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Based on interviews and document reviews, the facility failed to comply with the Medicare provider agreement as defined in §489.20 and §489.24 related to Emergency Medical Treatment and Labor Act (EMTALA) requirements.

FINDINGS

1. The facility failed to meet the following requirements under the EMTALA regulations:

Tag 2411: §489.24(f) A participating hospital that has specialized capabilities or facilities may not refuse to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual. Based on document reviews and interviews, the facility failed to accept a transfer patient who required specialty care from a referring emergency department (ED).

Based on document reviews and interviews, the facility failed to accept a transfer patient who required specialty care from a referring emergency department (ED).

Findings include:

Facility policy:

The Emergency Medical Treatment and Labor Act (EMTALA) policy read, the facility shall comply with the emergency care obligations imposed by EMTALA. The facility shall accept appropriate transfers of individuals with emergency medical conditions if the facility has the specialized capabilities not available at the transferring hospital and has the capacity to treat those individuals.

1. The facility failed to accept a transfer patient who required specialty care from a referring emergency department (ED).

a. Review of the audio file of the provider-to-provider call which occurred on 2/11/25 revealed Provider #2 stated multiple times they did not see a need for a patient in an outlying facility to be transferred across state lines during the night. The referring ED provider explained they were concerned about the patient's necrotic (death of skin cells) operative site and had attempted several other referral centers, which had not had a specialist or the capacity to receive the patient. The referring ED provider stated they could not refuse the patient transfer based on EMTALA regulations. Provider #2 declined to accept the patient transfer.

This was in contrast to the EMTALA policy which read, the facility should have accepted the patient with an emergency medical condition if the facility could treat the patient and had the specialized capabilities which were not available at the transferring hospital.

b. The facility's on-call list was reviewed and confirmed Provider #2 had been the hand specialist on-call the night of 2/11/25.

c. Review of information sent to Provider #2 after an internal review of the event was conducted, encouraged Provider #2 to review the education sent by Officer #4 with details about the EMTALA obligation to accept transfers.

d. A document from the facility's public relations firm was reviewed. The document read it had distributed EMTALA education on behalf of Provider #5 to all facility providers with an active email address in their database. Additionally, as of 6/9/25, the document read, 870 physicians had received the email and 298 providers had opened the email, which was an open rate of 34%.

Review of the document did not reveal a date by which the email was expected to be opened, or the expectation for follow-up with providers who had not opened the email.

e. On 6/10/25 at 12:14 p.m., an interview was conducted with ED provider (Provider) #1. Provider #1 stated they were only able to refuse transfers to the ED if the facility did not have the capacity to care for the patient. Provider #1 stated they were aware of EMTALA regulations and received annual compliance training on EMTALA. Provider #1 stated their physician group occasionally discussed EMTALA topics, such as form revisions or changes in the electronic health record (EHR). Provider #1 stated they were not aware of recent communications from the facility related to EMTALA.

f. On 6/12/25 at 7:00 a.m., an interview was conducted with hand specialist (Provider) #2. Provider #2 stated on the night of 2/11/25, they received a call from the transfer center and spoke with an ED provider from a smaller facility in a bordering state. Provider #2 stated the patient had a right radial (large artery in the wrist) heart catheterization (procedure where a tube was inserted through a blood vessel to the heart) the month before. Provider #2 stated the patient had developed a blockage of blood circulation to the hand and developed necrotic tissue after the procedure. Provider #2 stated the patient had required amputation of fingers two through four, which had been completed by an orthopedic surgeon at a sister facility four days before they had received the call. Provider #2 stated the patient had returned to the ED in another state on 2/11/25, and the referring ED provider had been concerned for additional necrosis. Provider #2 stated the referring ED provider had contacted the orthopedic specialist who had performed the amputation, and the orthopedic specialist stated the patient needed a hand specialist.

Provider #2 stated after they spoke with the referring ED provider, their opinion had been there was no urgent need to transfer the patient across state lines at night. Provider #2 stated necrosis along incision lines was common after amputation, and there had been no sign of infection or new concerns. Provider #2 stated the patient had outpatient care scheduled. Provider #2 stated the ED provider had called several other referral centers without a hand specialist or the capacity to care for the patient. Provider #2 stated at the end of the call, the referring ED provider told them to refuse the transfer would have been an EMTALA violation.

Additionally, Provider #2 stated they had not received EMTALA education and training during their 10 years of residency training. Provider #2 stated they had not heard of EMTALA before coming to practice in this state four years ago. Provider #2 stated they had not received formalized training about EMTALA until this situation occurred. Provider #2 stated after this occurrence, multiple emails were sent system-wide about rules for transfers and EMTALA information.

Provider #2 stated the EMTALA law was an important safety mechanism to ensure all patients treated in EDs received the care they needed, whether at the facility they were in or another facility that could have provided the services. Provider #2 stated patients were at risk for poor outcomes and not receiving the correct standard of care if EMTALA regulations were not followed.

g. On 6/10/25 at 3:17 p.m., an interview was conducted with compliance officer (Officer) #3. Officer #3 stated they had listened to the audio recording of the provider-to-provider phone call. Officer #3 stated they concluded it had not been appropriate for Provider #2 to decline the transfer of the patient. Officer #3 stated provider actions or inactions could cause an EMTALA violation, and it was important for them to understand the EMTALA law. Officer #3 stated after this event occurred, an opportunity was identified for education to all providers about EMTALA regulations and the obligation to accept transfers.

This was in contrast to the facility's public relations firm documentation, which revealed only 34% of providers had opened the facility's EMTALA education email.

h. On 6/12/25 at 7:31 a.m., an interview was conducted with chief medical officer (Provider) #4. Provider #4 stated Provider #2 had called them to discuss the provider-to-provider call soon after the call had occurred. Provider #4 stated they also received a notification from the transfer center with an audio recording of the call. Provider #4 stated the facility had the capacity and capability to care for the patient, and the referring ED provider had needed the patient to be transferred for specialty care.

Additionally, Provider #4 stated they had attempted to send EMTALA education to their providers on an every-other-year basis. Provider #4 stated education had been disseminated to providers through emails, newsletters, and committee meetings. Provider #4 stated the facility used to facilitate sessions where legal would educate the providers. Also, Provider #4 stated the facility used to have an EMTALA playbook for reference. Provider #4 stated there was no formal online EMTALA education module for the providers.

Further, Provider #4 stated every patient deserved equal care. Provider #4 stated EMTALA rules were written to ensure every patient received the same level of care at every facility. Provider #4 also stated if the facility had specialized care and the ability to provide the care, the facility should have accepted the patient, just like any other patient who walked through the door of the ED.

Finally, Provider #4 stated patients could experience delays in care and diagnoses or complications if EMTALA regulations were not followed.