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Based on observations, reviews of clinical records, Policies and Procedures, Medical Staff Rules and Regulations, Physician On-Call lists, recorded conversations, Palm West Hospital Transfer electronic Log, Medicare Database worksheet and interviews, it was determined the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required such specialized capabilities or facilities for whom a request for pediatric specialty services (pediatric gastroenterology) was made for 1 of 17 sampled patients (Patient #10). Refer to findings in tag 2411.

Based on observations, reviews of clinical records, Policies and Procedures, Medical Staff Rules and Regulations, Physician On-Call lists, recorded conversations, Palm West Hospital Transfer electronic Log, Medicare Database worksheet and interviews, it was determined the facility failed to accept from a transferring hospital an appropriate transfer of an individual who required such specialized capabilities or facilities for whom a request for pediatric specialty services (pediatric gastroenterology) was made for 1 of 17 sampled patients (Patient #10).


The findings are:

Observations on 1/29/14 at 3:00PM revealed a sign posted on the outside wall above the ED Entrance reads: The Children's Hospital at Palms West.

Review of the Medicare Hospital Data Base Worksheet revealed Pediatric Services and Pediatric Intensive Care Services are provided by the facility.

Review of the Palms West Hospital's EMTALA Transfer Policy reveals the following:
This policy reflects guidance under EMTALA and associated State laws only.
Each hospital CEO (Chief Executive Officer) must designate in writing the position of the hospital representative who is authorized along with the Emergency physician to accept or deny transfers of individuals with EMC's (emergency medical conditions) from other facilities. The Administrator On Call (AOC) or House Supervisor is the only individual authorized to accept or refuse a transfer of an individual from another facility on behalf of the receiving hospital. A Transfer Center may facilitate but does not take place of the CEO's designee.
The Transfer Center must first contact the facility DED (dedicated emergency department) and the CEO designee to verify with the facility that it does not have the capacity or capability to accept the transfer.
Recipient Hospital Responsibilities:
A participating hospital that has specialized capabilities or facilities, including facilities such as burn units, shock-trauma units; neonatal intensive care units, or regional referral centers in rural areas, may not refuse to accept an appropriate transfer from a transferring hospital within the boundaries of the United States, of an individual who requires such specialized capabilities or facilities if the receiving facility has the capacity to treat the individual.

The Transfer Policy reveals the Administrator On Call (AOC) or House Supervisor along with the Emergency physician is the only individuals authorized to accept or refuse a transfer of an individual from another facility on behalf of the receiving hospital.


The Pediatric subspecialties identified on the On-Call List and offered 24/7 include Peds(pediatric) Gastro; Peds General Surgery; Peds Neurosurgery and Peds Orthopedics. Additional Pediatric services are identified under Plastic (Adult and Peds); Podiatry (Adult and Peds) and Psychiatry (Adult and Peds). There are Pediatric Intensivists on staff. Review of the Hospital's Medical Staff Rules and Regulations: Section 9, Emergency Services Section 20.0 Emergency Department Call reveals: Call Rotation: The distribution and maintenance of the ED call list will be coordinated by the Medical Staff Office. On call rotation schedules shall be maintained in the ED.
Duration of Call Schedule: When a physician is scheduled for a particular day/date for coverage, he/she is on call from 7:30 a.m. until the following morning at 7:30 a.m., unless otherwise noted. He/she is responsible for the patient according to the time that the Emergency Department (ED) physician determines the need for consultation, not according to the time of arrival in the ED.
Verification of Availability: The hospital will contact the on-call specialist daily for verification of availability. The Medical Staffing Rules and Regulations reveal: Once the schedule is finalized and circulated it cannot be changed by Medical Staffing Services unless written confirmation is received from all parties involved.

Review of the On-Call List for the past 6 months verified the availability of Pediatric Services to include the subspecialty Pediatric Gastroenterology on a 24/7 basis.
The On-Call ED coverage for Peds Gastroenterology posted on 12/30 -12/31/13 was as follows:
Dr. G___, 12/30 07:00 - 12/31/13 17:00; Dr. S___, 12/31/13 17:00 - 1/1/14 07:00 and Dr. S___, 1/1 07:00 -1/2/14 07:00.

Interview with the CEO (chief executive officer) at 9:30 AM on 1/29/14 revealed requests for transfer of patients to the Palm West Hospital ED (emergency department) go through a Transfer Center. The CNO (chief nursing officer) stated at 9:40 AM on 1/29/14 that the call center/transfer center is in Broward County. She stated the transfer center contacts the ED physicians and they discuss the transfer ED to ED. In an interview with the risk manager at 10:15AM on 1/29/14, she stated all calls for transfers come through the HCA (Hospital Corporation of America) Call Center. During a telephone interview with the risk manager on 1/28/14 related to an emergency access survey conducted on 1/27/14 for the same concern, the risk manager stated the HCA One Step Transfer Center is a 3rd party service located off site in Broward County that coordinates emergency transfers for HCA facilities.

Review of the clinical record revealed Patient #10 was a pediatric patient who presented to the transferring hospital on 12/31/13 at 11:00 p.m. The History and Physical revealed in part, " History of Present illness " The patient presents with accidental ingestion and pt. brought in by mother ...may have ingested an unknown amount of Drano. Pt. now a present with vomiting ... the onset was just prior to arrival ...Physical Examination: General ...actively vomiting ...Impression and Plan: Accidental Toxic caustic ingestion ... Calls- Consults- Poison Control, observation with transfer to pediatric center with pediatric GI.
On 12/31/13 at 1121 hours the transferring hospital contacted the One Step Transfer Center seeking transfer for Patient #10. The Transfer Center (TC) contacted Palms West Hospital. The ED Physician at the transferring hospital requested the services of Pediatric Gastroenterology.
When the TC contacted Palms West Hospital at 2335 hours; the ED Physician at Palms West Hospital informed the ED Physician at the transferring hospital that Pediatric GI services ended at 5:00 PM and there was no additional coverage until 7:00 AM.
Review of the Palms West electronic Transfer Log dated 12/31/13 at 2325 hours for Patient #10 reveals the following:
Specialty Service Request: Other: Pedi GI.
Description of Problem: CAUSTIC INGESTION
PWH Specialist contacted: PEDI ED MD
Instructions given: No Pedi GI past 5 PM
Disposition Given: Accepted/Declined.
Reason for Decline:
Other (explain): Once Dr. D___ (Physician at Transferring Hospital), was told no Pedi GI he stated that was what he needed and hung up the phone. Review of the transfer form revealed that patient #10 was accepted and transferred on 12/31/2013 to another acute care local hospital.

A recording of the conversation between the ED physician from the transferring hospital and ED physician at Palms West Hospital was played for this surveyor on 1/29/14 at 1110 hours. The ED Physician at the transferring hospital stated he needed Peds GI. The physician ended the call.
Review of a letter to the Florida Agency for Healthcare Administration on Palms West Hospital letterhead documented as from the CEO dated 1/10/2014 Re: Self Reporting by Palms West Hospital of possible Right to Access non-compliance regarding sampled Patient #10 revealed in part:
At 0155 hours on 1/1/14 the Transfer Center (TC) contacted Palms West Hospital and spoke with the nursing supervisor. The TC informed the nursing supervisor that she had contacted the transferring hospital to check if the patient had been transferred to another local hospital. The patient had been transferred. The TC indicated from her reading of the On-Call list that Palms West Hospital did have Pediatric GI available. The nursing supervisor reviewed the On-Call list and agreed .....and it seemed the ED Physician (Palms West) misread the On-Call list. The supervisor notified the Administrator on Call regarding the incident.
The facility failed to accept Patient #10 on 12/31/13, an appropriate transfer who required the specialty services of Pediatric GI.

Interview with the ED Director on 1/29/14 at 0930 hours reveals the Pediatric Services are provided twenty four hours a day, seven days a week (24/7).

The Medical Staffing Manager stated at 1030 hours on 1/29/14 there are 2 Pediatric Gastroenterology (GI) groups that alternate to provide ED On-Call coverage. They provide their own scheduled times to provide services 24/7. On weekends and holidays the coverage is 1700 - 0700 and 0700 to 1700. The Medical Staffing Manager stated at 1030 hours on 1/29/14 verification with the On-Call Physician is made the day before the scheduled coverage. The schedules are requested to be submitted by the 15th day of the previous month.

The Risk Manager stated at 1045 hours on 1/29/14 the process regarding the unavailability of an On-Call physician is outlined in the Medical Staffing Rules and Regulations. The process is when the practitioner practicing the specialty is unavailable; it is the on-call physician's responsibility to find alternative coverage. The Chief of the Department will be notified by the ED physicians and/or hospital administrator, and involved in this process as needed.

The facility self-reported the incident.
In the self report the CEO writes:
1. The ED Physician misread the On-Call List and denied the transfer when the receiving hospital had the capability to accept the patient.
2. Per protocol, the Transfer Center has a copy of the On-Call List available. The Transfer Center employee accepted our ED Physician's statement about there being no coverage for Pediatric GI service and did not reference her copy of the On-Call List until approximately two hours after the initial contact. The Transfer Center employees are to use these lists when contacting hospitals about transfers.
3. Per protocol, if a transfer is denied, the Transfer Center employee is to immediately contact the AOC or the Nursing Supervisor at the receiving facility. The Transfer Center employee did not follow procedure and only contacted us when she realized that she had not reviewed the On-Call List, making an attempt for Palms West to rectify the transfer in a timely manner impossible.
The CEO verified the findings in the self-report on 1/29/14 at 0930 hours.
There was a lapse of approximately 2 hours before the facility recognized the subspecialty On - Call Pediatric Gastroenterology Service is available 24/7.
The ED Physician and the Transfer Center failed to communicate with the Administrator On- Call and the Nursing Supervisor to facilitate the transfer to the receiving hospital which had the capability and capacity to provide services for Patient #10 on 12/31/2013. The facility failed to follow their transfer decision protocols by failing to communicate with all parties.