note documented “Pt [patient] reports lightheadedness and dizziness onset today while at the gym working out. Pt states she went home and felt pain to lower back and right side of ribs. Patient denies lifting heavy weights, states she is 5 weeks pregnant. Patient denies vaginal bleeding. Patient ambulatory with steady gait. NADN [no acute distress noted].” ED Care Timeline review revealed at 2021 hours a pain score of 7 [on a scale of 0-10, with 10 being most severe pain]. Patient #3 was assigned a Triage acuity of 3. At 2029 hours, the PA placed orders for pregnancy testing, urinalysis, complete blood count [CBC] and comprehensive metabolic panel [CMP]. ED Timeline review revealed the CBC resulted at 2327, with the MPV abnormal at 11.5 [Reference Range {RR} 7.4-10.]. The urinalysis with reflex microscopic resulted at 2332 and had abnormal results of: Leukocytes urine Trace [RR negative {neg}] and Ketones urine 1+ [RR neg] The urinalysis with microscopic resulted at 2350 with the following abnormal results: Bacteria, Urine 1+ [RR neg], Mucus, Urine 3+ /HPF [RR - none seen]. The urinalysis showed 1+ ketones and trace leukocytes. The narrative for the urinalysis on the labs reads: “Antibiotic treatment of asymptomatic bacteriuria is not appropriate for most patients*, even if urinalysis shows pyuria. Inappropriate antibiotic use causes significant harm (C. difficile infection, resistant organisms, adverse drug reactions) and should be avoided. *Except for children less than 2 years old, during pregnancy, or for patients about to undergo invasive urologic procedures.” There was no documentation in the medical record that Patient #3’s UTI was treated. On 02/21/2023 at 0004 hours, per the ED Timeline, the CMP resulted with one slightly low result: Calcium 8.5 [RR 8.6-10.2]. ED Timeline review revealed a nurse documented on 02/21/2023 at 0005 hours that the patient “...reports, vomiting [sic] x3 today- reports around 1500 [hours]. Reports she is five weeks pregnant.... Emesis Color/Appearance: Brown, Red Number of Diarrhea Stools: 2....Watery. ...” At 0005 hours Patient #3 was roomed in the ED. A Mid-level provider was assigned at 0006 hours and the first provider evaluation was started. Review of the ED Provider Note, date of service documented as 02/20/2023 at 2010 hours [date/time of arrival] revealed “...HPI [History of Present Illness] Pt states she was at the gym today and felt lightheaded. Sattes [sic] has been having N/V/D as well. Denies any fever. States ABD (abdominal) pain so she was concerned since she is about 5 weeks pregnant. Denies any vaginal bleeding. Denies any dysuria. Nothing makes it better or worse. ...” In the “Review of Systems” the PA noted the patient was positive for abdominal pain, diarrhea, nausea and vomiting; otherwise, the ROS was negative. The Physical Exam indicated “...She is not in acute distress.... She is not ill-appearing or toxic-appearing....Abdomen is soft ....There is abdominal tenderness (mild) in the epigastric area. There is no guarding or rebound .... Clinical Impressions Viral gastroenteritis [space] Dehydration [space] less than 8 weeks gestation of pregnancy. ...” Review did not reveal evidence of further evaluation of pregnancy related concerns and did not reveal an attempt to complete an ultrasound or pelvic exam. Telephone interview on 02/15/2024 at 0913 hours with RN (Registered Nurse) #1 revealed the nurse did not recall Patient #3. Interview revealed that in reading the triage, the patient came in complaining of being lightheaded /dizzy, indicated she had no vaginal bleeding, and stated she had not been lifting heavy weights. Interview revealed that normally if patients indicated they were worried or requested specific testing RN #1 would make a note in the record. The RN stated the patient had a pain score of 7 - severe on arrival. Request to interview the RN who cared for Patient #3 during her visit to the ED revealed the RN was not available for interview. Telephone interview with PA #2 on 02/15/2024 at 1030 hours revealed the PA recalled Patient #3. Interview revealed the patient had epigastric pain and stated she was pregnant, maybe a month. Interview revealed in triage there was no bleeding, no urinary symptoms and vital signs were normal. PA #2 stated Patient #3’s pain was in the left ribs and back and was epigastric pain. Interview revealed PA #2 saw Patient #3 once she was to the back, after midnight. The patient was in a curtained room, B, which was a stretcher room. Interview revealed PA #2 examined the patient on the stretcher. Interview revealed no pelvic exam was completed because Patient #3 had no vaginal discharge or bleeding. The patient had been working out and felt dizzy and nauseous. Interview revealed “It was not likely a miscarriage if [there was] no pelvic pain or vaginal discharge.” Interview revealed Patient #3 had no signs/symptoms to indicate miscarriage or ectopic pregnancy. By complaint, the PA stated, the patient had “back pain” and by exam the only tenderness was the epigastric area; PA#2 thought the back pain was referred pain. Interview revealed Patient #3 was concerned about the baby in general but with no pelvic pain, no vaginal bleeding, and a low “quant” it was not likely to be an ectopic pregnancy. Interview revealed PA #2 did not recall if Patient #3 mentioned having had a past miscarriage and stated “unfortunately.... cannot predict.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 33790 Based on policy review and medical record reviews hospital staff failed to provide an appropriate transfer to one (1) of 5 patient’s transferred to other acute care hospitals, (Patient #29). The findings included: Review of the policy “Transfer of Patients from [Hospital A]”, dated 08/02/2023, revealed Procedural Guidelines 2. If it becomes necessary to transfer a patient, the patient’s safety and stability are the primary consideration. No patient is transferred from Hoke Hospital until: c. Transportation by qualified personnel and required equipment has been arranged. d. Copies of applicable medical records accompany the patient to the receiving facility. e. The physician has documented the risks and benefits of the transfer and has fully explained those to the patient and/or family.” The policy Procedural Guidelines also included “5. The patient’s assigned nurse from Hoke Hospital calls a report to a nurse at the receiving facility ...8. The inner hospital transfer (EMTALA) form is completed by the transferring physician for all transfers to acute care hospitals and is signed by the patient or patient’s legal representative and the transferring physician. 9. a. Private Vehicle Transport: Patients generally may not be transferred to a higher level of care via private vehicle. However, (i) when the purpose is to expedite getting the patient to the most appropriate care setting, (ii) when it is determined that there are no better alternative means of transportation, and (iii) where it is determined that no emergency medical condition exists or that a patient is medically stable and no continuous patient monitoring by qualified medical personnel is required, then a patient may choose to go by private vehicle to a higher level of care for continued medical treatment when the needed service is not presently available at the facility and/or ambulance/other medical transport is unreasonably delayed. In this case, all risks and benefits of private vehicle transportation shall be discussed with the patient, the patient must make and provide an informed consent to transfer care via private vehicle, it must be confirmed that a licensed driver other than the patient will be responsible for driving the private vehicle, and the remainder of this policy, including handoff reports and EMTALA form completion, otherwise applies. The attending physician is responsible for determining the appropriateness of private vehicle transport, for consulting with the receiving facility and confirming acceptance of the patient, and for documenting in the medical record: (i) the patient’s request and informed consent to transfer by private vehicle; ... (iii) factors indicating that transfer by private vehicle is appropriate, or the patient’s informed refusal to transfer by other means; (iv) that the patient is accompanied by competent person(s), including a licensed driver; ...(vi) the receiving facility’s agreement to accept the patient and agreement as to the appropriateness of the private vehicle transport .... Note that a patient needing OB/GYN services who is 20 weeks or greater gestation is not appropriate for private vehicle transport. ...” Dedicated Emergency Department (DED) record review of Patient #29, on 02/14/2024, revealed Patient #29 arrived at the hospital on 01/26/2024 at 1354 hours via private vehicle. Review of the Emergency Department Provide Note documented by Medical Doctor (MD) #4 at 1354 hours stated “ ...approximately 28 weeks [pregnant] presents after experiencing a gush of clear fluid from her vagina just prior to arrival. Patient denies any pelvic pain, no vaginal bleeding, no contractions. Patient states she is still feeling the baby move ...” The physical examination documented under genitourinary: “ ...No significant amount of fluid in the vaginal vault, no bleeding, cervix is closed.” A hospital document titled “Impression, Medical Decision Making, Progress Notes and Critical Care” documented differential diagnosis “ ...includes but not limited to: Preterm labor, premature rupture of membranes, urinary incontinence ...Unable to confirm whether or not this was premature rupture of membranes although there does not appear to be any obstetric emergency at this time ...I advised her to be seen by OB at labor and delivery for further evaluation. Patient understands and plans to check-in at Cape fear Valley labor and delivery. I communicated her anticipated arrival with [Physician name] at labor and delivery, they will see her when she arrives.” The hospital discharged Patient #29 at 1537 hours to herself. A hospital document titled “After Visit Summary” included instructions “If you continue to be concerned for premature rupture of membranes, I recommend that you are evaluated by OB at labor and delivery. You have been evaluated and determined to not be in active labor, no risk for imminent delivery. Your baby’s fetal heart rate is within normal limits. No emergency intervention needed. You may proceed to check-in at labor and delivery at Cape fear Valley if you continue to have concerns to be seen by OB/GYN.” There was no documentation in the medical record to reflect Patient #29’s medical records were sent to Cape Fear Valley, why the hospital’s transfer policy was not followed related to obstetrical patients greater than 20 weeks gestation, and no documentation related to a refusal to be transported via ambulance.”