HospitalInspections.org

1. On the days of the Emergency Medical Treatment And Labor Act (EMTALA) survey based on staff interviews, review of medical records, physician on call lists, telephone logs, and review of hospital policies and procedures, the hospital failed to ensure that a patient who had an identified emergency medical condition and in need of an appropriate transfer for specialized treatment(Neurosurgery) was accepted through a referral made to the hospital's emergency department from another hospital(Hospital 2) emergency department for one of one patient (Patient 1) in a total of 22 sampled patient medical records reviewed. Refer to findings in Tag A-2411.

2. Based on reviews of the hospital's policies and procedures and interview with the Emergency Department Medical Director, the hospital failed to have an effective and/or implement policies and procedures to address compliance with the EMTALA (Emergency Medical Treatment and labor Act) requirements of 489.24 as it relates to 482.24 (f) Recipient Hospital Responsibilities.


The findings included:


The Policy and Procedure, titled, " Operation of the Emergency Room " , Original policy: October 1973, Revised: August 2012 was reviewed. Review of the Policy and Procedure revealed in part, Purpose: Provide guidelines for the consistent provision of care in the Emergency Department ... 1. General Information ...II. Admission to the Emergency Department ... A. Triage ...D. Emergent patients ...E. Urgent Patients ...F. Non-Urgent Patients ...III. Completion of Charts ...IV. Examination and treatment ...V. Disposition of Patients ...5. Transfer of Patients to Other facilities ...7. Patient Refusal of Admission or Treatment (Against Medical Advice).. LWBS (Left without being seen) ...V. Special Circumstances: "


Review of facility policy, Emergency Department And Urgent Care Call Center Duties, (no policy number or revised date), reads, ".... 6. If a doctor from another medical facility calls asking to speak with a doctor, transfer to Zone 2....". On 9/8/14 at 6:20 p.m., review of Hospital 1's policies and procedures showed no system and/or written policies and procedures related to the recipient hospital's management of the request for patient transfer from another facility for care and services that is within the capacity and capability for Lexington Medical Center.

On 9/9/14 at 11:45 a.m., the ED Medical Director, stated, "We have nothing in writing regarding the role of the physician in regards to transferring patients in." This interview verified that Lexington Medical Center did not develop a policy and procedure that addressed the EMTALA requirement as it relates to Recipient Hospital Responsibilities.

On the days of the Emergency Medical Treatment And Labor Act (EMTALA) survey based on staff interviews, review of medical records, physician on call lists, telephone logs, and hospital policies and procedures, the hospital failed to ensure that a patient who had an identified emergency medical condition and in need of an appropriate transfer for specialized treatment(Neurosurgery) was accepted through a referral made to the hospital's emergency department from another hospital (Hospital 2) emergency department for one of one patient (Patient 1) in a total of 22 sampled patient medical records reviewed.


The findings are:


Review of hospital ' s policy, titled, Emergency Department And Urgent Care Call Center Duties, reads ".... 6. If a doctor from another medical facility calls asking to speak with a doctor, transfer to Zone 2... "

The medical record from the requesting hospital (Hospital #1) was reviewed. Review of the medical record revealed that an 84 year old elderly male veteran presented to the emergency department on 8/18/2014 at 11:50 a.m. The ED physician documented in part, " Patient arrived with ... speech slurred briefly ...complaining of " whole head " and neck pain, point to occipital area. Patient answers questions and follows simple commands, remain alert throughout long ED visit. However, he did become more confused in the past hour or so ,obeying instruction, understanding explanation, and then immediately forgetting., removing nasal cannula more than once, fussing with bedclothes, wanting to get out of bed to urinate, etc. Foley placed. Patient was NS (Normal Saline) @(at)100/hour>>slowed to 30. He was also given Vitamin K 10 mg(milligrams) (Vitamin K is required (as a co-factor) for the body to make four of the bloods coagulation(Clotting) factors; particularity prothrombin) ... we started first of 4 units of Frozen (FFP) plasma (separated plasma, frozen within 6 hours of collection, used in hypovolemia (low fluid volume), and coagulation factor deficiency, sending 3 units of FFP and 40 mg Lasix to be given en route ....Beginning at 1245 when Radiologist called, I made following phone calls ...Lexington: don ' t take (name of acute care Hospital- hospital #1) >> referred group ... Dr. (Name) Emergency Physician ACCEPTS shortly after 1505 (3:05 p.m.) ... ASSESSMENT: Acute Large Subdural Hematoma (Is a clot of blood that develops between the surface of the brain and the dura mater, the brains tough outer covering) ... Plan/Instructions: Transfer VIA ACLS(Advanced Cardiac Life Support) to Hospital #3 ... with oxygen. "

The medical record from Hospital #3 was reviewed. The discharge summary specified, in part, "The patient (#1) was admitted to my service on 08/18/2014 with diffuse subarachnoid, subdural blood secondary to fall on blood thinners. The patient is being discharged on 9/3/2014 with the same diagnosis as well as myocardial infarction(heart attack) and encephalopathy (disease of the brain) ...".

Procedures performed during admission was a right sided burr holes for subdural hematoma ...History of present illness: ... 84 year old ...who had struck his head the Friday before admission was on Coumadin( a blood thinner). He has been seen in Hospital #1's Emergency Room, had negative CT(computerized tomography) scan (visulization of the interior of the specified body part). He had gone home and then the day of admission he was noted to be more confused. He underwent a CT scan which showed diffuse subarachnoid, subdural blood, and apparently many hospitals refused to accept the patient in transfer, until hospital #3 was contacted. "

On 9/8/14 at 5:10 p.m., during the initial entry into the hospital's emergency department, Clinical Coordinator 1 revealed, "If there is a request for a patient to transfer to this hospital from another hospital, a physician to physician call must take place. The emergency department delegates the emergency department physician assigned to Zone 2 each shift to take the calls from physicians requesting transfers located in outlying facilities".

On 9/8/14 at 6:10 p.m., review of Lexington Medical Center neurosurgery call schedule for August 2014 verified that Neurosurgeon 1 was on call for the hospital's emergency department on August 18, 2014 from 8:00 a.m. to 8 a.m. on August 19, 2014; when the request was made for transfer from hospital #2 for patient #1 on 8/18/2014.

On 9/8/14 at 5:20 p.m., Emergency Department (ED) Medical Director 1 revealed that telephone requests for transfer of patients from other facilities are sent to the physician located in Zone 2. If the emergency department physician in Zone 2 is backed up, the telephone call is redirected to the Zone 1 Lead Physician. When requests for patient transfers come in from other facilities,we accept every patient if we have the services available. In an ER(emergency room) to ER situation, if the transfer is not accepted, it is because the services aren't available at this hospital such as inpatient psych(psychiatric), inpatient pediatrics, oral maxillary, and ophthalmology. We don't accept patients if we are on diversion status, but we keep a diversion log for those patients. We have probably been on diversion one time in the past three years. When the request for a patient transfer comes in, a patient summary is written down by the physician. Then, the summary goes to the charge nurse or flow manager depending on how far away the patient is. Then, an ER room is assigned. If, for whatever reason, a patient is not accepted, there probably is not a record of the request for the transfer of the patient because the summary completed by the physician is probably not kept.

On 9/8/14 at 6:00 p.m., the emergency department physician on - call schedule was provided for 8/18/14 that verified Emergency Department Physician 4 was assigned to Zone 2 from 07:00 a.m. until 12:00 a.m. and Emergency Department Physician 1 was assigned to Zone 1 from 07:00 a.m. until 4:00 p.m. during the time that the telephone call from Hospital 2 (hospital requesting patient transfer) was completed.

On 9/9/14 at 11:45 a.m., the ED Medical Director, stated, "We have nothing in writing regarding the role of the physician in regards to transferring patients in."

On 9/9/2014 at 1:00 p.m., the hospital's telephone log dated 08/18/2014 was requested. On 9/9/14 from 1:20 p.m. to 1:33 p.m., during an interview, Information Specialist(IS) 1 revealed, "I can confirm a telephone call came in to our ED from Hospital 2 (hospital requesting transfer) through the auto attendant line at 12:41:15 p.m.. The call was transferred into the call center room at extension 1013. The agent was on the line with the facility for 56 seconds, and then transferred the call to extension 7742 which we have listed as ED Zone 2 MD(medical doctor). The call to this extension lasted for 1 minute and seven seconds. The next transfer went to extension 2801 which is an ED hub zone where the unit secretaries are located. This call lasted for 50 seconds. The call was then transferred to extension 4117 which is an ED wireless phone, and that's where the call ended. Another call came in again at 12:59:37 p.m. that went to the main switchboard. It was transferred to the ED call center to extension 1012 and lasted for 51 seconds. Then, it was transferred to extension 4117, the ED wireless phone, and the call ended after 44 seconds."

On 9/9/14 at 2:10 p.m., Call Center Intake Representative 1 reported, "As soon as the calls come in, we get the name of the calling doctor and the name of the facility he is calling from. Once the information is received, we transfer the call back to the doctor on duty in Zone 2. The extension is 7742 for the Zone 2 physician. No one else answers that line but the Zone 2 doctor. If there is no answer, I will transfer the call to 1080 to the secretary. Once we transfer the call to the answering party, the time counter starts for that extension." On 9/11/14 at 2:10 p.m., during an interview with the ED Medical Director, the Medical Director stated, "If an ED doctor is in his work zone working, he would be the only one to answer his phone extension." The facility failed to have an effective system in place when zone 2 physician (responsible for calls as it relates to ED to ED transfers) does not answer phone or is not in zone 2 when call comes in from a referring hospital as it relates to EMTALA transfers from a transferring hospital requesting to transfer a patient with an emergency medical condition.

On 9/9/14 from 3:44 to 3:50, an interview with Call Center Intake Representative 2 was conducted in the administrative conference room. Call Center Intake Representative 2 described job duties as the following: answer calls, collect charts, answer calls and direct them to the right doctor in the ED, collect lost and found and deliver mail." When asked how a call is handled regarding a patient request for transfer to the hospital, Call Center Intake Representative 2 responded, "I ask who they are and where they are calling from, and then I get them to the doctor in Zone 2. The doctor in Zone 2 will answer the phone. We remain on the line until the doctor answers, and we give them a warm transfer. This means that we announce the call and once the doctor gets this information, we hang up. Once the phone is picked up at another extension, it only takes a couple of seconds to announce the call." When asked what documentation on incoming calls is kept, Call Center Intake Representative 2 stated, "We don't keep any notation on transfer patients. Once we write down who the doctor is and where the call is from, the information is shredded at the end of my shift."

On 9/11/14 at 10:06 a.m., an interview with IS Specialist 1 and 3 revealed, "We can locate an IP address from any PC (personal computer) and find out exactly which work zone orders and dictations come from. The dictation system is called Dragon, and the voice recognition only works when the physician is sitting at the work station." On 9/11/14 at 12:45 p.m., an interview with IS Specialist 2 confirmed work station tracking of orders and use of dragon dictation system between 12:36 p.m. and 1:00 p.m. when the call from Hospital 2 was transferred to the ED physician in Zone 2 and IS Specialist 2 stated that ED Physician 4 electronically signed an ED discharge summary for a patient at 12:44 p.m. when he was in Zone 2.

On 9/9/14 from 2:57 p.m. to 3:13 p.m., an interview with ED Physician 4 was conducted in the administrative conference room with the Chief Medical Office present. ED Physician 4 confirmed that he was on duty and worked a double shift from 7:00 AM to midnight on the day of 8/18/14 in Zone 2. ED Physician 4 reported that the ED physician speaks to the transferring facility and completes a form (ED Expected Arrivals-Physician Report- form #6231-058-1) that we should fill out, but we usually fill it out only if we have time. When I accept a patient for transfer, I will refer the hospital to the specialist on call by transferring them to the unit secretary. I can either speak to the specialist myself or have the secretary provide the phone number for the physician on call. When asked if he recalled a request for a transfer from Hospital 2 regarding an elderly patient with a subdural hematoma(bleeding in the brain), ED Physician 4 stated,"I have no recollection of that call, we actually don't get too many calls from the .....hospital 2. With those patients from Hospital 2, we pretty much treat them same as any other. We actually have an incentive to take anyone because we want more volume. If it's a disservice to the patient, I will refuse the patient, such as peds(pediatric) surgery, eye trauma or ophthalmology(eye problems). I would have to transfer that type patient to a third hospital. I just can't believe this has any type of indication of any EMTALA I've heard about. Who would refuse a patient anyway because we know they are going to have a pay source."

On 9/111/4 from 2:24 p.m. to 2:30 p.m., a second interview was conducted via telephone in the administrative conference room with ED Physician 4 with the Chief Medical Officer in attendance. ED Physician 4 stated, "It looks like IT proved that I was actually in Zone 2 during the time the telephone call came in from the other hospital (Hospital 2). I don't recall speaking to anyone at Hospital 2 or neurosurgery. I probably got ten to fifteen calls that day. I would have made a note if I could direct them. In this case, it sounds like it was a direct admit to neurosurgery. I still think I would remember rejecting a patient. If there was a rejection, I'd have to hear the whole story."

On 9/9/14 from 1:35 to 1:52 p.m., an interview was conducted with Neurosurgeon 1 in the administrative conference room with the Chief Medical Officer (CMO) present. When asked about the procedure for contacting the on call specialist for patient transfers into the ED to neurosurgical services, Neurosurgeon 1 reported, " ..... The calls go to the midlevel's who may run it by us. We will call the ED physician back and discuss the patient and assess the situation. The calls vary by the situation and by the doctors involved. We don't just ignore calls. When asked what criteria was used to determine whether a patient is accepted of denied for transfers, Neurosurgeon 1 reported, "Our general policy is to take anyone. We don't inquire about payment. We assess to see if there is sufficient severity of illness for a neurosurgery consultation and serious jeopardy for the patient. We do a lot of indigent patients. We do not care about payment status. When asked if the emergency department contacted him on 8/18/14 related to the transfer of a patient with a subdural hematoma, Neurosurgeon 1 said, "We fill a lot of calls when we are on call. A subdural hematoma is a pretty common condition we see. I don't recall. I would have to look at the record. Sometimes, we make notes when we are on call and sometimes we don't. I just can't remember that call. The midlevel may have taken the call. We lost our only neuro interventional radiologist about a year ago, so if patients with aneurysms present and require an interventional procedure, we send them to another facility."

On 9/9/14 from 2:43 to 2:50 p.m., an interview with Physician Assistant (PA) 1 was conducted in the administrative conference room with the Chief Medical Officer present. When asked how he handled calls from the ED regarding request for transfer of patients from another facility to their service was handled, PA 1, "I don't make that decision. If I'm on first call, which I typically am during office hours, I do not admit or transfer. I will take the information, pass it on to my attending, and then, my job is done." When asked if he/she recalled a request for a transfer of a patient with a subdural hematoma on 8/18/14, PA 1 stated, "I do remember something regarding this patient. I spoke to someone from the ER on the telephone, but I don't remember who it was. I told them that I don't admit or transfer. I basically remember saying that I have to contact my attending, and that's exactly what I did. At that point, I was done. I spoke Dr......(Neurosurgeon 1) about the patient, and that was the end of the conversation."

On 9/10/14 from 12:00 p.m. to 12:15 p.m., a second interview was conducted with PA 1 in the administrative conference room with the Chief Medical Officer present. PA 1 stated, "I never received a phone call from anybody about the patient. I received a text message when I was on call from our office. Typically, the way things work, is the calls are triaged in the office by the staff, and they send out the information in a text. After the text, I called the number to the .....(Hospital 2). I called the on call neurosurgeon and told him. I don't accept a patient without the attending agreeing. Typically, the way things work, is the calls are triaged in the office by the staff and they send out the information in a text. After the text, I called the number to the ....(Hospital 2). PA 1 further stated, "When Dr... (Neurosurgeon 1) called me yesterday and asked about the situation, I told him I remembered receiving a text message and talking to him about it. I don't remember the details of the discussion we had at the time."

On 9/10/14 from 10:55 a.m. to 11:14 a.m., a second interview was conducted in the administrative conference room with Neurosurgeon 1 with the Chief Medical Officer present. Neurosurgeon 1 reported, "I spoke with PA 1 yesterday (September 9, 2014) for probably around thirty minutes. I asked him(PA 1) if he remembered the patient that ....(Hospital 2) had requested a transfer for. He(PA 1) said that we were sitting in my office when it occurred, and then that jogged my memory. I had been seeing patients in the office and he(PA 1) had spoken to the ED doctor at (Hospital 2), and then he relayed the story to me. I called ..... (Hospital 2) and spoke to a woman doctor. We talked about the patient. We talked about his exam and his CT (computerized tomography) scan. She(Doctor at Hospital 2) told me that he was an elderly gentleman that had trauma several days earlier and came to the ED with some dizziness and a mild headache, but he was neurologically intact. I asked further questions to clarify that, such as mental status and vital signs. We have our own criteria to ask in our language, such as is he alert, answering questions, following commands, etcetera.... The answer to my questions was "yes". The CT showed some subdural blood, a small amount, with no significant mass on the brain. In my mind, the patient did not have the severity and was not in jeopardy, therefore was not requiring any neurosurgical treatment at that time. I informed her that if the patient worsens to call me back. It was very clear this was a stable patient. I'm not sure if she's familiar with a subdural but the CT and exam sounded stable. I certainly didn't refuse the patient, but I didn't inquire further about him after the call ended. She(Doctor) seemed okay with my questions and conclusion. I didn't hear any protest from her. We left the conversation open-ended. We were dealing with the situation at that moment and came to a mutual agreement. When asked if PA 1 was notified by Hospital 1, Neurosurgeon 1 stated, "Since it was during business hours, he (PA 1) was probably notified by my nurse. The ER probably called her and left the information, and my nurse passed it on to my PA. He (PA 1) would have called the hospital (Hospital 2), informed me, and then, I called the hospital (Hospital 2) back. Basically, the patient was stable and had a low severity with no problems."

On 9/10/14 from 10:55 a.m. to 11:14 a.m., a second interview was conducted in the administrative conference room with Neurosurgeon 1 with the Chief Medical Officer present. Neurosurgeon 1 reported, "I spoke with PA 1 yesterday (September 9, 2014) for probably around thirty minutes. I asked him(PA 1) if he remembered the patient that ....(Hospital 2) had requested a transfer for. He(PA 1) said that we were sitting in my office when it occurred, and then that jogged my memory. I had been seeing patients in the office and he(PA 1) had spoken to the ED doctor at (Hospital 2), and then he relayed the story to me. I called ..... (Hospital 2) and spoke to a woman doctor. We talked about the patient. We talked about his exam and his CT (computerized tomography) scan. She(Doctor at Hospital 2) told me that he was an elderly gentleman that had trauma several days earlier and came to the ED with some dizziness and a mild headache, but he was neurologically intact. I asked further questions to clarify that, such as mental status and vital signs. We have our own criteria to ask in our language, such as is he alert, answering questions, following commands, etcetera.... The answer to my questions was "yes". The CT showed some subdural blood, a small amount, with no significant mass on the brain. In my mind, the patient did not have the severity and was not in jeopardy, therefore was not requiring any neurosurgical treatment at that time. I informed her that if the patient worsens to call me back. It was very clear this was a stable patient. I'm not sure if she's familiar with a subdural but the CT and exam sounded stable. I certainly didn't refuse the patient, but I didn't inquire further about him after the call ended. She(Doctor) seemed okay with my questions and conclusion. I didn't hear any protest from her. We left the conversation open-ended. We were dealing with the situation at that moment and came to a mutual agreement. When asked if PA 1 was notified by Hospital 1, Neurosurgeon 1 stated, "Since it was during business hours, he (PA 1) was probably notified by my nurse. The ER probably called her and left the information, and my nurse passed it on to my PA. He (PA 1) would have called the hospital (Hospital 2), informed me, and then, I called the hospital (Hospital 2) back. Basically, the patient was stable and had a low severity with no problems."

On 9/8/14 at 6:20 p.m., review of the Hospital 1's polices and procedures showed that the hospital failed to have a system and/or written policies and procedures in place related to the recipient hospital's management of the request for patient transfer from another facility for care and services that is within the capacity and capability of Lexington Medical Center when the request was made from Hospital #2 for the acceptance of an appropriate transfer for Patient #1 on 8/18/2014.