Trinity Medical Ctr East &trinity Medical Ctr West

“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: 21893 Based on record review and interview, the facility failed to ensure individuals who were transferred to another hospital had appropriate transfers including a physician signed certification with a summary of the risks and benefits of the transfer. This affected five (Patients #6, #7, #8, #9, and #11) of six medical records of transferred patients reviewed. In the last six months, the facility saw 15,140 patients and 371 patients were transferred to other facilities. Findings include: 1. Review of the medical record for Patient #6 revealed an arrival date of 06/27/24 at 7:53 PM to the emergency department. The medical record contained documentation the patient had a displaced femur fracture and was transferred to a higher level of care. The “Transfer Summary” form signed by the physician lacked documentation of patient specific risks and benefits of the transfer. 2. Review of the medical record for Patient #7 revealed an arrival date of 07/14/24 at 12:43 PM to the emergency department. The medical record contained documentation the patient had a non-traumatic subarachnoid hemorrhage and was transferred to a higher level of care for neurosurgical evaluation by air ambulance. The “Transfer Summary” form signed by the physician lacked documentation of patient specific risks and benefits of the transfer. 3. Review of the medical record for Patient #8 revealed an arrival date of 07/04/24 at 9:14 PM to the emergency department. The medical record contained documentation the patient was suicidal and was transferred to an inpatient psychiatric facility. The “Transfer Summary” form signed by the physician listed only “psych” in the patient specific risks and benefits of the transfer. 4. Review of the medical record for Patient #9 revealed an arrival date of 10/12/24 at 10:14 PM to the emergency department. The medical record contained documentation the patient was suicidal and was transferred to an inpatient psychiatric facility. The “Transfer Summary” form signed by the physician lacked documentation of patient specific risks and benefits of the transfer. 5. Review of the medical record for Patient #11 revealed an arrival date of 09/28/24 at 4:31 PM to the emergency department. The medical record contained documentation the patient had displaced fractures of the tibia, fibula, and humerus and was transferred to a higher level of care. The “Transfer Summary” form signed by the physician lacked documentation of patient specific risks and benefits of the transfer. Review of the “Transfer Summary” form revealed three sections, Patient Transfer Request, Physician Certification, and Transfer Information. Under the Physician Certification section, there was a pre-printed section that stated: “Risks of all transfers include the possibility that the patient’s condition may worsen en route; patient may be injured by a vehicular accident or equipment failure; and if the patient is in labor, she may progress to delivery while en route. Summary of additional risks/benefits:”. During an interview on 12/11/24 at 2:07 PM, Staff B and Staff C verified the above findings.”

“NURSING CARE PLAN CFR(s): 482.23(b)(4) The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient’s goals and the nursing care to be provided to meet the patient’s needs. The nursing care plan may be part of an interdisciplinary care plan. This Standard is not met as evidenced by: 44810 Based on policy review, interview, and record review, the facility failed to develop a care plan to meet the care needs for two of ten patients reviewed (Patient #1 and #5). The census was 86. Findings include: 1. Review of the medical record for Patient #1 revealed an admission date of 09/29/23 and a discharge date of 10/01/23. Patient #1 was admitted with gait ataxia and slurred speech. Review of nursing assessments dated 09/29/23, 09/30/23, and 10/01/23 revealed Patient #1 had a reddened area to his coccyx. No other documentation related to care of his coccyx was noted. There was no documentation of a waffle overlay being added to the patient’s bed. Review of pressure ulcer risk assessment dated 09/29/23 revealed Patient #1 scored a 16 meaning at risk for developing pressure ulcers. 2. Review of the medical record for Patient #5 revealed an admission date of 10/01/23 and a discharge date of 10/01/23. Patient #5 was admitted with intractable pain. Review of two nursing assessments dated 10/01/23 revealed Patient #5 had a stage two pressure ulcer on her coccyx. No other documentation related to care was noted. Review of the pressure ulcer risk assessment for Patient #5 dated 10/01/23 revealed Patient #5 was at high risk for developing pressure ulcers. Interview on 11/20/22 at 2:00 P.M. with Staff D confirmed Patient #1 and #5’s documentation did state they had alterations in skin integrity with no documentation of care provided. Staff D also confirmed there was no update to the care plan with interventions for either patient. Staff D reported when patients were admitted a pressure ulcer risk assessment and head to toe nursing assessment was completed. Patients at high risk of developing pressure ulcers and those with current alterations were referred to the wound care nurse for further evaluation. Interview on 11/21/23 at 8:53 A.M. with Staff F confirmed Patient #1 and #5 had documented skin alterations. Staff F was unfamiliar with either patient but reported if care was provided it would have been documented in the care plan. Review of facility policy titled, Skin Care (Adults), effective November 1994 and revised November 2023, revealed nursing care is initiated and modified based on findings from the risk assessment to include the appropriate patient-specific interventions. When implementing any asterisked intervention (use waffle overlay on beds for patients at mobility high risk. Atmosaire mattress may be substituted for low air loss mattress. Use waffle overlay for patients who are greater than 200 lbs. Use high air loss bed only if patient has muscle flaps or grafts or complex wounds with ET recommendation. Use Bariatric waffle overlay for patients greater than 350 pounds. Dietary consult/Nutrition Team. Stage 2: Apply wound dressing as directed by physician. Stage 3 and 4: Consult Enterostomal Therapist. Utilize waffle overlay for pressure reduction), a protocol order for that item must be written on the chart for reimbursement purposes. For a patient with a pressure risk score of 15-18: Use waffle overlay to reduce pressure on bony prominences. This deficiency represents non-compliance investigated under Substantial Allegation OH00147231.”