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On the days of the Emergency Medical Treatment and Labor Act (EMTALA) investigation based on review of the hospital's emergency department staff and call center staff interviews, review of the hospital's physician on call schedules for the emergency department, review of the emergency department's policies and procedures, review of the hospital's telephone logs from its communication center, and review of bed census statistics, it was determined that the hospital violated its provider agreement with CMS(Center for Medicare Medicaid Services)by failing to accept an appropriate transfer of a referral for a patient requiring specialized emergency treatment(Neurosurgey) provided at the hospital for one (Patient #21) of 21 sampled patient medical records reviewed.


The findings include:


Cross Reference to A 2411: The participating hospital with capability and capacity failed to accept a patient with an identified emergency medical condition requiring medical services that were not available at the referring hospital.

On the days of the hospital's Emergency Medical Treatment and Labor Act (EMTALA) investigation based on review of the hospital's emergency department and call center staff interviews, review of the hospital's physician on call logs for the emergency department, review of the emergency department's policies and procedures, review of the hospital's telephone logs from its communication center, and review of bed census statistics , the participating hospital (Hospital 1) with capability and capacity failed to accept an appropriate transfer of a patient with an identified emergency medical condition requiring medical services that were not available at the referring hospital (Hospital 2) for 1 (Patient #21) of 21 sampled patients medical records reviewed.


The findings include:

On 9/16/2014 at 4:00 p.m., review of Palmetto Health Richland's policy, "Emergency Care/EMTALA (Emergency Medical Treatment and Labor Act)", states, "...---shall not refuse to accept an appropriate transfer of an individual requiring specialized capabilities or facilities available at ---."

On 9/16/2014 at 4:00 p.m., review of Palmetto Health Richland's policy, titled, " ...Accepting Transfers from Outside Facilities to the MICU (Medical Intensive Care Unit), states, " ----has an EMTALA obligation to accept patients with an Emergency Medical Condition (EMC) regardless of admission status...If an EMC exists that the requesting facility cannot treat, the transfer should always be accepted if --- has the capacity and capability to accept...".

The medical record from the requesting hospital (Hospital #1) was reviewed. Review of the medical record revealed that an 84 year old elderly male (Patient #21) 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 ... Richland Transfer: refused to accept because they are on diversion for critical care beds ... 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 (#21) 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 (Patient #21) ...who had struck his head the Friday before admission was on Coumadin
(a blood thinner). He has been seen in Hospital #1 Emergency Room, had negative CT(computerized tomography) scan. 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 may hospitals refused to accept the patient in transfer, until hospital #3 was contacted. " The hospital failed to ensure that their policies and procedures were followed as evidenced by failing to accept an appropriate transfer of Patient #21 who required specialized neurosurgical services or facilities that were available on 8/18/2014.

On 9/17/2014 at 2:30 p.m., review of Palmetto Health Richland ' s on -call physician roster revealed 24 hour physician coverage for Neurosurgery with backup coverage for 8/18/2014. Palmetto Health Richland had the capability to provide the needed specialty services (Neurosurgery) for Patient #21 on 8/18/2014, when Hospital #2 called requesting a transfer for the patient.

On 9/16/2014 at 3:00 p.m., during an interview with the Director of Patient Placement at Palmetto Health Richland (Acute Care Hospital where Patient 21's transfer was requested), he/she revealed, "...When no beds are available, as determined during the patient huddle, which is composed of the Administrator on duty, patient placement personnel, the Acute Care Executive, the Chief Nursing Officer, and the Physician Executive, who are all part of decision making team regarding when to go on diversion and not accept patients for admission to this hospital. The last time we were on diversion was August 16, 2014 through August 19, 2014. We were on diversion for Adult inter-facility critical care, trauma, and stroke diversion. We (our department) puts the physician here with the physician from the hospital requesting transfer. They have a conversation regarding whether the patient will be accepted or not. The decision is made by them. The specialty attending available when the call comes in and the referring facility physician make the decision. If the patient will be admitted, the call goes to patient placement. The calls come through the communication center, and, if a bed is needed, we fill out a patient placement sheet after the call is sent to patient placement. This is decided by communication...".

On 9/16/2014 at 4:00 p.m., review of the hospital ' s log for patient placement referrals dated 8/18/2014 showed there were no referrals received from Hospital 2 (hospital requesting transfer of Patient #21).

On 9/16/2014 at 4:15 p.m., review of the hospital's bed status for 8/18/2014, revealed, "Total patients in 534 staffed beds was 440 patients, with a capacity percentage of 85%. Available beds showed the Medical Intensive Care Unit (MICU) had 2 beds available, 7 East Critical Care area had 4 beds available, and the Medical Surgical units had 20 beds available. On 9/17/2014 at 1:15 p.m., review of the activity log for Palmetto Health Richland Hospital dated 8/18/2014 verified that Palmetto Health Richland Hospital admitted 47 patients on 8/18/2014 throughout the hospital. The Hospital had the capacity to provide the needed neurosurgical specialty services for Patient #21 on 8/18/2014.

On 9/17/2014 at 9:20 a.m., during an interview with the Director of Emergency Services, he/she revealed, "...We do not go on Emergency Medical Services (EMS) diversion. We take all patients that come in the door, either by EMS or that walk in. We hold them in the emergency department. If the patients are critical, we place them in the hallway or find some where for them. If they need surgery, we send them to surgery. Then, the patients are held in the Post Anesthesia Care Unit (PACU)...".

On 9/17/2014 at 10:10 a.m., during an interview with the Manager of the Communication Center, he/she revealed, "...When a call comes in to the communication center and we are on diversion, we refer the call to the attending physician and allow the physician to talk with the referring hospital physician and allow the physicians to talk. This call is directed to the specialty on call. We tape the conversations that come in on the communication line. Sometimes the quality is very bad and it is very hard to decipher what is on the tape. The staff in the communication center work 6 days on and 6 days off. There are 2 staff members on at all times. They work from 7:00 a.m. to 7:00 p.m...". The schedule for 8/18/2014 for the 24 hour shift was requested with the staff members assigned to the call center on 8/18/2014, and each of the assigned staff members were interviewed in the conference room individually.

On 9/17/2014 at 11:00 a.m., during an interview with the Acute Care Executive, he/she revealed, "...All referrals to this hospital come through the communication center and straight to the attending on call. The only time the call would go to a Physician Assistant (PA) would be if the on call physician were in surgery or involved with a patient and the PA would relay directly to the physician on call. All calls for beds go directly to the on call physician. At 10:00 a.m., we have a huddle and make decision as to whether anyone can come out of a critical care bed to free critical care beds. We look at all areas of the hospital also. We try to empty out beds and place patients. We only make the decision to go on diversion if there are no other options. We have a call log for all calls coming into the hospital."

On 9/17/2014 at 11:30 a.m., review of the hospital ' s telephone log revealed a telephone call was received in Hospital 1's communication center on 8/18/2014 at 12:38 p.m. from Hospital 2 (hospital requesting transfer) with duration of 56 seconds.

On 9/17/2014 at 1:00 p.m., during an interview with Communication Specialist 1 who was on duty in Hospital 1's communication center on 8/18/2014 from 7:00 a.m. to 7:00 p.m., revealed, "...I was working and I think we were on diversion during that time. When a call comes into the communication center, I text the attending on call and let them know to call and get referral. I do not recall a specific call from.....(Hospital 2) on August 18, 2014...". When Communication Specialist 1 was asked, "Why would this verified telephone call from Hospital 2 that was validated received on 8/18/2014 at 12:38 p.m. on your hospital telephone log be absent from the list of calls documented as received by the communication department staff, Communication Specialist 1 reported, "...Maybe we just got busy and did not log it in and maybe several calls came in at once. It should have been on the communication center log we keep. When we are on diversion, we tell the calling facility/physician that we are on diversion. Sometimes they just hang up. We tell them we are on diversion and offer to connect them with the attending on call, but they usually don't want to talk to us when they find that we don't have a bed. We audit each other (my co-worker and I) to be sure that we did not miss a call, but we can miss calls when we get really busy. We have no other tracking mechanism in place to keep up with calls received. When a physician calls in and we tell them we are on diversion, they usually hang up and say, "...Never mind, we'll contact another hospital...".

On 9/17/2014 at 1:35 p.m., during an interview with Communication Specialist 2, he/she revealed, "...I take calls from other facilities for patients that need to come here. We were on diversion from August 16-19, 2014. We were on Critical Care, Trauma, and Stroke (adult) diversion. When a call comes in for a referral, I let the caller know we are on diversion and ask if the caller wants to talk with the physician on call. Usually, they do not and state they will call someone else. If they want to talk to the physician on call, I connect them. I do not remember a call coming in on that day (August 18,2014) from .....(Hospital 2). We take so many calls, I just can't remember that call...".

On 9/17/2014 at 2:00 p.m., during an interview with the Director of Regulatory Compliance, he/she revealed, "...We thought the procedure for diversion for the communication center staff was for the call center staff to connect the referral physician and the attending physician on call and allow the physicians to communicate to the caller that we are on diversion. We did not realize the communication center staff told the calling facility/physician that we were on diversion and did not always connect the physicians to discuss the patients...".

On 9/18/2014 at 11:15 a.m., during an interview with the Director of Transport (Communication) Department, he/she revealed, "...I have been with this department (communication center) for 8 months. After taking over this position, I discovered there was no standard process for orientation for the communication center staff. While I was reviewing orientation, I realized that not enough education was given to staff regarding how to handle a call if the hospital is on diversion. I thought the call was sent straight to the physician on call, and did not realize that my staff told referring physicians that the hospital was on diversion, and then offered to connect with the on call physician...".

On 9/16/14 at 3:30 p.m., review of the hospital ' s policies and procedures for its communication center and review of the hospital's orientation and training for the communication center staff showed the hospital's call center had no system in place to monitor the ongoing competency of its call center staff through its policies and procedures and to ensure the appropriate training for call center staff for their responsibilities in appropriately expediting requests from other facilities for placement of patients with identified emergency medical conditions when the hospital invokes a diversionary status. This systemic failure impairs hospital management's ability to determine its own staff and on call physicians compliance with the EMTALA requirements.