Integris Miami Hospital

“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: 39648 Based on record review and interview, the hospital failed to ensure treatment within its capability for one (Patient #10) of 20 patients. This failed practice had the likelihood to result in delayed care. (See 2407) Based on record review and interview the hospital failed to restrict transfer for 1 (Patient #10) out of 20 records reviewed. This failed practice had the potential to result in delayed care and possible deterioration of health. (See 2409)”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 42140 Based on record review and interview, the hospital failed to ensure treatment within its capability for one (Patient #10) of 20 patients. This failed practice had the likelihood to result in delayed care. Findings: Patient #10 Review of the clinical record showed the patient presented to Integris Miami ED department on 09/07/24 at 7:25 PM with extensive wounds/pressure ulcers. Review of the ED Flowsheet dated 09/07/24 at 8:56 PM read in part, “Skin Integrity ...multiple sites of breakdown ...Location scattered.” Review of a document titled “ED Provider Note” dated 09/07/24 read in part: 1. “The patient presents to the ED by EMS for a chief complaint of wounds.” 2. “The wounds are located on ...bilateral lower legs, sacral region, complete upper and lower back. There is no obvious purulent drainage from these wounds. There is a large amount of associated cellulitis.” 3. “Per chart review [the patient] has come in frequently for these wounds and been admitted to this hospital.” 4. “Due to lack of wound care at this facility ...the patient has been accepted at Mercy Joplin ...will be transferred to their facility.” Review of an internal document dated 09/07/24 showed the summarization of recorded transfer center phone call conversations for Request #176412 and showed they occurred on 09/07/24 from approximately 9:30 PM to 10:31 PM. Review of a recorded phone call “[omitted] 9.7.24 4.wav” between Staff J and the receiving physician showed the following was stated: 1. Staff J: “[the patient has] chronic venous stasis ulcers and decubitus ulcers. All ...decubitus ulcers are just Stage 1, super erythematous. I don’t see any purulent drainage. They proceed all the way up [the patient’s] back.” 2. Receiving physician: “We don’t have wound care over the weekend.” 3. Staff J: “We actually don’t have wound care over the weekend or during the week.” 4. Staff J: “We don’t have wound care during the week, it doesn’t sound like.” 5. Receiving physician: “Do you want to check if you have wound care in the hospital?” 6. Staff J: “I know for sure we don’t.” Review of a document titled “Wound Care Guideline” read in part, “Wound Care Guidelines are meant as a starting point for treatment based on wound bed characteristics. As a wound evolves, treatment modalities may change.” The document provided pictures and descriptions of wound depths and drainage. The document provided the following instructions: 1. “Shallow & Dry/Lightly Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... Apply TheraHoney Gel, cover with Curad Oil Emulsion Gauze then Optifoam Gentle. change Q 3 days and prn. 2. Shallow & Wet/Heavily Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... for moderate drainage, cover with Optifoam Gentle, apply directly to wound. Change q 3 days and prn. For heavy drainage, use Qwidk or Opticel AG* and cover with Optifoam Gentle. Change q 3 days and prn. 3. Deep & Lightly Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... Apply Silvasorb Gel to gauze and loosley fill depth of wound. Cover with Optifoam Gentle. Change Q 3 days and prn. 4. Deep & Wet/Heavily Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... Place Qwick or Opticel Ag* to fill wound. Cover with Optfoam EX. Change Q 3 days and prn. 5. Necrotic Tissue. Cleanse with Skintegrity Wound Cleanser or normal saline... Apply TheraHoney Gel to wound bed. Cover with Optifoam Gentle. Change Q 3 days and prn.” A review of the “Wound Classification Guide National Pressure Injury Advisory Panel (NPIAP) International Skin Tear Advisory Panel (ISTAP)” list the following wounds with definition: 1. “Deep Tissue Pressure Injury... 2. Stage 1 Pressure Injury... 3. Stage 2 Pressure Injury... 4. Stage 3 Pressure Injury... 5. Stage 4 Pressure Injury... 6. Unstageable Pressure Injury... Skin Tears 7. Type 1: No skin loss... 8. Type 2: Partial flap Loss... 9. Type 3: Total Flap Loss...” On 01/16/25 from 11:34 AM to 11:52 AM, Staff K stated: 1. Floor staff could float to work in the ED. 2. On 09/07/24, an ICU nurse floated down to work in the ED. 3. It was the practice of their hospital nurses to provide wound care according to the wound care protocol and algorithm which was approved by the hospital’s medical staff and put in place a few years ago. On 01/16/25 at 12:21 PM, Staff M stated: 1. ED providers were taught the wound care algorithm as part of their onboarding. On 01/16/25 at 2:16 PM, Staff K stated: 1. The patient had received wound care at their facility during a previous hospital admission. 2. The nursing staff were last educated on the wound care algorithm in the fall of 2024. On 01/16/25 at 3:06 PM, Staff L stated the wound care algorithm is directed toward inpatient care and is posted in areas in the emergency department. On 01/16/25 at 2:53 PM, Staff K stated no wound care was documented for Patient #10 and the wound care protocol and algorithm was not followed. On 01/16/25 at 3:10 PM, Staff L stated [the receiving facility] had a dedicated wound care team and a more dedicated infectious disease service, but he or she was not sure that was established, and the ED provider’s note did not document that [the receiving facility] had a dedicated wound care team.”

“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: 39648 Based on record review and interview the hospital failed to restrict transfer for 1 (Patient #10) out of 20 records reviewed. This failed practice had the potential to result in delayed care and possible deterioration of health. Findings: Patient #10 A review of the clinical record showed the patient presented to Integris Miami ED department on 09/07/24 at 7:25 pm with extensive wounds/pressure ulcers (bilateral lower legs, sacral region, upper and lower back). Documentation showed the physician documented that due to lack of wound care at the facility, the facility reached out to Integris transfer center and discussed case with the transfer center at Joplin Mercy. Patient was accepted at Joplin Mercy, transferred in stable condition. Review of a document titled “Wound Care Guideline” read in part, “Wound Care Guidelines are meant as a starting point for treatment based on wound bed characteristics. As a wound evolves, treatment modalities may change.” The document provided pictures and descriptions of wound depths and drainage. The document provided the following instructions: 1. “Shallow & Dry/Lightly Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... Apply TheraHoney Gel, cover with Curad Oil Emulsion Gauze then Optifoam Gentle. change Q 3 days and prn. 2. Shallow & Wet/Heavily Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... for moderate drainage, cover with Optifoam Gentle, apply directly to wound. Change q 3 days and prn. For heavy drainage, use Qwidk or Opticel AG* and cover with Optifoam Gentle. Change q 3 days and prn. 3. Deep & Lightly Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... Apply Silvasorb Gel to gauze and loosley fill depth of wound. Cover with Optifoam Gentle. Change Q 3 days and prn. 4. Deep & Wet/Heavily Draining. Cleanse with Skintegrity Wound Cleanser or normal saline... Place Qwick or Opticel Ag* to fill wound. Cover with Optfoam EX. Change Q 3 days and prn. 5. Necrotic Tissue. Cleanse with Skintegrity Wound Cleanser or normal saline... Apply TheraHoney Gel to wound bed. Cover with Optifoam Gentle. Change Q 3 days and prn.” A review of the “Wound Classification Guide National Pressure Injury Advisory Panel (NPIAP) International Skin Tear Advisory Panel (ISTAP)” list the following wounds with definition: 1. “Deep Tissue Pressure Injury... 2. Stage 1 Pressure Injury... 3. Stage 2 Pressure Injury... 4. Stage 3 Pressure Injury... 5. Stage 4 Pressure Injury... 6. Unstageable Pressure Injury... Skin Tears 7. Type 1: No skin loss... 8. Type 2: Partial flap Loss... 9. Type 3: Total Flap Loss...” On 09/26/24 at 10:20 am, Staff C stated: 1. “We have a wound clinic on 4th South that is open Monday - Friday and is available at times for consults. 2. Nurses on the floor can provide ordered wound care for admitted patients. 3. The ED nurses can provide ordered wound care in the ED. Patients can be referred to the wound clinic when discharged from the hospital or ED.” On 09/26/24 at 10:20 am, Staff H stated: 1. A nurse or physician can perform wound care. 2. Different wounds have a protocol for wound care. 3. Nursing staff complete quarterly training and once a year wound training in person. On 01/16/25 from 11:34 AM to 11:52 AM, Staff K stated: 1. Floor staff could float to work in the ED. 2. On 09/07/24, an ICU nurse floated down to work in the ED. 3. It was the practice of their hospital nurses to provide wound care according to the wound care protocol and algorithm which was approved by the hospital’s medical staff and put in place a few years ago. On 01/16/25 at 12:21 PM, Staff M stated: 1. ED providers were taught the wound care algorithm as part of their onboarding. On 01/16/25 at 2:16 PM, Staff K stated: 1. The patient had received wound care at their facility during a previous hospital admission. 2. The nursing staff were last educated on the wound care algorithm in the fall of 2024. On 01/16/25 at 3:06 PM, Staff L stated the wound care algorithm is directed toward inpatient care and is posted in areas in the emergency department.”