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Based on review of medical records, EMTALA (Emergency Medical Treatment & Labor Act) Transfer Acceptance or Denial Form, Daily Census Report, facility's EMTALA policy and interviews, it was determined the facility failed to ensure the on call thoracic surgeon accepted the transfer of Patient Identifier (PI) # 1 from Hospital # 1 (33.2 miles from East Alabama Medical Center - EAMC) and EAMC had the capacity and capability to treat. PI # 1 was ultimately transferred on 5/29/18 at 12: 02 AM to Hospital # 4 (139 miles from originating Hospital # 1).

This affected 1 of 15 emergency department requests of patients appropriate for transfer.

Findings include:

Refer to A2404 - On Call Physicians and A2411 - Recipient Hospital Responsibilities for findings.

Based on review of medical records, EMTALA (Emergency Medical Treatment & Labor Act) Transfer Acceptance or Denial Form, Daily Census Report, facility's EMTALA policy and interviews, it was determined the on call thoracic surgeon failed to accept Patient Identifier (PI) # 1, which the facility had the capacity and capability to treat. This affected 1 of 15 emergency department (ED) requests of patients appropriate for transfer. PI # 1 was ultimately transferred on 5/29/18 at 12: 02 AM to Hospital # 4 (139 miles from originating Hospital # 1).

Findings include:

Facility Policy and Procedure
Subject: Emergency Medical Screening, Treatment and Transfer
Issued: 01/91
Revised: 6/96, 5/98, 1/06, 10/16

It is the policy of East Alabama Medical Center ("EAMC") and its affiliated entities to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act... This Act applies to hospital with emergency departments participating in the Medicare program, and includes all individuals regardless of their Medicare/Medicaid eligibility or their ability to otherwise pay for services rendered. An Emergency Department physician, other EAMC staff physician, or nurse practitioner will evaluate all individuals arriving at the Emergency Department unless alternative arrangements are made pursuant to this policy. Child Birth Unit nurse, in personal or phone consultation with Obstetricians, will evaluate and triage patients in suspected labor...

D. Transfers In

Federal Law requires that a hospital with specialized capabilities or facilities cannot refuse to accept an appropriate transfer of an individual needing such specialized treatment if the transferring facility does not have such services. Only if the specialized personnel are unavailable at the time of transfer, equipment is in use, or specialized facilities are filled to capacity, can the hospital legitimately refuse the transfer.

The process for handling requests for a transfer from a referring hospital is:

(1) All transfer requests must be routed first to the Bed Capacity Center Transfer Coordinator or manager/director during business hours and to the House Supervisor after hours and on weekends.

(2) The designated staff listed above shall make an initial assessment regarding whether or not EAMC offers the services needed and whether or not there is an appropriate bed available. If the answer to either of these is NO the transfer request will be denied by the Transfer Coordinator, manager/director or House Supervisor and communicated to the requesting hospital. If the answer to BOTH of these questions is YES, the designated staff listed above shall contact the appropriate physician on-call.

(3) If transfer is clearly appropriate, the on-call physician may immediately accept the patient. If so, the Transfer Coordinator or designated staff as previously listed will contact the requesting hospital and communicate acceptance. The physician on-call may want to discuss the patient with the requesting hospital. If so, the switchboard will initiate a 3-way call between the requesting hospital, physician on-call, and Transfer Coordinator, Acceptance is communicated during this call...

Physician on-call refuses patient:

... (5) If refusal is clearly appropriate, reason for refusal is communicated to requesting hospital by Transfer Coordinator for clinical reasons, the Transfer Coordinator will consult an ED physician. If the ED physician agrees with refusal, reason for refusal is communicated to requesting hospital by Transfer Coordinator. If the ED physician does not agree with the reason for refusal, the Transfer Coordinator will call the Administrator-on-call (AOC), who will discuss the reasons for refusal with the physician on-call. If the AOC determines that refusal is valid, Transfer Coordinator will communicate reason for refusal to requesting hospital. If AOC determines that transfer is appropriate, Transfer Coordinator will be instructed to accept transfer. AOC will communicate acceptance to on-call physician.

Review of PI # 1's medical records from Hospital # 1 revealed:
PI # 1 presented to Hospital # 1's ED via ambulance on 5/28/18 at 2:35 PM with chief complaints of, "... pt (patient) reports left rib pain, shortness of breath after falling 4 days... Onset: about 4 days ago..." Review of the Triage / Assessment at 2:40 PM, revealed the patient's vital signs were stable at that time with no documented shortness of breath and no abnormal respiratory findings. Review of the ED physician's assessment on 5/28/18 at 3:04 PM revealed, "... Respiratory: Chest tender; moderate tenderness located in the central, left and lateral chest... Chest wall: moderate tenderness located in the middle, left and lateral chest... Breath sounds abnormal. Decreased breath sounds in the left lung base posteriorly and mid-lung posteriorly..."

Review of the left chest / ribs x-ray dated 5/28/18 at (transcribed at 6:21 PM) revealed, "... 3 views of the chest were obtained showing a large layering left-sided pleural effusion with left lower lobe atelectasis. The right lung is well expanded and clear. No focal rib fractures are identifier. There is no pneumothorax. Conclusion: Large left-sided pleural effusion as discussed above..."

Review of the ED Physician's documentation dated 5/28/18 revealed the patient was sedated; a chest tube was inserted, secured with sutures. The chest tube placement was confirmed with chest x-ray and the tube was attached to a drainage system with suction and a single-bottle collection system. The physician documented the estimated blood loss was 1650 ml (milli-liters). The Registered Nurse (RN) documented the time as 7:15 PM, "... Time-out completed immediately before the procedure per protocol... Chest tube insertion performed by ED physician. Assisted by two nurses and one tech... Total time of assist / procedure: 45 minutes..."

Review of the ED physician's documentation revealed, "... Progress and Procedures: Course of care: 8:21 PM - Hospital # 2 called re-transfer at 1900 hours (7:00 PM) and declined referral since they have no Thoracic Surgeon... 1915 (7:15 PM) Hospital # 3 declined as they ave no Trauma Surgeon... 19:30 (7:30 PM) Employee Identifier (EI) # 1, Thoracic Surgeon at EAMC (East Alabama Medical Center) declined transfer since Hospital # 3 should have accepted. Subsequently spoke to (Physician's name) at Hospital # 4 who accepted the patient on the understanding that an Abdominal CT (computed tomography) would be performed to r/o (rule out) other trauma. This was done and proved to be negative.... 22:15 (8:15 PM) (Physician at Hospital # 4) accepted transfer to (Hospital # 4)..."

The patient's ED care also included the patient having received one unit of packed red blood cells.

On 5/28/18 at 8:36 PM, the RN documented, "... Report from (ED Physician at Hospital # 1) that (EI # 1 EAMC Thoracic Surgeon) refused to accept stating that if Hospital # 3 will call and explain why the pt was refused he would accept the pt, that (Hospital # 3) should take the pt (patient)..."

Disposition of the patient was a transfer to Hospital # 4, which the patient was in agreement. The patient was transferred via ambulance to Hospital # 4 on 5/29/18 at 12:02 AM.

Review of the medical record documentation from Hospital # 4 revealed:

Review of the History & Physical dated 5/29/18 revealed the patient was received in transfer from Hospital # 1. The patient was admitted to Hospital # 4 with hemothorax with left rib fracture, hypertension, schizophrenia and questionable peptic ulcer disease. The physician documented, "...I have seen and evaluated the patient... L (left) hemothorax s/p (status / post) fall causing 11th rib fracture... (he/she) is breathing room air comfortably. Hemodynamics stable... CT scan shows minimal residual hemothorax, L lung contusion. Will minimize IV (intravenous) fluids, work on pain control and hopefully d/c tube and d/c home tomorrow..."

Review of the Discharge Summary dated 5/30/18 revealed the reason for hospitalization included, "...transfer for possible decortication, but not needed, only pulmonary contusions on CT chest..." (Decortication is a surgical procedure that removes a restrictive layer of fibrous tissue overlying the lung, chest wall, and diaphragm. The aim of decortication is to remove this layer and allow the lung to re-expand.)

The patient was discharged home in stable condition on 5/30/18.

Review of the EMTALA Transfer Acceptance or Denial Form (EAMC form) dated 5/28/18 revealed EI # 2, RN - Nursing Shift Supervisor documented having received a call from Hospital # 1 requesting transfer of PI # 1 to EAMC. "... Transfer Information: Reason for Transfer: Needs Specialized Level of Care Other Thoracic Surgery. Have you been denied transfer by another facility / MD (physician)... Who? Explain: (Hospital # 2) - Does not have a Thoracic Surgeon on Call (Hospital # 3) - Thoracic refused because he does not have a trauma surgeon for back up... Comments: ED physician at Hospital # 1 and EI # 1, Thoracic Surgeon at EAMC spoke regarding the patient and... diagnosis as well as the current treatment plan. The patient fell at home last Friday and landed on... ribs... came in today because... was having increased pain and difficulty breathing. A CT scan showed a hemothorax. Hospital # 1's ED physician drained about 1600 mls of blood and inserted a chest tube... has already tried to get the patient to Hospital # 2 and Hospital # 3... Hospital # 2 said they no longer have a thoracic surgeon. Hospital # 3's Thoracic Surgeon refused the patient because he does not have a trauma surgeon back up. EI # 1, (Thoracic Surgeon at EAMC) and Hospital # 1's ED physician disagreed with this. EI # 1 said he would take the patient, but the thoracic surgeon at Hospital # 3 needs to call him and explain why he is refusing. Hospital # 1's ED physician agreed with this and thanked EI # 1 for his time..." There was no documentation of the "Transfer Status" on this document.

Review of the Daily Census Report dated 5/28/18 revealed the following beds were available for patient placement:
2 SW (Southwest) - Cardiac Step Down Unit - 3 beds, 4 SE (Southeast) - Medical - 5 beds
5 ST / T (South Telemetry / Telemetry) Orthopedics - 8 beds (5 ST/T was included due to the patients who were assigned to that unit on 5/28/18 included medical patients.)
6 ST / T - Surgical - 9 beds, 7 ST / T - Medical - 3 beds
8 SE - Progressive Care Unit - 2 beds, 8 SW - Cardiac Special Care Unit - 2 beds
CVU / CVICU (Cardiovascular Intensive Care Unit) - 4 beds
ICU (Intensive Care Unit) - 4 beds

It was determined through review of the above census; the facility had capacity available for the requested transfer of the patient, PI # 1.

An interview was conducted on 6/20/18 at 10:15 AM with EI # 3, RN - Patient Flow Coordinator to determine the process for requests for transfer from another hospital to EAMC. EI # 3 stated when a call is received the Bed Capacity Center (BCC) staff or House Supervisor (if after 10 PM and on weekends) finds out what service is needed, places the call on hold and contacts the on-call physician. Once the on call physician is on the telephone, we have a three way call between the facility and the on call physician. The surveyor asked at what point in the process is the physician contacted. EI # 3 stated the staff check to see if there is a bed available first, then the on-call physician is contacted.

An interview was conducted on 6/20/18 at 4:30 PM with EI #2, RN - Nursing Shift Supervisor. The surveyor presented the above EMTALA Transfer Acceptance or Denial Form (EAMC form) dated 5/28/18 concerning a request to transfer PI # 1 to EAMC and asked what he recalled. EI # 2 stated he received the call from Hospital # 1's ED physician who led the conversation stating, "we have an EMTALA situation... patient fell Friday before and (Hospital # 1's ED physician) tried to get the patient transferred to 2 other hospitals about transferring the patient..." EI # 2 stated Hospital # 1's ED physician had spoken with a Thoracic surgeon at Hospital # 3 and transfer was refused. EI # 2 stated that EI # 1, Thoracic surgeon at EAMC stated he would accept the patient, but he wanted to speak to the physician that refused the patient due to no trauma surgeon for back up. The surveyor asked what the outcome was for this patient. He stated that EI # 1 accepted the patient but wanted to speak with the physician at Hospital # 3.

A telephone interview was conducted on 6/21/18 at 12:36 PM with Hospital # 1's ED physician that cared for PI # 1 on 5/28/18, who verified he recalled the patient. When questioned about the events, he stated they had a difficult time finding a hospital that could take the patient. He stated they called Hospital # 2 and were informed they did not have a thoracic surgeon. Then called Hospital # 3 and the thoracic surgeon stated he did not have trauma back up surgeon. The physician stated he then called EAMC and spoke with the thoracic surgeon there (The thoracic surgeon's name was that of EI # 1). The ED physician stated EI # 1 said that Hospital # 3 should have accepted the patient, if the thoracic surgeon (Hospital # 3) will call him and explain why the patient was not accepted; then he would take the patient. Hospital # 1's ED physician stated that he told EI # 1 that was up to him (EI # 1) to contact the thoracic surgeon at Hospital # 3. The ED physician stated once he hung up the phone with EI # 1, the decision was made immediately to contact Hospital # 4 to get the patient transferred. The surveyor asked at that point, did he think that was a denied transfer, he stated, "Yes." Once he hung up the phone with EI # 1, he immediately got on the telephone with Hospital # 4 to get the patient transferred.

Based on review of medical records, EMTALA (Emergency Medical Treatment & Labor Act) Transfer Acceptance or Denial Form, Daily Census Report, facility's EMTALA policy and interviews, it was determined the on call thoracic surgeon failed to accept Patient Identifier (PI) # 1, which the facility had the capacity and capability to treat. This affected 1 of 15 emergency department (ED) requests of patients appropriate for transfer. PI # 1 was ultimately transferred on 5/29/18 at 12: 02 AM to Hospital # 4 (139 miles from originating Hospital # 1).

Findings include:

Facility Policy and Procedure
Subject: Emergency Medical Screening, Treatment and Transfer
Issued: 01/91
Revised: 6/96, 5/98, 1/06, 10/16

It is the policy of East Alabama Medical Center ("EAMC") and its affiliated entities to comply with all applicable laws and regulations relating to the provision of emergency services, including the Emergency Medical Treatment and Active Labor Act... This Act applies to hospital with emergency departments participating in the Medicare program, and includes all individuals regardless of their Medicare/Medicaid eligibility or their ability to otherwise pay for services rendered. An Emergency Department physician, other EAMC staff physician, or nurse practitioner will evaluate all individuals arriving at the Emergency Department unless alternative arrangements are made pursuant to this policy. Child Birth Unit nurse, in personal or phone consultation with Obstetricians, will evaluate and triage patients in suspected labor...

D. Transfers In

Federal Law requires that a hospital with specialized capabilities or facilities cannot refuse to accept an appropriate transfer of an individual needing such specialized treatment if the transferring facility does not have such services. Only if the specialized personnel are unavailable at the time of transfer, equipment is in use, or specialized facilities are filled to capacity, can the hospital legitimately refuse the transfer.

The process for handling requests for a transfer from a referring hospital is:

(1) All transfer requests must be routed first to the Bed Capacity Center Transfer Coordinator or manager/director during business hours and to the House Supervisor after hours and on weekends.

(2) The designated staff listed above shall make an initial assessment regarding whether or not EAMC offers the services needed and whether or not there is an appropriate bed available. If the answer to either of these is NO the transfer request will be denied by the Transfer Coordinator, manager/director or House Supervisor and communicated to the requesting hospital. If the answer to BOTH of these questions is YES, the designated staff listed above shall contact the appropriate physician on-call.

(3) If transfer is clearly appropriate, the on-call physician may immediately accept the patient. If so, the Transfer Coordinator or designated staff as previously listed will contact the requesting hospital and communicate acceptance. The physician on-call may want to discuss the patient with the requesting hospital. If so, the switchboard will initiate a 3-way call between the requesting hospital, physician on-call, and Transfer Coordinator, Acceptance is communicated during this call...

Physician on-call refuses patient:

... (5) If refusal is clearly appropriate, reason for refusal is communicated to requesting hospital by Transfer Coordinator for clinical reasons, the Transfer Coordinator will consult an ED physician. If the ED physician agrees with refusal, reason for refusal is communicated to requesting hospital by Transfer Coordinator. If the ED physician does not agree with the reason for refusal, the Transfer Coordinator will call the Administrator-on-call (AOC), who will discuss the reasons for refusal with the physician on-call. If the AOC determines that refusal is valid, Transfer Coordinator will communicate reason for refusal to requesting hospital. If AOC determines that transfer is appropriate, Transfer Coordinator will be instructed to accept transfer. AOC will communicate acceptance to on-call physician.

Review of PI # 1's medical records from Hospital # 1 revealed:
PI # 1 presented to Hospital # 1's ED via ambulance on 5/28/18 at 2:35 PM with chief complaints of, "... pt (patient) reports left rib pain, shortness of breath after falling 4 days... Onset: about 4 days ago..." Review of the Triage / Assessment at 2:40 PM, revealed the patient's vital signs were stable at that time with no documented shortness of breath and no abnormal respiratory findings. Review of the ED physician's assessment on 5/28/18 at 3:04 PM revealed, "... Respiratory: Chest tender; moderate tenderness located in the central, left and lateral chest... Chest wall: moderate tenderness located in the middle, left and lateral chest... Breath sounds abnormal. Decreased breath sounds in the left lung base posteriorly and mid-lung posteriorly..."

Review of the left chest / ribs x-ray dated 5/28/18 at (transcribed at 6:21 PM) revealed, "... 3 views of the chest were obtained showing a large layering left-sided pleural effusion with left lower lobe atelectasis. The right lung is well expanded and clear. No focal rib fractures are identifier. There is no pneumothorax. Conclusion: Large left-sided pleural effusion as discussed above..."

Review of the ED Physician's documentation dated 5/28/18 revealed the patient was sedated; a chest tube was inserted, secured with sutures. The chest tube placement was confirmed with chest x-ray and the tube was attached to a drainage system with suction and a single-bottle collection system. The physician documented the estimated blood loss was 1650 ml (milli-liters). The Registered Nurse (RN) documented the time as 7:15 PM, "... Time-out completed immediately before the procedure per protocol... Chest tube insertion performed by ED physician. Assisted by two nurses and one tech... Total time of assist / procedure: 45 minutes..."

Review of the ED physician's documentation revealed, "... Progress and Procedures: Course of care: 8:21 PM - Hospital # 2 called re-transfer at 1900 hours (7:00 PM) and declined referral since they have no Thoracic Surgeon... 1915 (7:15 PM) Hospital # 3 declined as they ave no Trauma Surgeon... 19:30 (7:30 PM) Employee Identifier (EI) # 1, Thoracic Surgeon at EAMC (East Alabama Medical Center) declined transfer since Hospital # 3 should have accepted. Subsequently spoke to (Physician's name) at Hospital # 4 who accepted the patient on the understanding that an Abdominal CT (computed tomography) would be performed to r/o (rule out) other trauma. This was done and proved to be negative... @ 22:15 (8:15 PM) (Physician at Hospital # 4) accepted transfer to (Hospital # 4)..."

The patient's ED care also included the patient having received one unit of packed red blood cells.

On 5/28/18 at 8:36 PM, the RN documented, "... Report from (ED Physician at Hospital # 1) that (EI # 1 EAMC Thoracic Surgeon) refused to accept stating that if Hospital # 3 will call and explain why the pt was refused he would accept the pt, that (Hospital # 3) should take the pt (patient)..."

Disposition of the patient was a transfer to Hospital # 4, which the patient was in agreement. The patient was transferred via ambulance to Hospital # 4 on 5/29/18 at 12:02 AM.

Review of the medical record documentation from Hospital # 4 revealed:

Review of the History & Physical dated 5/29/18 revealed the patient was received in transfer from Hospital # 1. The patient was admitted to Hospital # 4 with hemothorax with left rib fracture, hypertension, schizophrenia and questionable peptic ulcer disease. The physician documented, "... I have seen and evaluated the patient... L (left) hemothorax s/p (status / post) fall causing 11th rib fracture... (he/she) is breathing room air comfortably. Hemodynamics stable... CT scan shows minimal residual hemothorax, L lung contusion. Will minimize IV (intravenous) fluids, work on pain control and hopefully d/c tube and d/c home tomorrow..."

Review of the Discharge Summary dated 5/30/18 revealed the reason for hospitalization included, "... transfer for possible decortication, but not needed, only pulmonary contusions on CT chest..." (Decortication is a surgical procedure that removes a restrictive layer of fibrous tissue overlying the lung, chest wall, and diaphragm. The aim of decortication is to remove this layer and allow the lung to re-expand.)

The patient was discharged home in stable condition on 5/30/18.

Review of the EMTALA Transfer Acceptance or Denial Form (EAMC form) dated 5/28/18 revealed EI # 2, RN - Nursing Shift Supervisor documented having received a call from Hospital # 1 requesting transfer of PI # 1 to EAMC. "... Transfer Information: Reason for Transfer: Needs Specialized Level of Care Other Thoracic Surgery. Have you been denied transfer by another facility / MD (physician)... Who? Explain: (Hospital # 2) - Does not have a Thoracic Surgeon on call (Hospital # 3) - Thoracic refused because he does not have a trauma surgeon for back up... Comments: ED physician at Hospital # 1 and EI # 1, Thoracic Surgeon at EAMC spoke regarding the patient and... diagnosis as well as the current treatment plan. The patient fell at home last Friday and landed on... ribs... came in today because... was having increased pain and difficulty breathing. A CT scan showed a hemothorax. Hospital # 1's ED physician drained about 1600 mls of blood and inserted a chest tube... has already tried to get the patient to Hospital # 2 and Hospital # 3... Hospital # 2 said they no longer have a thoracic surgeon. Hospital # 3's Thoracic Surgeon refused the patient because he does not have a trauma surgeon back up. EI # 1, (Thoracic Surgeon at EAMC) and Hospital # 1's ED physician disagreed with this. EI # 1 said he would take the patient, but the thoracic surgeon at Hospital # 3 needs to call him and explain why he is refusing. Hospital # 1's ED physician agreed with this and thanked EI # 1 for his time..."

There was no documentation of the "Transfer Status" on the above document.

Review of the Daily Census Report dated 5/28/18 revealed the following beds were available for patient placement:
2 SW (Southwest) - Cardiac Step Down Unit - 3 beds, 4 SE (Southeast) - Medical - 5 beds
5 ST/ T - (South Telemetry / Telemetry) Orthopedics - 8 beds (5 ST/T was included due to the patients who were assigned to that unit on 5/28/18 included medical patients.)
6 ST / T - Surgical - 9 beds, 7 ST / T - Medical - 3 beds,
8 SE - Progressive Care Unit - 2 beds, 8 SW - Cardiac Special Care Unit - 2 beds
CVU / CVICU (Cardiovascular Intensive Care Unit) - 4 beds
ICU (Intensive Care Unit) - 4 beds

It was determined through review of the above census; the facility had capacity available for the requested transfer of the patient, PI # 1.

An interview was conducted on 6/20/18 at 10:15 AM with EI # 3, RN - Patient Flow Coordinator to determine the process for requests for transfer from another hospital to EAMC. EI # 3 stated when a call is received the Bed Capacity Center (BCC) staff or House Supervisor (if after 10 PM and on weekends) finds out what service is needed, places the call on hold and contacts the on-call physician. Once the on call physician is on the telephone, we have a three way call between the facility and the on call physician. The surveyor asked at what point in the process is the physician contacted. EI # 3 stated the staff check to see if there is a bed available first, then the on-call physician is contacted.

An interview was conducted on 6/20/18 at 4:30 PM with EI #2, RN - Nursing Shift Supervisor. The surveyor presented the above EMTALA Transfer Acceptance or Denial Form (EAMC form) dated 5/28/18 concerning a request to transfer PI # 1 to EAMC and asked what he recalled. EI # 2 stated he received the call from Hospital # 1's ED physician who led the conversation stating, "we have an EMTALA situation... patient fell Friday before and (Hospital # 1's ED physician) tried to get the patient transferred to 2 other hospitals about transferring the patient." EI # 2 stated Hospital # 1's ED physician had spoken with a Thoracic surgeon at Hospital # 3 and transfer was refused. EI # 2 stated that EI # 1, Thoracic surgeon at EAMC stated he would accept the patient, but he wanted to speak to the physician that refused the patient due to no trauma surgeon for back up. The surveyor asked what the outcome was for this patient. He stated that EI # 1 accepted the patient but wanted to speak with the physician at Hospital # 3.

A telephone interview was conducted on 6/21/18 at 12:36 PM with Hospital # 1's ED physician that cared for PI # 1 on 5/28/18, who verified he recalled the patient. When questioned about the events, he stated they had a difficult time finding a hospital that could take the patient. He stated they called Hospital # 2 and were informed they did not have a thoracic surgeon. Then called Hospital # 3 and the thoracic surgeon stated he did not have trauma back up surgeon. The physician stated he then called EAMC and spoke with the thoracic surgeon there (The thoracic surgeon's name was that of EI # 1). The ED physician stated EI # 1 said that Hospital # 3 should have accepted the patient, if the thoracic surgeon (Hospital # 3) will call him and explain why the patient was not accepted; then he would take the patient. Hospital # 1's ED physician stated that he told EI # 1 that was up to him (EI # 1) to contact the thoracic surgeon at Hospital # 3. The ED physician stated once he hung up the phone with EI # 1, the decision was made immediately to contact Hospital # 4 to get the patient transferred. The surveyor asked at that point, did he think that was a denied transfer, he stated, "Yes." Once he hung up the phone with EI # 1, he immediately got on the telephone with Hospital # 4 to get the patient transferred.