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Based on record review and interview, the general acute care hospital (GACH) 1 failed to implement its "ER - ER Transfer Process Determination of Hospital Capacity" and "EMTALA (Screening, Stabilization and Management of Emergency Transfers)" policies and procedure. GACH 2 requested to transfer Patient 23 who was involved in motor vehicle accident and requiring a higher level of care (Level 1 trauma). GACH 1 would not accept Patient 23 due to no capacity as indicated from GACH 2 staff interview, documented call log, and the medical alert system (MAC) documentation. A review of the Diversion History Report for GACH 1 indicated 0 (zero) hours diversion for "Trauma" services and there was no documented evidence GACH 1 staff upon receipt of the transfer request documented the request for transfer, reason for the transfer, level of care needed, patient information, time of call, name of requesting facility and the reason for refusing Patient 23. This deficient practice resulted in Patient 23 traveling 21 miles from GACH 2 to GACH 3, instead of 3.9 miles from GACH 2 to GACH 1, this placed Patient 23 at risk for significant complications.

Findings:

A review of the general acute care hospital (GACH) 1 policy and procedure titled, "ER - ER Transfer Process Determination of Hospital Capacity" dated last revised on July 1, 2013, indicated "On all ER - ER transfer requests, the Transfer Center staff will inquire as to the level of care needed by the patient including the type of bed and clinical services (surgery or other procedure)...The information will be documented by the Transfer Center on the transfer log in accordance with II. G of EMTALA Policy No. 1333." The policy and procedure also indicated if there is no ER capacity, "the Transfer Center will ask the accepting Attending physician if the patient could be accepted, treated and managed in an appropriate area other than the ER."

A review of GACH 1's policy and procedure titled, "EMTALA (Screening, Stabilization and Management of Emergency Transfers) HS 1333" dated last revised on June 30, 2014, indicated the following: II.G. Documentation - The Medical Center will maintain a transfer log of incoming requests to accept emergency patients Transfers. The log will include (as applicable to the information obtained from the transferring facility): 1. The time of the call; 2. The name of the requesting facility; 3. The name of the transferring physician or requesting facility staff member; 4. The name of the individual; 5. Whether the Medical Center accepted or refused the Transfer and the reasons for refusing a Transfer (as applicable); and 6. The name of the receiving physician and/or Medical Center staff member receiving the request to accept the Transfer.

During an interview on September 15, 2014 at 1:15 p.m., the director of patient placement (RN 4 at GACH 1) stated as soon as a call was received, depending on service, team, acceptance, if there is no bed, attempt to make bed available. RN 4 stated it is very rare not to accept patient, only when there is no capacity. It is constantly changing, always trying to jog the patients for patient safety. If the patient is not accepted, it is documented.

A review of the Diversion History Report for GACH 1 indicated 184 hours, 58 minutes ED diversion in May 2014. The report indicated 0 hours, 0 minutes diversion for Trauma.

A review of Diversion History Report for GACH 1 dated May 23, 2014, indicated multiple times of emergency department (ED) diversion. For example, Hospital Diversion Category: ED; Diversion Requested Date/Time 05/23/14 16:00:01; Diversion withdrawn Date/Time 05/23/14, 2014 17:00:01.

On September 16, 2014 at 3:40 p.m., administrative assistant I (RN 5 at GACH 1)stated during an interview, when a call was received, ask the transferring facility the reason for transfer, (higher level of care, lateral, life threatening or EMTALA transfer), diagnosis. Ask transferring facility to fax demographic face sheet, and ask for the patient's level of care. RN 5 further stated all calls were to be documented on the transfer center reports and to document everything at the time.

GACH 1's Transfer Center Report for May 2014 was reviewed. Patient 23's name was not in the report, and the transfer center report log for May 23, 2014 was requested. A review of the log indicated Patient 23's name was not in the report dated May 23, 2014.

The ED record of Patient 23 at GACH 2 was reviewed on September 24, 2014. Patient 23 was a 72 years old female brought in by an ambulance after being involved in motor vehicle accident.

The (GACH 2) Consultation Report dated May 23, 2014 and dictated at 3:41 p.m., indicated Patient 23 sustained a loss of consciousness, did not remember being brought to the ED. Patient 23 was currently reporting chest and abdominal pain, and had extremity fracture (break in the bone). The patient had a cervical (neck) spine, chest and pelvis (hips) x-rays and laboratory workup. The impression indicated complex trauma motor vehicle accident with multiple rib fractures (broken rib), pneumothorax on the left (abnormal collection of air in the space that separates the lung from the chest wall), significant scapular fracture (broken shoulder blade) and splenic laceration (cut on the spleen). The plan indicated repeat complete blood count. Should there be any signs of dropping hematocrit (percentage of the volume of the red blood cells), the patient would likely require an angiogram (imaging test that uses x-rays to take pictures of blood vessels). Chest tube placement at this time and repeat chest x-ray after chest tube placement.

The report further indicated, "Due to this complex level of trauma and the fact that she (Patient 23) appears stable presently, I would recommend that she be transferred to an appropriate level 1 trauma center for appropriate trauma level of care as soon as possible."

During an interview on September 24, 2014 at 1:20 p.m., the administrative associate from GACH 2 (Staff 1) stated she spoke with Staff 2 (first name written on the log with no last name) from the Transfer Center at GACH 1. Staff 1 stated she gave the patient information to Staff 2. She stated at 4:48 p.m., Staff 2 called back and informed Staff 1 that GACH 1 would not take the transfer and to call Medical Alert Center (MAC) and pointed to the documentation on the log. Staff 1 stated she called MAC and spoke with Employee 1 (first name documented) from MAC and informed him GACH 1 would not take the patient.

A review of the ED Log from GACH 2 indicated 4 entries regarding Patient 23. The initial entry indicated a call to GACH 1 at 4:35 p.m. The second entry timed at 4:50 p.m. indicated a call to MAC. The third entry timed at 5:17 p.m. indicated GACH 3 accepted Patient 23, and the fourth entry was GACH 3's address and report to charge nurse.

On October 1, 2014, at 10:10 a.m., a telephone interview with Staff 2 (from GACH 1's Transfer Center) was conducted in the presence of RN 4 and Admin 1. Staff 2 stated he worked with the transfer center, he was an intake coordinator and the support staff as well. He stated when he got the intake, he ran it by one of the registered nurses to review the case. He asked for the patient information includes name, date of birth, diagnosis, level of care (urgent, emergent, life threatening). Staff 2 stated the practice was to document everything in the log. Staff 2 stated he worked on May 23, 2014. When asked regarding a request for patient transfer as documented from GACH 2's ED log on May 23, 2014 at 4:35 p.m., to the Transfer Center, Staff 2 stated he could not recall. Staff 2 stated GACH 2 should have called the ED directly and should have called MAC. Staff 2 also stated GACH 2 should have known the catchment area. (According to Department of Health Services, County of Los Angeles Trauma Patient Destination, trauma catchment area is a geographical area surrounding a trauma center strictly defined by streets/freeways or other physical landmarks.)

The Medical Alert Center (MAC) document/audio record dated May 23, 2014 for Patient 23 was reviewed on September 19, 2014. The entry timed at 4:40 p.m. (1640) indicated GACH 3 ED physician feels patient should be presented to GACH 1 due to it being a closer facility. At 4:41 p.m., the documentation indicated MAC relayed the previous note to GACH 2 and GACH 2 to contact GACH 1. At 4:53 p.m., GACH 2 staff (first name documented - Staff 1) informed MAC that GACH 1 "denied patient - No capacity."

A review of the Emergency Department Trauma Flow Sheet from GACH 3 dated May 23, 2014, at 7:30 p.m., indicated Patient 23 was brought in by an ambulance, the patient had chest tube to the left chest, left upper arm splint, and urine (Foley) catheter. The patient was alert and Trauma team at the bedside. Initial vital signs indicated a blood pressure reading of 141/58 (141 over 58 millimeter of mercury [mmHg]), pulse rate of 92 beats per minute, respiratory rate of 23 breaths per minute and a pain score of 8/10 (0 for no paint and 10 being the worst pain).

Patient 23 was given intravenous push morphine 5 milligrams (mg) for pain, zofran 4 mg for nausea, intravenous fluids, had laboratory tests to include blood gas and serial hemoglobin (protein in the red blood cells that carries oxygen) and had computerized tomography scan (CT - computer-processed x-rays to produce dimensional images of a specific area) of the chest, abdomen and pelvis.

A review of Patient 23's Discharge Summary by Trauma Service (GACH 3) for admission date of May 23, 2014, indicated the following diagnoses: status post motor vehicle accident with bilateral pneumothorax (abnormal collection of air in the space that separates the lung from the chest wall), fracture of manubrium (upper part of the breast bone) with small retrosternal (behind the breast bone) hematoma (localized collection of blood outside the blood vessels), bilateral pleural effusions (abnormal collection of fluids in the pleural cavity), right scapular fracture, left clavicle (broken collarbone) fracture, left T 11 and T 12 (thoracic [broken back] vertebra) fracture, left rib fractures 1 through 4 and 10 to 12, right rib fractures 1 through 9, splenic laceration grade 2. The documentation indicated with all the injuries the patient presented, the patient was admitted to the surgical intensive care unit for observation, analgesia, orthopedic consult and neurological consult.