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Based on record reviews and staff interviews, it was determined Hospital #2 was a "Rural Regional Referral Center" and failed to ensure compliance with 489.24(f), regarding recipient hospital responsibilities in accepting transfers from other hospitals. Hospital #2's On-Call Surgeon refused to accept a patient from Hospital #1 for transfer even though Hospital #2 had the capacity and specialized capabilities required to treat Patient #1. This was found for one of twenty-one records (Patient #1) reviewed during the abbreviated survey (KY #15638) on 11/30/10 through 12/03/10. Findings include:

Refer to: A2411

Based on record reviews and staff interviews, it was determined that Hospital #2 was a "Rural Regional Referral Center" and the hospital's On-Call Surgeon refused to accept a patient from Hospital #1 for transfer even though Hospital #2 had the capacity and specialized capabilities required to treat Patient #1. This was found for one of twenty-one records (Patient #1) reviewed during the abbreviated survey (KY #15638) on 11/30/10 through 12/03/10. Findings include:

Review of Hospital #1 and Hospital #2's contracts revealed the hospitals had a current, signed "Transfer Agreement" which was initiated on 08/30/00 and automatically renewed for one year terms. There was an "Addendum" to the Transfer Agreement, dated 05/09/02, due to "the two hospitals contracting under the patient agreement (Critical Access Hospital Program)." Further review, revealed Hospital #2 was a "Rural Regional Referral Center."

The medical records from Hospital #1 and Hospital #3 were reviewed for Patient #1. The Incident Report from Hospital #1's Emergency Room (ER) was also reviewed. The reviews revealed Patient #1 presented to the ER at Hospital #1 on 09/13/10 at 12:09 PM with complaints of "abdominal pain and right side back pain." The medical screening examination and diagnostic testing revealed Patient #1 had an "acute appendicitis" which required specialized surgical intervention, which was a service not provided at Hospital #1. The ER Physician at Hospital #1 attempted to contact the On-Call Surgeon at Hospital #2 (13.83 miles in distance/approximately 21 minutes away) on 09/13/10 at 2:15 PM. However, Hospital #2's On-Call Surgeon was in a scheduled gall bladder surgical case at the time of the call. The ER Physician from Hospital #1 requested the Surgical Clerk from Hospital #2 write down the information concerning Patient #1's need for transfer to the services of the On-Call Surgeon due to an acute appendicitis and to inform the On-Call Surgeon. At approximately 2:30 PM Hospital #2's Surgical Clerk returned the call for the On-Call Surgeon and asked the ER Physician at Hospital #1 what type of insurance Patient #1 had, and when informed the patient had no insurance, the Surgical Clerk stated the On-Call Surgeon "declined acceptance and said he was not on call for Hospital #1." The ER Physician from Hospital #1 requested the Surgical Clerk explain to the On-Call Surgeon that this was an acute appendicitis and she was informed "he still refused to accept" the patient. Hospital #1's ER Physician contacted Hospital #3 (96.80 miles in distance/approximately 1 hour and 37 minutes away) and the On-Call Surgeon for Hospital #3 told Hospital #1's ER Physician he could not accept Patient #1 until a bed was available at Hospital #3. He suggested Hospital #1's ER Physician once again contact Hospital #2's On-Call Surgeon and give him the opportunity to reconsider accepting Patient #1. Hospital #3's On-Call Surgeon informed Hospital #1's ER Physician that if Hospital #2's On-Call Surgeon still refused to accept Patient #1, she should inform him his refusal to accept the patient as a transfer was an EMTALA violation. Hospital #3's On-Call Surgeon informed Hospital #1's Physician that he would contact her when a bed was available, in case she hadn't found an accepting hospital and Surgeon for Patient #1. Hospital #1's ER Physician contacted Hospital #2's On-Call Surgeon on 09/13/10 at 4:50 PM and requested he accept Patient #1 as a transfer. She informed Hospital #2's Surgeon that she was unable to find a facility with a bed and she "was in need of his help with the situation." Hospital #2's Surgeon then asked Hospital #1's ER Physician if she was working in the ER for free. He said, "Exactly, if you don't work for free, why should I?" Hospital #1's Physician informed Hospital #2's Physician that she had contacted numerous hospitals but no beds were available. She stated, "You are the surgeon on-call and you are the closest facility with a surgeon available. The patient suffers from acute appendicitis and needs surgery. Are you still refusing?" Hospital #2's On-Call Surgeon still refused to accept Patient #1. Hospital #1's ER Physician informed Hospital #2's On-call Surgeon that after speaking to Hospital #3, she was concerned about the "EMTALA law" and didn't know if he (Hospital #2) or she (Hospital #1) could be held responsible. He (Hospital #2) asked her (Hospital #1) if she was "threatening him." She told him "No" she was only trying to do what was right for the patient. He asked her if she "was being a smart ass" and then he hung up the phone. Hospital #3's Surgeon called Hospital #1's ER Physician back on 09/13/10 at 5:30 PM and informed her a bed was available for Patient #1 to be transferred to if it was still needed. Hospital #1's ER Physician gave report to Hospital #3's On-Call Surgeon and Patient #1 was transferred to Hospital #3 on 09/13/10 at 6:00 PM. Patient #1 arrived at Hospital #3 on 09/13/10 at approximately 9:00 PM with the diagnosis of an acute appendicitis. Hospital #3's On-Call Surgeon examined Patient #1 and performed "Emergency General Surgery" which consisted of a "Laparoscopic Appendectomy" on 09/13/10 at 9:49 PM. Patient #1 was discharged home on 09/14/10.

A telephone interview was conducted with Hospital #1's ER Physician on 11/18/10 at 3:15 PM. She revealed she attempted to transfer Patient #1, who suffered from acute appendicitis and required surgery, to Hospital #2's On-Call Surgeon on two different occasions on 09/13/10, with no success. She revealed the first transfer attempt was on 09/13/10 at approximately 2:15 PM, but he refused to accept the transfer when he found out Patient #1 had no insurance. She stated she called numerous hospitals and no beds were available and/or the hospital was on a diversionary status and was only accepting trauma patients. She revealed she called Hospital #2's On-Call Surgeon a second time on 09/13/10 at approximately 4:50 PM and he once again refused to accept Patient #1. He (Hospital #2) informed her (Hospital #1) that she was "threatening" him when she mentioned not accepting Patient #1 would be an "EMTALA" violation and then Hospital #2's On-Call Surgeon hung up the phone on Hospital #1's ER Physician during her second transfer attempt for Patient #1. She (Hospital #1) revealed Patient #1 was transferred to Hospital #3's On-Call Surgeon by ambulance on 09/13/10 at 6:00 PM due to Hospital #2's On-Call Surgeons continued refusal to accept Patient #1 as a transfer.

An interview was conducted at the facility on 11/30/10 at 3:40 PM with Hospital #2's On-Call Surgeon for 09/13/10. He stated, "I didn't feel I could take the patient, I had other obligations, I had children who needed to be picked up from school. I already performed two surgeries, and I wasn't on call for Hospital #1, I was on call for Hospital #2." He revealed the patient "wasn't an emergency case and could wait." He stated his/her vital signs were normal, the CT Scan showed no rupture of the appendix or fluids present, and his/her white blood cell count was elevated but not too elevated as he recalled. He stated he recalled asking the Surgical Clerk if Patient #1 had insurance after reading the information about Patient #1's case, which was called in to him by Hospital #1's ER Physician. He revealed the Surgical Clerk called Hospital #1 back to inquire about Patient #1's insurance at his request. He stated, "I always ask about insurance, out of habit I think." When the surveyor asked if the patient not having insurance had anything to do with him not accepting the patient, he stated, "No, I thought I had a right to refuse a patient. Are you saying I have to accept all patients, because this is new to me." He stated the ER Physician from Hospital #1 called him back and informed him a doctor from Hospital #3 suggested Hospital #1's doctor call him again to see if he'd reconsider accepting Patient #1, because his refusal to accept Patient #1 as a transfer was an "EMTALA violation." He stated, "I felt she (Hospital #1's ER Physician) was threatening me when she brought EMTALA into it." When questioned and asked if he had asked Hospital #1's ER Physician if she was working for free, he responded, "I did ask her if she was working for Hospital #1's ER for free." When asked if he was aware of the transfer agreement Hospital #2 had with Hospital #1 and/or if he was aware Hospital #2 was a Rural Regional Referral Center, he stated, "No", he was not made aware of the transfer agreement or that Hospital #2 was a Regional Referral Center.

Telephone interviews were conducted with Hospital #3's On-Call Surgeon on 11/22/10 at 3:00 PM (during a different investigation, KY #15570, related to Patient #1 and the 09/13/10 incident) and on 12/09/10 at 3:45 PM. He revealed Hospital #2's On-Call Surgeon should have accepted Patient #1 since Hospital #2 was the closer hospital and had the capacity and capabilities to perform what the patient needed, which was a "simple appendectomy." He stated there was no reason for the patient to be transported a long distance for an appendectomy. He revealed the delay in treatment could have resulted in the patient's appendix rupturing which could have resulted in sepsis. He revealed the patient was fortunate and had no complications. He stated he felt this was an EMTALA violation and this type of transfer should stop. He requested to be made aware of CMS's final determination.

An interview was conducted with Hospital #2's Chief Executive Officer (CEO) on 11/30/10 at 9:00 AM. He revealed he was not aware of an on-call physician refusing to accept a transfer. He stated no patient should be refused care if the hospital had the capacity and capabilities to treat the patient. He acknowledged Hospital #2 was a "Rural Regional Referral Center" and had a "Transfer Agreement" with Hospital #1.