Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670031 (X3) Date Survey Completed 02/02/2017
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A2409 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:
Based on record review and interview the facility failed to utilize it's specialized on call surgical services to provide stabilizing treatment for a patient who presented to the ER and was diagnosed with Gas Gangrene of his leg. The patient was transferred to another facility for the needed surgical intervention. This failed practice had the potential to cause deterioration in the patient's medical condition which could result in death. Citing one (1) patient named in a complaint, Patient #1. Findings: Complaint Narrative: Review of complaint (TX00252790) narrative revealed allegation that on 1/19/2017 at 12:50 am, Dr. A51, Emergency Room Physician at Hospital C, called the transfer Center at Hospital Q requesting a transfer of a 34 year old male diagnosed with Gas Gangrene. The complainant alleged Dr. A51 reported that Hospital C did not have a Podiatrist on call and the surgeon on call was not willing to evaluate and treat the patient for his gas gangrene, a potential emergency condition. Dr. A51 desire to transfer the patient to Hospital Q for treatment. The patient arrived at Hospital Q at 3:10 am, the patient was evaluated and taken to the Operating Room at 5:35 am for a below the knee amputation of the left leg. The patient remained in the hospital as an inpatient. The complainant believes Hospital C could have treated the patient if the surgeon on call had evaluated the patient and that the transfer would not be necessary. Medical Record Review for Patient #1 at Hospital C: Review of demographic data for Patient #1 revealed he was admitted to the Emergency Room (ER) on 1/18/2017 at 2140 hours. He was unemployed and had no insurance. He was listed as Self Pay. Review of Triage Nurses notes dated 1/18/2017 at 2242 revealed Patient (#1) Thirty four (34) year old male presented at the ER with wound, edema and purulent drainage to left foot. The patient had toes amputated in 2012. He reported wound to the bottom of his foot for a week. Patient (#1) states "I don't have insurance so I have not been to a doctor". There was documentation that vital signs were within normal limits and oxygen (o2) saturation on room air was 97%. Pain scale 10/10, blood pressure 137/60, Temperature 99.9, Respiratory Rate 19 breath per minute (bpm), Pulse Rate 102 beats per minute (bpm). Oxygen saturation by pulse oximetry 97% room air. Review of Physician notes dated 1/18/2017 revealed documentation the physician saw the patient "on arrival in triage room 5". (A time of day was not documented). The notes documented that 34 year old Patient (#1) arrived at the Emergency Room of Hospital C on 1/18/2017 at 2140 with complaints of Left foot pain, swelling and purulent discharge for the past week. The patient also gave history of having recent black stool. He had past history of Diabetes and hypertension and surgical history of Trans Metatarsal Amputation (TMA) of left foot in 2012. Rectal Guaiac was negative, scant brown stool. Laboratory: white blood cell count 26.1 Hemoglobin 6.1, hematocrit 18.1, glucose 258, Blood Urea Nitrogen (BUN) 12 and Sodium 122. Clinical Impression: Gas Gangrene, Osteomyelitis, Anemia, GI Bleed, Hypernatremia. Disposition: Transfer. Review of physician's certification notes dated 1/19/2017 revealed the reason for transfer was for a higher level of care, surgical debridement and GI work up. Summary of Risk to Transfer: motor vehicle accident, death. Risk if the individual is not transferred: death, sepsis, loss of limb. The patient was transferred from the facility on 1/19/2017 at 0220. Review of X-ray report dated 1/18/2017 at 23:09 revealed the following information: Impression: Status Post amputation of the forefoot with new extensive osseous destruction of the cuneiforms, talus, calcaneus compatible with osteomyelitis. Marked associated soft tissue gas and swelling could be due to soft tissue spread of infection. The report was signed and dated 1/19/2017 at 12:14 am. There was no documentation that Physician A51 requested on call physician at Hospital C for consultation or to treat the patient. Review of Recorded transfer request from Transfer Center Hospital Q: Review of recorded conversation from the transfer center between Dr. A51, ER physician at Hospital C, and Dr. B52, on call Surgeon at Hospital Q, revealed Dr. A51 gave Dr. B52 a history of the patient's condition and stated he was making the request for the transfer because Hospital C did not have a Podiatrist and he did call his surgeon who said he would take a look at the patient "tomorrow". Dr. A51 stated it was his "feeling that the patient was not going to get anything done tonight". He stated Hospital C was a small hospital and did not have a surgical room open at that hour of night and the patient needed higher level of care for his condition. The following information revealed the facility did have functional on call services for physicians and emergency surgical services at Hospital C on 1/18/2017 WHEN Patient #1 required emergency services. Facility Policy/Procedure (Hospital C): Review of the facility's Surgery Call Process Policy/Procedure effective August 2016 revealed the following information: "The surgery call schedule will contain a minimum of one Registered Nurse and one Certified Surgical Technologist. Normal operating hours are Monday - Friday 0630 -1700. 0n Call will begin at 1700 and additionally there will be a surgical call team covering all weekends and holidays. Weekend and Holidays will consist of 24 hour coverage starting at 0700 until 0700 the following morning". Review of the facility's operating room schedule from November 2016 through January 2017 revealed there were adequate on call staff on the schedule. On 1/18/2017 when Patient #1 required surgical services at Hospital C, there was one (1) Registered Nurse, one (1) Certified Surgical Technologist and one (1) Anesthesiologist on the OR call schedule. Review of the facility's physician on call schedule from November 2016 through January 2017 revealed there were adequate on call physicians on the schedule for the four (4) specialty areas including General Surgery provided at the facility. The facility listed five (5) General Surgeons on the facilities on call schedule. Review of the facility's Operating Room after hours activities from November 2016 through January 2017 revealed the following information: In November 2016 there were six (6) after hour's surgeries including week ends and nights. In December 2016 there were six (6) cases and in January 2017 eight (8) cases. After hours cases conducted on the night shift in January 2017 revealed the following information: 1/19/2017 case done at 8:00pm 1/22/2017 done at 10:29 pm 1/23/2017 done at 0400 am 1/29/2017 done at 11:13 pm. Medical Record Review for Patient #1 from Hospital Q: Patient #1 arrived at Hospital Q on 1/19/2017 at 0302. Physical examination documentation revealed the following information: Abdomen soft non-tender, TMA stump with distal wound (about 4 cm in diameter) with active pus extrusion. Marked edema and tenderness elicited on palpation. Vital signs Blood Pressure 128/66 Pulse 105 (bpm). Temperature 101 degrees Fahrenheit O2 saturation 98% on room air. Surgery assessment and plan: Diabetic foot ulcer with likely wet gangrene. Signs of systemic infection including fevers and tachycardia. Operating Room (OR) 1/19/2017 for left lower Below the Knee Amputation (BKA) Guillotine (first stage, needed immediately) would need formal BKA later. Broad spectrum antibiotics, Intravenous Fluids, Nothing by Mouth. Interviews with facility staff: During a follow up telephone interview on 2/8/2017 at 8:30 am with Staff C53, Chief Nursing Officer at Hospital C, regarding Operating Room (OR) services at the facility, she stated the OR is staffed with Nurses and Technicians for services 24/7. The staffs are on call from 5:00 pm until 6:00 am seven (7) days a week. During an interview on 2/1/2017 at 11:00 am with Staff D54, Registered Nurse Director of the Emergency Room (ER) at Hospital C, he stated the ER had four (4) dedicated on call services. General Surgery, Internal Medicine, Orthopedics and Invasive Cardiology (Cardiac Cauterization only). He stated amputations are procedures that are done at the hospital. These services are available twenty four (24) hours a day seven (7) days a week. In addition the Operating Room (OR) IS available 24/7 on an on call basis. During an interview on 2/2/2017 at 10:15 am with Dr. E55, Surgeon at Hospital C, he stated he was on call on 1/18/2017 and was available for calls. The physician stated he was never called to see Patient (#1) nor for a consultation about the patient. He stated a patient with Gas Gangrene has an emergency medical condition and, if he was called, he would have come to see the patient. During a telephone interview on 2/2/2017 at 9:15 am with Dr. F56, Medical Director for the ER, he stated he was aware of the details of the case. He stated Dr. A 51 (ER Physician) called him regarding the Patient (#1), stating the patient had Gas Gangrene Low hemoglobin levels, Gastric involvement and thinks the patient would be better served if he was transferred to a tertiary facility for a higher level of care. According to Dr. F56 he agreed with the decision to transfer the patient and, in retrospect, he would have done the same thing. During an in person interview on 2/2/2017 at 11:10 am in the hospital's conference room with Dr. A51, he stated he did not call Dr. E55, on call surgeon, to see the patient and maybe that was the reason he did not document that he talked to the doctor. He stated the decision to transfer was his, because he felt the patient needed more services than could be provided at Hospital C. Review of facility's Emergency Medical Policy/Procedure: Review of the facility's Policy/Procedure titled Medical Screening, Stabilization and Transfer of Individuals with Emergency Medical Conditions dated January 2016 gave the following information: Individuals who Have An Emergency Medical Condition: "When it is determined that an individual has an Emergency Medical Condition, Hospital C shall: Within the capability of staff and facilities available at Hospital C stabilize the individual to the point where the individual is either "stable for discharge" or "stable for transfer" as defined in section IV. G and Section IV.H; or Provide for an appropriate transfer of the unstabilized individual to another medical facility in accordance with these procedures. Transfers of unstabilized individuals are allowed only pursuant to patient request or when a physician certifies that the expected benefits to the patient from the transfer outweigh the risk of the transfer".