Legal Review and Commentary: Improper transfer to nursing home results in death
Legal Review & Commentary
Improper transfer to nursing home results in death
News: A 73-year-old woman with a history of peripheral artery disease underwent elective femoral bypass surgery. Post-surgical complications developed, but six weeks later she returned to the nursing home where she had been prior to the hospitalization. The nursing home refused the transfer, and she was taken back to the hospital. The hospital then transferred the patient to another nursing home, where she died 24 hours later. Her estate brought suit against the hospital, which settled the case for $325,000.
Background: The nursing home resident was admitted to the hospital to undergo elective femoral bypass surgery on her left leg. The elective surgery was intended to address conditions related to her peripheral artery disease by leading some of the blood from the unblocked artery carrying blood to the woman's right leg to the blocked artery in her left leg via a new piece of artificial artery called a vascular graft.
The surgery was successful; however, significant post-surgical complications developed. The principal complication was a large ulcer in the groin area at the site of the vein harvest for the surgical procedure. The harvest site became infected, and the wound would not heal.
At the six-week post-surgery appointment, the hospital attempted to transfer the patient back to the nursing home despite the open wound. Upon the patient's arrival at the nursing facility, staff refused to admit her because she was not stable and they were not able to treat the ulcers.
The woman was returned to the hospital, where she stayed in the emergency department (ED) three hours without any further evaluation. The woman then was taken by ambulance to a second nursing home. She was admitted, but died 24 hours later. The emergency medical services technicians maintained that throughout the transports, the patient's leg looked and smelled gangrenous. An autopsy revealed that the plaintiff died of sepsis, a severe illness caused by overwhelming infection of the bloodstream by toxin-producing bacteria.
The patient's estate alleged violations of the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA imposes an affirmative obligation on the part of the hospital to provide a medical screening examination to determine whether an emergency medical condition exists, imposes restrictions on transfers of persons who exhibit an emergency medical condition, and imposes an affirmative duty to institute treatment if an emergency medical condition does exist. As soon as a patient is formally admitted to the hospital for treatment, the application of EMTALA ceases. Therefore, if an individual develops an emergency medical condition while an inpatient, EMTALA does not apply. If the patient presents to the ED without an emergency medical condition, the statute imposes no further obligation on the hospital.
The plaintiff in this case argued that the hospital violated EMTALA's requirements. The plaintiff alleged that because an ED doctor signed the transfer papers without having seen and evaluated the patient, the physician failed to screen the patient before ordering her transfer.
The plaintiff also argued that the patient was not stable before she was transferred to either nursing home. The hospital maintained in its defense that the decedent was stable at the initial transfer and that she was evaluated upon her return to the ED.
The hospital also claimed that the patient's death so soon after the transfer to the second nursing home was just a coincidence. Prior to trial, the hospital reached a $325,000 settlement with the decedent's estate.
What this means to you: Every time a patient presents at the ED, EMTALA requires that a pre-screening take place.
"The biggest issue in this case appears to be a lack of education," says Kenneth R. Nanni, PhD, health care risk manager and director of the Graduate Certificate in Health Care Risk Management Program at the University of Florida in Gainesville. It appears neither the physician nor the admissions staff knew about EMTALA's requirements.
"Appropriate staff education involves a risk manager who knows about EMTALA and who can educate the entire staff about the law," Nanni says. "EMTALA's requirements should be understood not just by the admissions nurse, but also by the admissions clerk in the emergency department and the doctors."
Every staff member on the entire campus should be aware that EMTALA requires a screening exam and stabilization or a transfer. In fact, Nanni suggests that EMTALA training be made mandatory for all new members of the medical staff as condition of privileges and that continuous training be provided for all staff.
Considering that violations of EMTALA can carry civil monetary penalties of up to $50,000 per violation and/or decertification of Medicare decertification, Nanni strongly recommends that every hospital have a policy in place to ensure compliance with the law.
A hospital's policy should include: identifying dedicated EDs, which must comply with EMTALA; designating qualified medical personnel who will perform screening examinations on behalf of the hospital; maintaining a list of on-call physicians to help the ED determine if a patient has an emergency medical condition and to help treat patients that the hospital accepts in transfer; defining the hospital's "standard medical screening examination process," which should focus on excluding the presence of an emergency medical condition and stabilizing patients who do have an emergency medical condition; addressing the treatment of nonemergencies; making triage decisions without knowledge of the patient's insurance status; ensuring that all patients get the exact same screening exam based on their chief complaint and medical condition; and implementing an "EMTALA checklist," which helps to ensure that the medical staff effectively executes EMTALA's directives by providing an easy screening tool.
Items on the checklist should include: documentation of initial medical evaluation and stabilization; informed consent disclosing the benefits and risks of being transferred; medical indications for the transfer; and any physician-to-physician communications with the names of the accepting physician and the receiving hospital.
This case highlights several important aspects of EMTALA compliance. Nanni suggests that the entire hospital staff is educated as to the meaning of statutory and regulatory definitions of common medical terms, that EMTALA policies and procedures are drafted very carefully, that the hospital and medical staff cooperate in implementing these policies and procedures, and that accurate documentation is emphasized as a critical step in complying with the statute.
If all of these steps had been followed in this case, the hospital likely could have avoided liability.
Reference
• U. S. District Court, District of Michigan, Case No. 2:03-CV-72598.
A 73-year-old woman with a history of peripheral artery disease underwent elective femoral bypass surgery. Post-surgical complications developed, but six weeks later she returned to the nursing home where she had been prior to the hospitalization.Subscribe Now for Access
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