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Based on interview and record review, the facility failed to ensure one of 21 sampled patients (Patient 21) was provided care within the hospital's specialized capabilities when Physician 1 refused to accept a transfer requiring trauma and orthopedic services. This failure resulted in delay of care causing the patient to be transferred to a trauma center over 2 hours away.

Findings:

During a review of Patient 21's "Emergency Room Note (EN)," from Hospital A, dated 1/27/24, the "EN" indicated, "Trauma Narrative: 19 year old otherwise healthy male with isolated GSW [gunshot wound] to the left thigh resulting in an open comminuted [multiple fragments] femur [long bone in the thigh] fracture. Review of Systems: Extremities: . . . Positive GSW to the left thigh. . . Left leg is externally rotated with a shift at the midline [deformed]. . . Patient will require Ortho [Orthopedic] and trauma services. X-ray done with 4 views of the left femur. Impression: 1. Acute Comminuted fracture of the mid to distal femur. 2. Bullet fragments peripheral to the fracture. 3. Soft tissue emphysema [air sacs in tissue], suspicious for infection. Consultations: Consultation #1: Spoke with [Hospital B] transfer center. Declined the patient for transfer. Consultations #2: Spoke with [Hospital C] transfer center. [Physician] from [Hospital C] accepts the patient for transfer. Trauma Differential Diagnosis: Femur fx [fracture], hip fx, GSW."

During a review of Hospital B's "Transfer Log (TL)," dated 1/27/24, the "TL" indicated, there was a request for ED (Emergency Department) to ED incoming transfer. Status indicated "DECLINED" on 1/27/24 3:16 a.m.- "Services not available at sending facility [Hospital A]." Services requested- Trauma. Diagnosis- Left Femur Fracture. Reason Declined- (Hospital B Physician) declined. "[Physician 1] said did not need transfer."

During a concurrent interview and record review on 2/27/24 at 12:18 p.m. with Director of Case Management (DCM), the "TL" dated 1/27/24 was reviewed. The TL indicated, trauma services was the requested from Hospital A for Patient 21. DCM stated trauma services should have been involved and contacted in this case. DCM stated Hospital B had Trauma Physicians on-call on 1/27/24. DCM confirmed only the Orthopedic Surgeon was contacted and declined the transfer without consulting the Trauma Physician.

During an interview on 2/27/24 at 9:38 a.m. with Risk Manager (RM), RM stated Hospital B had capacity on 1/27/24 to take Patient 21. RM stated Physician 1 was the Orthopedic Surgeon on call 1/27/24 and that Trauma Services had two physicians on call 1/27/24.

During an interview on 2/27/24 at 12:30 p.m. with RM, RM stated, "I reached out to Hospital A about this case, they told me that their [Hospital A's] Orthopedic Surgeon that was on call 1/27/24 did not handle traumas.

During an interview on 2/27/24 at 6:15 p.m. with Physician 1, Physician 1 stated he was the Orthopedic Surgeon on-call for Hospital B on 1/27/24 and was contacted by Hospital B's transfer center stating Hospital A wanted to transfer a patient with a GSW to the thigh that caused a femur fracture. Physician 1 stated that he requested x-ray images and was told there was not a radiologist report yet so Hospital A sent the x-ray image to his cellphone. Physician 1 stated the x-ray "was a very simple fracture that any orthopedic surgeon could handle and was told that [Hospital A] had an orthopedic Surgeon on call, and felt that he should handle it. There was no reason for the patient to be transferred." Physician 1 stated there was not a doctor-to-doctor conversation done with Hospital A because one wasn't requested. Physician 1 stated he did not consult trauma services because the only diagnosis the patient had was a Femur Fracture and Patient 21 did not require trauma services.

During a Review of "Transfer Center Documentation (TCD)," dated 1/27/24, the "TCD" indicated, "Case number 8655. 1/27/24 at 3:16 am. Indicated, "Sending location Case Type: ED to ED incoming. Sending hospital: [Hospital A] Receiving hospital [Hospital B]. Patient Type- Emergency. Transfer Reason- (EMTALA) Services not available at sending facility. Diagnosis: Trauma; Femur Fracture. Disposition: Declined/Time: 1/27/24 0432am Decline Reason: [Hospital B Physician] Declined. Physician (Declining) [Physician 1] Note: 0255- R/C [received call] from [Hospital B] requesting to initiate a transfer request for trauma requiring ortho [Orthopedic] services as [Patient 21] has a long bone fracture. 0258- S/W [spoke with] HS [house Supervisor] informing her of request. 0315- S/W [Hospital A] at which time he answered the above EMTALA Questions. After stating both trauma and orthopedic services needed and agreeing to speak to orthopedic on call first, attempted to connect both physicians yet [Physician 1] stated no need to discuss case as the only injury was to the femur. In fact, [Physician 1] requesting images to be sent to his cell number. [Hospital A] informed of [Physician 1's] request, at which time verbalizing understanding. In addition, I let [Hospital A] know we would await orthopedics decision before calling trauma physician, as [Physician 1's] decision would determine. 0324- R/C from [Physician 1] who reported after viewing images there was no need for HLOC [Health Locus of Control] as patient's femoral shaft fracture was requiring a nail repair, which could be done by any orthopedist. 0327- S/W [Hospital A] and updated him on [Physician 1's] decision, at which time he reported he would have to reach another trauma facility. 0329- S/W HS at which time was updated, with [house supervisor] stating she would reach out to on call director."

During a review of "Agreement for On-Call Coverage (AOC)," dated 10/31/23, the "AOC" indicated, Physician 1 signed the agreement. ". . . 5. Call Responsibility. During the term of this Agreement, . . . Participating physician shall provide call coverage to the Hospital in the Specialty for all Emergency Department patients and any request for EMTALA compliance-required transfers of patients to Hospital from outlying emergency departments requiring specialty evaluations, treatment, consultations, or admission . . . in accordance with the medical staff bylaws, rules/regulations, clinical protocols, and policies/procedures.

During a review of "On-Call Schedule (OCS)," dated 1/27/24, the "OCS" indicated, Physician 1 was on-call for Orthopedic Surgery. Physician 2 and Physician 3 was on call for Trauma Services.

During a review of "Medical Staff Rules and Regulations (MSRR)," dated 9/27/23, the MSRR indicated, on page 44, 11.3 On-Call Responsibilities: (a) At a minimum, participants in the on-call roster are expected to follow all applicable laws and regulations, including EMTALA, and respond in accordance with the time frames outlined in Section 2.3 (b) of these Rules and Regulations. Page 49- 13. 1 EMTALA Transfers: (a) The transfer of a patient with an emergency medical condition from the Emergency Department to another hospital will be made in accordance with the districts applicable policy and in compliance with all applicable state and federal laws, such as EMTALA.

During a review of the facility's policy and procedure (P&P) titled, "Compliance with EMTALA," dated 2/27/23, the P&P indicated, "A. Compliance: It is the policy of [Hospital B] to comply with EMTALA regulations. These regulations are mandated. . . III. General Policies: C. On-Call Response: [Hospital B] shall maintain a schedule of on-call physicians available to respond to consult or provide treatment necessary to stabilize a patient with an emergency medical condition. On-Call physician responsibilities to respond, examine, and treat emergency patients are defined in the med staff bylaws and or within the physician on call agreement. The Emergency department shall be prospectively aware of physicians who are on call to the department. The notification of an on-call physician shall be documented in the medical record and any failure or refusal of the on call physician to respond to call shall be reported to the medical staff office and the executive team member/chief medical officer."