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Based on interview and record review, the hospital failed to adhere to the provider's agreement that required a hospital to be compliant with §42 CF R 489.24, Special responsibilities of Medicare hospitals in emergency cases. The facility failed to accept a pediatric patient in transfer, when they had the capacity and capability of providing care for emergency medical condition for Patients ID #1 and #8.

Refer to tag A 2411 for additional information.

Based on review of documents and interviews with Facility A staff, Facility A failed to accept appropriate transfer of pediatric patients with emergency medical conditions, who required specialized capabilities, which Facility A had the capability and capacity to treat in 2 of 7 transfer in requests reviewed. Facility A's

1) On-call pediatric critical care medicine physician (Staff ID # 73) and pediatric hematologist/oncologist (Staff ID # 72) refused to accept a pediatric patient with concern for pneumonia, sepsis and anemia. (Patient ID #1).

2) On-call pediatric hospital medicine physician (Staff ID #83) refused to accept a patient who may have required pediatric surgery consultation and/or surgery, stating they did not have the capability of providing care for the likely diagnosis of biliary atresia (Patient ID #8).

Findings Included:

Patient ID #1

Record review of Facility B ED Medical Record for Patient ID #1 reflected she was a 6-year-old female with a history of leukemia who completed chemotherapy six months prior, who presented to Facility B with ongoing cough, fever, and new pallor in the context of recent influenza illness and subsequent pneumonia on outpatient antibiotics. She was found to be septic from pneumonia and had pancytopenia with neutropenic fever and anemia with hemoglobin of 5.7. Medical records reflect transfer to Facility A was declined due to lack of bone marrow transplant services. However, Facility A had the capability and capacity to stabilize and treat the patient's Emergency Medical Conditions (EMC) of possible sepsis due to pneumonia, fever and anemia.

Review of facility A document labeled "Transfer Center Timeline for (redacted) Patient ID #1" reflected Facility B contacted Facility A on 2/20/2025 at 3:27 pm. Record stated "Capacity MC (Main Campus - PED (Pediatrics floor)/PICU (Pediatric Intensive Care Unit) open." The Transfer record reflected Facility B ED Staff Physician ID # 89 requested transfer to Facility A for higher level of care for Patient ID #1 through the patient placement center (transfer center). Transfer center records reflected Pediatric Hematology/Oncology specialist Staff ID # 72 and Pediatric Critical Care Medicine physician Staff ID # 73 participated in the recorded doctor to doctor call with Facility ED Staff Physician ID #89. "4:09 pm Transfer record stated "Transfer Request Canceled. Reason: Service Unavailable." Records reflect Facility A refused transfer for Patient ID #1 on 2/20/2025 at 4:09pm due to lack of capability.

Record review of Facility A pediatric critical care medicine call schedule for 2/20/2025 reflected pediatric critical care medicine Staff ID # 73 was on call for 24 hour period for Facility A's main campus pediatric critical care unit, which had pediatric inpatient capacity and capability.

Record review of Facility A pediatric hematology/oncology call schedule for 2/20/2025 reflected pediatric hematology/oncology Staff ID # 72 was on call for 24 hour period for Facility A's main campus.

Telephone Interview with Facility A Hematology/Oncology Physician Staff ID # 72 on 4/8/25 at 3:35 pm. He confirmed that he participated in the transfer center phone call for Patient ID #1. He stated that he believed the facility did not have capability to provide the bone marrow transplant that the patient may need for likely relapsed leukemia. He confirmed that the facility had pediatric medicine, pediatric intensive care medicine and unit and pediatric infectious disease consultants. He confirmed he was aware that patient had infection, concern for sepsis and anemia. However, he felt the care needed to be provided at a comprehensive center that could manage the patient's likely leukemia reoccurrence. He confirmed Facility A had the ability to perform diagnostic hematologic testing such as bone marrow aspirations, peripheral smears, etc. He stated he felt that should be perfromed by the center who would be responsible for definitive bone marrow transplant.

Patient ID #8:
Review of facility A document labeled "Transfer Center Timeline for (redacted) Patient ID #8" stated "13:36 Call for Capacity - As of 0400, the outside hospital transfer status is as follows: MC (Main campus)- ... PED (Pediatric) open; PICU (Pediatric Intensive Care Unit) saturation; CLC (Clear Lake Campus) ... PED case by case. (Redacted) House Supervisor Staff ID # 82 from Facility A states "capacity available." 13:38 Call (redacted) Facility C. Nurse Practitioner Staff ID #90 (referring provider) connected to Facility A Pediatric Hospitalist Staff ID # 83. Clinicals discussed. Physician Staff ID # 83 "states no service available due to concern for biliary atresia." 13:53 per Patient Placement Center Rep Staff ID #84, "request cancelled, reason: service unavailable."

Record review of facility pediatric surgery call schedule for 03/02/2025 reflected pediatric surgeon Staff ID # 86 was on call for 24 hour period for Facility A's main campus and clear lake campuses, which had pediatric inpatient capacity and capability.

Review of facility A policy "Admissions, Transfers, Discharges", last reviewed 11/17/2017, stated "Policy: In accordance with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA), the (facility) is committed to accepting patients with emergency medical conditions from other facilities when (the facility) has capacity, its medical services are available and the transferring facility represents it cannot provide the medical services required by the patient. (The facility) accepts interfacility patient transfers for patients with emergency medical conditions. All interfacility patient transfers for patients with emergency medical conditions are arranged through the Patient Placement Center (PPC) and must have a bed assignment prior to transfer to (the facility)." It further stated "When the PPC receives a call from a facility requesting the transfer of a patient with an emergency medical condition in an Emergency Room, the PPC, in conjunction with the Clinical Operations Administrator (COA)/House Supervisor, will determine capacity at (the facility). If capacity is available, the PPC will contact the facility physician assigned to the call coverage and connect the facility physician with the transferring facility physician to discuss patient care issues. Once the clinical discussion has taken place, the PPC will secure a bed assignment and will provide to the referring facility the administrative approval and bed assignment information for the direct admission."

Record review of Facility A Patient Placement Center (Transfer Center) Pediatric Algorithm provided by Director Staff ID # 56 signed by "PPC Leadership" and dated 3/6/25. The algorithm for pediatric floor requests for Clear Lake Campus stated "Is Bed available? - Yes" then states "Connect referring provider with pediatrician on-call and subspecialist as needed."

Interview with Patient Placement Center (Transfer Center) Manager Staff ID # 66 on 4/8/2025 at 11:50 am. She confirmed that requests for transfer in, which involve possible need for subspecialist, include the subspecialist on the intake call to assist with determining capability. She confirmed that the hospitalist or intensivist has admitting privileges and may serve as the primary service once the patient arrives to the facility.

Telephone Interview with Facility A Pediatric Surgery Staff ID # 85 on 4/8/25 at 3:25 pm. He confirmed that Facility A has the capability of caring for infants with biliary atresia and has provided care for neonates and infants with this diagnosis. He confirmed that the transfer center recording did not include a pediatric surgery staff consultation, prior to hospitalist staff #83 stating that "the service is unavailable" and recommending transfer of the patient to another pediatric institution in the region.

Telephone Interview with Facility A Transfer Center Medical Director Staff ID # 71 on 4/8/25 at 3:50 pm. She confirmed that Patient IDs # 1 and 8 denials for "the service is unavailable" had not been reviewed or evaluated through the transfer center committee which meets monthly.