HospitalInspections.org

Based on Hospital A (recipient facility) policy reviews, plan for provision of patient care services review, transfer center report review, transfer center audio recording reviews, on-call physician schedule reviews, procedure case count reviews, credential file reviews, daily census e-mail report reviews, staff and physician interviews and Hospital B (transferring facility) closed medical record reviews, the hospital failed to comply with 42 CFR 489.20 and 42 CFR 489.24 by failing to accept transfer upon request of a patient with an emergency medical condition for 3 of 10 patients reviewed (#31, #33, and #32) with requests for transfer from another hospital's dedicated emergency department. The hospital had Gastroenterology Services and beds available at the time of the requests.

Findings included:

The hospital failed to accept the transfer of a patient with an emergency medical condition that required specialized services from an outside hospital's emergency department that did not have the availability of the required specialized services; when the hospital had the capacity and capability to provide the specialized services for 3 of 10 sampled patients referred from outside hospitals' emergency departments (Patients #31, #33, and #32).
~cross refer to 489.24(f), Recipient Hospital Responsibilities - Tag A2411.

Based on Hospital A (recipient facility) policy reviews, plan for provision of patient care services review, transfer center report review, transfer center audio recording reviews, on-call physician schedule reviews, procedure case count reviews, credential file reviews, daily census e-mail report reviews, staff and physician interviews and Hospital B (transferring facility) closed medical record reviews, the hospital failed to accept the transfer of a patient with an emergency medical condition that required specialized services from an outside hospital's emergency department that did not have the availability of the required specialized services; when the hospital had the capacity and capability to provide the specialized services for 3 of 10 sampled patients referred from outside hospitals' emergency departments (Patients #31, #33, and #32).

Findings included:

Review on 05/24/2017 of current health system "2015-2016 PLAN FOR PROVISION OF PATIENT CARE", revealed, " ...OUR MISSION (Name) Health System, a regional health care center, is guided by its mission to provide exceptional healthcare for all of our patients. ...SCOPE OF SERVICE The scope of care provided under the Health System encompasses a wide array of services that are provided to our patients. The services include both inpatient and outpatient services provided at (Hospital A), which is a large tertiary, care hospital, as well as other facilities within the Health System. We have the capacity to treat any patient condition with the exception of conditions such as major burns, extensive trauma, and pediatric cardiology. ...The services within the Health System include care of our patients throughout the entire life span therefore, we staff a full range of service areas including the Neonatal Intensive Care Unit. There is a vast array of cardiac, medical, surgical and diagnostic services available to our patients. ..."

Review on 05/24/2017 of current health system policy and procedure (Hospital A is part of health system), "Title: Transfer of Patients into (Name) Health System" effective date: 12/29/2016, revealed "Purpose: To comply with Emergency Medical Treatment and Active Labor Act (EMTALA). Policy: As a regional referral center for southeastern North Carolina, [Name] Valley Health System (CFVHS), in concert with qualified physicians holding staff privileges, accepts the appropriate transfer of patients from other facilities who require the specialized/emergency medical services that are available at CFVHS. ...Procedural Guidelines: 1. An appropriate transfer to CFVHS is a transfer in which the following conditions are met: a. The transferring facility has provided medical treatment within its capacity to minimize risks to the individual's health, and, in the case of a woman in labor, includes the health of the mother and the unborn child, or a patient requests to be transferred to the facility. b. CFVHS: i. Has qualified personnel for the treatment of the individual. ii. Has agreed to accept the transfer and provide treatment. iii. Has a qualified physician staff to render treatment. The transferring facility provides CFVHS physicians with the applicable medical records or copies of the medical records, indicating the examination and treatment that was provided at the transferring facility and the written informed consent of the patient for transfer to CFVHS. c. The transfer is accomplished through the use of qualified personnel and equipment. d. The transfer meets regulatory requirements that are established in the interest of the health and safety of the patient who is being transferred. 2. CFVHS agrees to accept such appropriate transfers from other facilities and to provide necessary care. At the point where continued care can be provided by the transferring facility, CFVHS, as appropriate, makes arrangements to transfer the patient back to the original transferring facility. 3. Transfers of patients requiring specialized/emergency medical services to CFVHS proceed as follows: a. The transferring physician, or his designee, contacts the Transfer Center and discusses the request for transfer with the staff on duty. The Transfer Center inquires if the patient has any respiratory risk, such as cough or fever, with concerns for infectious diseases (e.g., TB, SARS, Avian Flu, Pandemic Flu, etc.) or has traveled to any foreign countries. If the request for transfer of a patient comes from another portal, for example, the Emergency Department (ED) or Admitting, the call is transferred to Transfer Center for processing. 4. Suspected Inappropriate Transfer: Receiving hospitals are required by EMTALA to report promptly the receipt of suspected inappropriate transfers to the Center for Medicare and Medicaid Services (CMS). Nursing Performance Improvement monitors and reviews transfers according to EMTALA requirements. Suspected inappropriate transfers are reviewed with the Chief Executive Officer (CEO) and/or the designee to determine if further action is necessary. (Decision Tree) A. Patient referral called to Transfer Center --> B. Determine if CFV has appropriate specialty on call with privileges needed for this patient --> C. Determine bed status --> D. If no bed available, the patient is not to be accepted --> D. If bed available, contact and determine appropriate admitting service --> E. Bed assignment made --> F. Transfer Center coordinates transport --> G. Patient to assigned bed ...For conditions needing specialty services beyond general medical, ICU, pediatrics or PICU, consult with ED physician and specialist as needed. ...Transfers of patients into Behavioral Health Care (BHC) are arranged directly with the BHC Admissions Office, in accordance with CFVHS's Administrative policy, 'Scheduled Admissions'."

1. Hospital B (transferring facility), closed medical record review on 06/16/2017 for Patient #31, revealed a 42-year-old male presented to the hospital's DED via emergency medical services (EMS) ambulance on 04/13/2017 at 1307 with a chief complaint of syncope and was triaged at 1308 by a Registered Nurse (RN). "PT (patient) ARRIVED VIA EMS FROM....CORRECTIONAL FOR SYNCOPAL EPISODE. CORRECTIONAL NURSE CALLED PRIOR TO ARRIVAL & (and) REPORTS PT WAS HYPOTENSIVE (low blood pressure), DIAPHORETIC (sweating), SKIN WAS PALE. ON ARRIVAL TO ED PT WAS ON NONBREATER [sic] WITH O2 SATS AT 100%, SKIN WARM & DRY. PT REPORTS HE SIGNED OUT AMA (against medical advice) A FEW DAYS AGO DUE TO BEING HUNGRY & STAFF WOULDN'T LET HIM EAT. PT REPORTS LEFT SIDE LLQ (left lower quadrant) PAIN." Initial triage vital signs were Temperature (T) 97.5° F (Fahrenheit), Pulse (P) 84, Respirations (R) 16, Blood Pressure (BP) 128/98, and Pulse Oximetry (SpO2) 100%. Pain was assessed using a numerical pain score with a reported pain of 8/10 (0 pain free - 10 worst pain). The patient was assigned an acuity of 2-Emergent. Review of medical screening examination (MSE) documentation by Physician #2, revealed "HISTORY OF PRESENT ILLNESS: ...is a 42-year-old male....brought into the ED today....for evaluation following a syncopal episode that occurred approximately 30 minutes prior to ED arrival. Patient states that he has been having grossly bloody, dark red bowl movements x 4 days and was seen in this ED for the same on yesterday. Previous record review indicates Hgb (hemoglobin) at that time was 13 and admission was recommended however patient signed out AMA....today's episode was witnessed and proceeded by diaphoresis, pallor, and hypotension. He currently complains of leftsided abdominal pain that he states began several days ago and has been intermittent however it did worsen significantly in route to the ED. ...EMERGENCY DEPARTMENT COURSE AND TREATMENT: Decision made to obtain prior medical records. Prior records indicate patient was last admitted at this facility from 04/11-04/12/17 for treatment of GI bleeding however he left AMA. Hgb (hemoglobin) at that time was 13.5, 12.1. Patient treated initially with 4 mg (milligrams) of Zofran (for nausea) and 1L (liter) NS (normal saline) bolus. Hgb now 7.5, down from 13 yesterday. HR (heart rate) now slightly tachycardiac (elevated heart rate). Patient has high possibility of imminent or life threatening deterioration in condition. 1455: Patient type [sic] and screened for 2 units PRBC (packed red blood cells). ...1615: ...(Hospital A) contacted for GI consult though their GI provider on call, Dr. (Physician #3), refused to discuss the patient despite having been advised that we currently have no GI provider on call. 1652: (Hospital C) advises that they are currently on diversion. Will consult (Hospital D). 1728: Case discussed with (Hospital D) transfer center. Will await call back from GI and hospitalist. 1815: Dr. (Physician #13), GI on call with (Hospital D), is agreeable to see the patient in consult once accepted by the hospitalist team. 1905: Case discussed with Dr. (Physician #14), hospitalist, who is agreeable to accept the patient in transfer with Dr. (Physician #13) consulting. ...After the evaluation in the Emergency Department, my clinical impression is GI bleed, anemia. PLAN: Patient transferred to (Hospital D)." Record review revealed the patient departed the DED at 0001 (04/14/2017) and was transferred via ambulance to Hospital D. Departure vital signs BP 99/74, P 86, R 17, T 98.2, SpO2 97%.

Review on 05/24/2017 of recipient facility, "(Hospital A) Thursday, April 13, 2017 EMERGENCY DEPARTMENT MEDICAL STAFF ON-CALL ROSTER" revealed Physician #3 was the physician listed On-Call for "GI" (Gastroenterology) Service.

Review on 05/24/2017 of Hospital A's (recipient facility) "TransferCenter (Trademark) Transfer Order TeleTracking" report for Transfer #20170413-0009 dated 04/13/2017 at 1604 by TCS #1 (Transfer Center Staff) revealed, "Referring Facility (Hospital B name)." "Referring Unit ED." "Caller Dr. (Physician #2)." "Patient (Patient #31, a 42-year-old male)." "Transfer Reason Patient Requires Higher Level of Care." "Requested Facility (Hospital A)." "Redirect Reason Physician Refusal." "Bed Type ED." "Hospital Service Gastrenterology [sic]." "Diagnosis GIB (Gastrointestinal Bleed)" "Referring Physician (Physician #2)." "Disposition Declined." "Disposition Reason Physician Refusal." "Transport Mode No transport required due to disposition." "Payors Primary: Self Pay." "Physician Name/On Call (Physician #3)." "Paged Date/Time 04/13/2017 16:23." "Returned Call Date/Time 04/13/2017 16:29." "Phys (physician) Type Declining." "Decision Date/Time 04/13/2017 16:30." "Consult Notes ...04/13/2017 16:07 DR (Physician #2) CALLED AND REQUESTED TO TRANSFER A PT (patient) TO (Hospital A) FOR A GI BLEED. ...16:26 DR (Physician #3) STATED THAT HE WILL NOT ACCEPT THIS PT ITS NOT PART OF OUR HOSPITAL SYSTEM AND THEY HAVE GI DOCTORS. I EXPLAINED THAT THEY HAVE NO GI AT THIS TIME. DR (Physician #3) STILL REFUSED AND STATED THE PT NEEDS TO GO TO (Hospital C) OR (Hospital D). ...16:39 CALLED DR. (Physician #2) BACK AND INFORMED HER OF [sic] (what) DR (Physician #3) HAD SAID AND HIS DECLINE. DR (Physician #2) STATED SHE WILL CALL ANOTHER HOSPITAL."

Review on 05/24-25/2017 of Hospital A's Transfer Center Audio recording for Patient #31 on 04/13/2017 from 1603 to 1607 (3 minutes 50 seconds), revealed:
(TCS #1) - "This is (TCS #1 name) how may I help you?"
(Physician #2) - "Hey this is Dr. (Physician #2 name) over at (Hospital B name) in Lumberton, I've got a transfer here that I need to set up, I don't have any GI for the next few days and he's got a....GI bleed."
(TCS #1) - "What's the patient's last name?"
(Physician #2) - "(Patient #31 last name) (last name spelled out)."
(TCS #1) - "First Name?"
(Physician #2) - "(Patient #31 first name) (first name spelled out)." ...
(TCS #1) - "Is he is in the ED?"
(Physician #2) - "He is." ...

Review on 05/24-25/2017 of Hospital A's Transfer Center Audio recording for Patient #31 on 04/13/2017 from 1609 to 1624 (14 minutes 31 seconds), revealed:
(Pre-recorded Message) - "Thank you for calling (Name) Gastroenterology Associates..."
(Front Desk Staff) - "(Name) Gastroenterology front desk can I help you?"
(TCS #1) - "Yes, my name is (TCS #1 name) with (Hospital A) Transfer Center."
(Front Desk Staff) - "Hi."
(TCS #1) - "Hey, I need the on-call GI Doctor paged."
(Front Desk Staff) - "Is it a consult or just a call?"
(TCS #1) - "It's for a possible transfer." ...
(TCS #1) - "He can talk to anyone of us. It's for ah, it's (Hospital A) Transfer Center. It's for patient (Patient #31 last name)."...

Review on 05/24-25/2017 of Hospital A's Transfer Center Audio recording for Patient #31 on 04/13/2017 from 1626 to 1627 (0 minutes 55 seconds), revealed:
(TCS #1) - "This is (TCS #1 name) how may I help you?"
(Physician #3) - "Dr. (Physician #3 name)."
(TCS #1) - "Hey, I have a patient (Patient #31 name) at (Hospital B)."
(Physician #3) - "No. Nope, Nope, Nope, Nope, they need to send it to (Hospital C) or (Hospital D). They are not part of our community system."
(TCS #1) - "Yea, I mean but we usually accept patients from (Hospital B)."
(Physician #3) - "Umm, I don't they have three GI Doctors there, they need to call one of them."
(TCS #1) - "Yea, but she says she does not have any GI Doctors on call for three days."
(Physician #3) - "Ah that's not my problem they're not part of this community, they're not part of Cumberland County, Harnett or Hoke."
(Physician #3) - "We are not a tertiary referral center. They need to call a tertiary referral center."
(TCS #1) - "Alright."
(Physician #3) - "It's not 5 o'clock and they got 30 minutes to get one of their Docs to see him, he is right around the corner there."
(TCS #1) - "Alright."
(Physician #3) - "Thanks."
(TCS #1) - "Thanks."

Review on 05/24-25/2017 of Hospital A's Transfer Center Audio recording for Patient #31 on 04/13/2017 from 1638 to 1641 (3 minutes 03 seconds), revealed:
(Hospital B DED Staff) - "ER (emergency room) this is (Hospital B DED Staff name)."
(TCS #1) - "Hey (Hospital B DED Staff name), is Dr. (Physician #2 name) available?" ...
(Physician #2) - "This is Dr. (Physician #2 name)."
(TCS #1) - "Hey Dr. (Physician #2 name)."
"(TCS #1) - "So I have some bad news for you."
(Physician #2) - [laughter] "What you got for me [laughter], not taking anybody?"
(TCS #1) - "He's refusing. The doctors refusing."
(Physician #2) - "Really, without evening talking to him?"
(TCS #1) - "Yea, He."
(Physician #2) - "Can he do that?"
(TCS #1) - "[inaudible] If you want his name it's, ah."
(Physician #2) - "I would, that would be great". [laughter]
(TCS #1) - "His first name is (Physician #3 first name), last name is spelled (Physician #3 last name)."
(Physician #2) - "Did he say why?"
(TCS #1) - "So I will tell you exactly what he told me."
(TCS #1) - "As soon as I said I have a patient at (Hospital B), he said Nope, Nope, Nope, Nope."
(Physician #2) - "Really?" ...
(TCS #1) - "I said ah, No why?"
(TCS #1) - "He said the patient is not part of our hospital system, part of our community system."
(Physician #2) - "He is not part of mine either, because he is a prisoner and he is brand new so, but ok."
(TCS #1) - "And ah, well he was saying the hospital is not part of our system, he said it's not Bladen, Hoke or Harnett, and yada, yada, ya. And I was like, I was like ok and he was like they have GI doctors. And I explained to him that right at this time they do not have GI doctors. He goes well its before 5 o'clock and they can, they can call a clinic down the road from them."
(TCS #1) - "And I was like ok, I was like ok, I said so you are refusing to speak to the doctor and he said yep, so."
(Physician #2) - "Ok. I will probably be reporting that."
(Physician #2) - "What happens here and where we get stuck, is that somedays we have GI, some days we have Urology, some days we have Neuro Surgery; but there is one or two of them each and they don't take calls 30 days a week from the ER or from Inpatient. So, you know I don't blame my hospitalist team for saying you have somebody here for GI bleed or an infected [inaudible] kidney stone and I don't have Urology on for days or I don't have GI on for days. Like I understand them not wanting [inaudible] like that."
(TCS #1) - "And that was our GI Doctor."
(Physician #2) - "Yea."
(TCS #1) - "Ya know and."
(Physician #3) - "Yea."
(TCS #1) - "I have never had one of them just be blank like that, No."
(Physician #2) - "Yea."
(TCS #1) - "Without even speaking to you." ...
(Physician #2) - "Thank you very much. I appreciate you calling. I appreciate you giving me his name, because I mean really and truly that was an EMTALA violation."
(TCS #1) - "Yea, I documented it."
(Physician #2) - "Unfortunately. So, no I appreciate your help and I will call someone else."
(TCS #1) - "Yea, I apologize." ...

Review on 05/24/2017 of Hospital A's credential file for Physician #3 revealed a reappointment letter dated June 21, 2016 from Hospital A's CEO to Physician #3. Review reveled " ...Dr. (Physician #3) This is to notify you that your requests for reappointment and renewal of clinical privileges with the ...Health System have been reviewed and approved by the Board of Trustees through the next reappointment cycle as follows: Department: Medicine Specialty: Gastroenterology From/To: 7/1/2016 - 6/30/2018 Primary Hospital Practice Site(s) (Hospital A name) Medical Staff ..." Further credential file review revealed the following "Current Physician Privilege/Procedure Listing" with:

"Procedure Listing for: (Physician #3)
Appointed to the Department of: Medicine
Medicine - Gastroenterology ... CORE PRIVILEGES - GASTROENTEROLOGY: Core privileegs [sic] in Gastroenterology include being able to admit, work-up, and diagnose patients presenting will illnesses, injuries and disorders of the stomach, intestines, and related structures such as the esophagus, liver, gallbladder, and pancreas, including the provision of consultation. Physician credentialed in gastroenterology will be permitted to remove percutaneous gastrostomy tubes. ...
Diagnostic EGD
ERCP [endoscopic retrograde cholangio-pancreatography] (diagnostic and therapeutic) ...
Sigmoidoscopy, flexible
Small bowel enteroscopy
Total colonoscopy ..."

Review on 05/25/2017 of an "ERCP Volumes" for May 2016 to April 2017 provided by Hospital A's Director of Quality, revealed Physician #3 performed zero (0) ERCP's in the previous 12 months and Physician #8 (the on-coming on-call GI physician at 1700 on 04/13/2017) performed four-hundred thirty-one (431) ERCPs in the previous 12 months. Further review revealed a total of six (6) physicians listed who performed a total of five-hundred and seventy-six (576) ERCP's from May 2016 to April 2017.

Review on 05/25/2017 of an electronic mail, subject "FW: DELTA" (NS House Report), dated 04/13/2017 at 0652, revealed at 0600 the DED was on "Delta" status and there were 12/331 listed adult beds available in-house. Review of an electronic mail, subject "NS Shift Report" dated 04/13/2017 at 1840, revealed at 1815 the DED was on "Delta" status and there were 46/495 listed adult beds available in-house. Date Hospital B requested transfer of Patient #31 to Hospital A.

Telephone Interview on 05/25/2017 at 1252 with Physician #20, revealed he was the Chief Medical Officer for Hospital A. When physicians are on-call for the ED or hospital, the physicians take call for any patients unattached or unassigned. The "motif operandi" is to communicate with the Transfer Center. The Transfer Center contacts the provider on-call for the ED. A conversation takes place between the on-call provider at Hospital A and the referring provider at the outside hospital. Transfers are not done blindly. The capability, capacity, available resources of the hospital and acuity of patients are taken into consideration when accepting transfers. Interview revealed it was not acceptable to refuse a transfer without speaking directly to the referring physician at the outside hospital.

Interview on 05/25/2017 at 1418 with Physician #3 revealed he was a Gastroenterologist on the medical staff of Hospital A. He participated in the hospital's physician on-call schedule for the ED/hospitalist. He did not admit patients to the hospital. The hospitalist admitted and he consulted. He was notified of transfers and consults by the Transfer Center. When accepting patients, there was physician to physician discussion. The telephone to telephone conversation between providers was "a very important component." He tried not to make the call to decline or refuse patients as long as a hospitalist would admit. He stated, "I will see anyone I am called to see." He was on-call for Gastroenterology on 04/13/2017 when Hospital B requested transfer of Patient #31 to Hospital A. He was made aware of the transfer request. He did not talk with Physician #2 at Hospital B. The physician was played the Transfer Center Audio Recording by Manager #2, involving Patient #31 on 04/13/2017 (Transfer #20170413-0009). He confirmed his voice on the recording. He stated, the hospital was on "Delta Status" in the ED. He had worked 7 straight days. He did not admit patients and did not think about capacity. He was going off call. He was unaware Hospital A was considered a regional referral center with specialized capabilities by hospital policy. He was thinking from a GI standpoint. The on-call physician changed at 1700 for his physician group. The request came in on Thursday between 1600-1700. The on-coming physician would have been Physician #8. Physician #8 performed ERCPs. It was not 1700 yet and he wanted to see if Hospital B would try to get a local GI doctor. He was waiting to be told by the Transfer Center that Hospital B tried to get a local GI doctor. If the hospitalist had called him there would not have been an issue. He was currently privileged to do ERCPs but he no longer performed them. He had not performed an ERCP in the previous 12 months. Over the past 5-10 years performing ERCPs has become a sub-specialty to GI. He also no longer did internal medicine. He performed GI only. He was provided annual EMTALA training from the hospital. Here felt there was a communication issue.

Interview on 05/25/2017 at 1530 with Manager #2, revealed she was Hospital A's Transfer Center manager. She stated hospitalist do 95% of the admits. The majority of other specialties do consults. Generally, Transfer Center staff consult the specialist for initial consult then call the hospitalist to admit patients. The physician makes the decision to accept or decline a transfer/consult. The physician makes the decision based on communication with the requesting/referring physician at the outside hospital. It is physician to physician responsibility to talk to each other. The Transfer Center staff are not responsible to gather all the information to give to the physician to make their decision. Any identified issues are supposed to be reported to the Manager who reports it to the CMO or Asst. CMO and Head of hospitalist.

2. Hospital B (transferring facility), closed medical record review on 06/16/2017 for Patient #33, revealed a 57-year-old non-English speaking male presented to the hospital's DED via private transportation on 01/01/2017 at 1042 with a chief complaint of "abdominal pain in RLQ (right lower quadrant) started the am (morning) with vomiting" and was triaged at 1047 by a Registered Nurse (RN). Initial triage vital signs were Temperature (T) 98.0° F (Fahrenheit), Pulse (P) 66, Respirations (R) 18, Blood Pressure (BP) 164/79, and Pulse Oximetry (SpO2) 99%. Pain was assessed using a numerical pain score with a reported pain of 10/10 (0 pain free - 10 worst pain). The patient was assigned an acuity of 3-Urgent. Review of MSE (medical screening examination) documentation by Physician #5, revealed "HISTORY OF PRESENT ILLNESS: ...is a 57-year-old male who complains of burning, non-radiating RLQ abdominal pain since 9:30 AM today (approximately 2 hours ago), consistent and worsening. Patient states it feels like there is a ball inside where the pain is. Patient reports some diaphoresis (sweating) with pain. Patient also reports 2 episodes of non-bloody vomiting this morning. ...EMERGENCY DEPARTMENT COURSE AND TREATMENT: Patient's condition remained stable during Emergency Department evaluation. Decision made to obtain prior medical records. Prior records reviewed....patient last evaluated in this ED on 09/06/2011 (5 years ago) for abrasion and concussion, with normal CT Head. Orders written. Patient treated with Zofran (for nausea) 4 mg IV, Dilaudid (for pain) 0.5 mg IV, and Bentyl (for abdominal cramps) 20 mg IM (intramuscular). Diagnostics reviewed. Orders written. Patient treated with NS 0.9% 500 mL (milliliters) IV (intravenous) bolus, Dilaudid 0.5 mg IV, and Zosyn (antibiotic) 3.375 gm IV. 1408: Case discussed with Dr. [Physician #18 name] (Surgery), who recommends MRCP (magnetic resonance cholangiopancreatography) be performed through the ER. Dr. (Physician #18 name) advises that patient will require transfer to another facility if he is discovered to have a gallstone, as this will require ERCP and there is no GI on-call today due to the New Year holiday. Dr. (Physician #18 name) advises that patient can have cholecystectomy performed at this facility if no gallstone is present. 1620: MRCP results discussed with Dr. (Physician #18 name), who recommends transfer to facility capable of ERCP due to risk of CBD (common bile duct) stone. Examination findings, diagnostic results, and consultation results discussed with patient (via Hospital Translator....). Patient agrees with plan for transfer. Patient was given the opportunity to ask questions and verbalizes understanding. 1624: Case discussed with (TCS #2 name) (Hospital A) Regional Transfer Center. She states that their Gastroenterologist refuses transfer because he states that (Hospital B) has an on-call GI today. She was informed that there is no on-call GI today due to the New Year holiday. She will contact (Hospital A) GI again. 1641: Case discussed with (TCS #2 name) from (Hospital A) Regional Transfer Center, who reports that Gastroenterologist continues to refuse transfer. 1651: Case discussed with Dr. [Physician #4 name] (Gastroenterology, [Hospital A]), who reports that he does not perform ERCPs. Will explore transfer to another facility. 1701: Call placed to (Hospital C) Transfer Center. 1716: Case discussed with Dr. [Physician #19 name] (Emergency Department, [Hospital C]), who agrees to accept patient in ED-to-ED transfer. After the evaluation in the Emergency Department, my clinical impression is 1) calculus of gallbladder with acute cholecystitis without obstruction 2) calculus of bile duct with acute cholecystitis without obstruction. PLAN AND FOLLOW-UP: Based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of medical treatment at (Hospital C) outweigh the increased risk to the patient for transfer from this facility because patient requires a specialized gastroenterological procedure (ERCP) and our Gastroenterologist is unavailable due to the New Year's holiday. I have described the inherent risks and benefits of the transfer to the patient via Hospital Translator, and patient agrees to transfer. I have spoken to Dr. [Physician #19 name] (Emergency Department, [Hospital C]) who has agreed to accept transfer of the patient and provide further medical treatment at the receiving facility in an ED-to-ED transfer. At the time of transfer, copies of all medical records sent which related to the emergency condition for which the individual presented. These records include observations of signs or symptoms, preliminary clinical impression, treatment provided, results of any completed test and an informed written consent to the transfer. ..." Record review revealed the patient departed the DED at 1858 and was transferred via ambulance to Hospital C. Departure vital signs BP 128/70, P 84, R 16, T 97.6, SpO2 100%.

Review on 05/24/2017 of recipient facility, "(Hospital A) Sunday, January 1, 2017 EMERGENCY DEPARTMENT MEDICAL STAFF ON-CALL ROSTER" revealed Physician #4 was the physician listed On-Call for "GI" (Gastroenterology) Service.

Review on 05/24/2017 of Hospital A's (recipient facility) "TransferCenter (Trademark) Transfer Order TeleTracking" report for Transfer #20170101-0016 dated 01/01/2017 at 1606 by TCS #2 (Transfer Center Staff) revealed, "Referring Facility (Hospital B name)." "Referring Unit ED." "Caller (Physician #5)." "Patient (Patient #33, a 57-year-old male)." "Transfer Reason On-Call Specialist Not Available." "Requested Facility (Hospital A)." "Redirect Reason Service Not Available." "Bed Type Medical." "Hospital Service Gastrenterology [sic]." "Diagnosis Cholecystitis" "Referring Physician (Physician #5)." "Disposition Declined." "Disposition Service Not Available." "Transport Mode No transport required due to disposition." "Payors Primary: (Left Blank)." "Physician Name/On Call (Physician #4)." "Paged Date/Time 01/01/2017 16:11" "Returned Call Date/Time 01/01/2017 16:18." "Phys (physician) Type Declining" "Decision Date/Time 01/01/2017 17:05." "Consult Notes ...01/01/2017 16:07 DR (Physician #5 name) FROM (Hospital B) ED REQUESTING TRANSFER OF 57 Y/O MALE TO (Hospital A). PT HAS HAD MRCP (magnetic resonance cholangiopancreatography) DONE AND NOW NEEDS ERCP (endoscopic retrograde cholangio-pancreatography). REQUESTING GI SERVICES. ...16:11 CONTACTING (Gastroenterology Office Practice Name) FOR A PAGE TO THE ON-CALL GI, DR (Physician #4 name). ...16:23 DR (Physician #4 name) CALLED BACK AND REFUSED TO SPEAK WITH THE REFERRING, STATED THAT THEY HAVE GI SERVICES. INFORMED THEM [sic] THAT THE PT NEEDED ERCP AND THE REFERRING STATES THIS IS NOT AVAILABLE. DR (Physician #4 name) STATES THEY HAVE THE SERVICE BUT THEY DO NOT WANT TO HANDLE THIS ON THE WEEKEND. EXPLAINED SAME BACK TO DR (Physician #5 name). DR (Physician #5 name) STATES THAT THEY DO NOT HAVE ANYONE WHO WILL PREFORM ERCP BEFORE TUESDAY AND THE PATIENT CAN NOT WAIT. ...16:26 CONTACTING (Gastroenterology Office Practice Name) FOR A PAGE TO THE ON-CALL GI, DR. (Physician #4 name). ...16:34 CLARIFIED TO DR (Physician #4 name) THAT THE PATIENT CAN NOT WAIT UNTIL AFTER THE HOLIDAY FOR THE PROCEDURE AND HE STATES THAT IT WILL BE THE SAME SITUATION HERE AT (Hospital A), THE PT WILL NOT BE SEEN ANY SOONER IF TRANSFERRED. ...16:39 EXPLAINED SAME TO DR (Physician #5 name). SHE STATES THAT THIS SOUNDS LIKE AN EMTALA VIOLATION. WILL SEEK HIGHER GUIDANCE WITH MANAGER. INSTRUCTED TO CONTACT DR (Physician #6 name), LEAD HOSPITALIST FOR ACCEPTANCE. ...16:53 CONNECTING DR (Physician #6 name) AND DR (Physician #5 name). ...17:02 DR (Physician #6 name) EXPLAINING TO DR (Physician #5 name) THAT ALTHOUGH WE HAVE GI ON-CALL, ONLY (Physician #7 name), (Physician #8 name) PREFORM [sic] THE ERCP AND THAT THEY WILL NOT BE AVAILABLE THROUGH THE HOLIDAY. DR (Physician #5 name) DID NOT RECEIVE THIS PART OF THE INFORMATION IN OUR EARLIER CONVERSATIONS BECAUSE DR (Physician #4 name) REFUSED TO COME TO THE LINE AND I DID NOT KNOW THAT THE PROCEDURE WAS LIMITED TO SELECT GI DOCTORS. ...17:03 DR (Physician #4 name) JOINING THE CONFERENCE. DR (Physician #4 name) ADDS THAT THE WAIT MAY EXTEND UNTIL THURSDAY OR EVEN LATER DEPENDING ON WORK-LOAD. PT WILL NOT TRANSFER TO (Hospital A). NOTHING FURTHER NEEDED FROM THE TC (Transfer Center) AT THIS TIME."

Review on 05/24-25/2017 of Hospital A's Transfer Center Audio recording for Patient #33 on 01/01/2017 from 1603 to 1609 (5 minutes 18 seconds), revealed:
(TCS #2) - "Transfer Center this is (TCS #2 name)."
(Hospital B DED Staff) - "(TCS #2 name) this is (Hospital B DED Staff name), I am calling from (Hospital B name) emergency services, calling to see if ya'll have GI coverage?"
(TCS #2) - "Do we have GI? One moment let me check the book here. We do have GI on-call, yes."
(Hospital B DED Staff) - "Ok, they do have GI, and y'all have beds, have medical beds?"
(TCS #2) - "I believe we are holding on those."
(TCS #2) - "What's wrong with your patient?"
(Hospital B DED Staff) - "She said she believed they are holding but she wants to know what is wrong with the patient."
(TCS #2) - "I'll double check."
(Hospital B DED Staff) - "Cholecystitis and we have no GI, and he needs an ERCP."
(TCS #2) - "ERCP?"
(Hospital B DED Staff) - "Umm huh."
(TCS #2) - "Ok."
(TCS #2) - "I can call bed placement real quick."
(TCS #2) - "We are holding a lot of things, that's an ERCP." [inaudible]
(TCS #2) - "Do they need tele or just medical?"
(Hospital B DED Staff) - "She said medical."
(