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Based on review of medical records, policy and procedure review, review of on-call schedules and facility bed census reports; and staff interviews it was determined the facility failed to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized capabilities of a Urologist and facilities for 1 (#21) of 21 sampled patients with an identified emergency medical condition.

Refer to findings in Tag A-2411.

Based on review of medical records, policy and procedure review, review of on-call schedules and facility bed census reports; and staff interviews it was determined the facility failed to accept from a referring hospital within the boundaries of the United States an appropriate transfer of an individual who required such specialized capabilities of a Urologist and facilities for 1 (#21) of 21 sampled patients with an identified emergency medical condition.

Findings were:

1. Hospital A Medical Record
Closed medical record review of Patient #21 revealed a 62 year old female who presented to Hospital A ' s DED (Dedicated Emergency Department) on 11/11/2018 at 0958 with a chief complaint of flank pain with nausea and vomiting. Review revealed the MSE began at 1017 by PA (Physician Assistant) #1. Review of the ED Provider Notes on 11/11/2018 at 1027 revealed " HPI: Patient is a 62 year old female with a history of prior nephrolithiasis (The presence of kidney stones in the kidney) who presents the emergency department she complained of pain to the left flank [sic]. Patient states this started early morning on Friday and was subsequently associated with nausea and vomiting. The patient has had vague " chills " associated with her symptoms but no documented fever ....ED COURSE & MEDICAL DECISION MAKING: Patient has a 2 mm obstructing stone in the distal left ureter ....ED Course: ... After reviewing the patient ' s laboratory studies and urine analysis I ordered 2 g (grams) of Rocephin ... Her situation is however she has a pyelonephritis (sudden and severe kidney infection) of the left kidney and obstructing stone in the left ureter ... I consulted with Hospital B ' s transfer center, however the urologist (MD #1) at Hospital B declined to accept the transfer. Review of the facility's "Patient Transfer EMTALA FORM, dated 11/11/2018 revealed in part, "Emergency Medical Condition identified, Patient stable for transfer ...Clinical Impression/Diagnosis: Pyelonephritis, obstructing distal ureteral kidney stone, at high risk for sepsis (a very serious medical condition characterized by an inflammatory state of the entire body), history of diabetes, history of kidney stones. Reason for transfer: Medically indicated, as determined by MD, with patient consent ...Mode of transfer ALS (Advance Life Support) ...Receiving Facility (Facility C) ...Acceptance time 1257 ...Transfer time: 1417."

I have spoken to Hospital C ' s transfer center and their urologist has agreed to accept the patient for further evaluation and treatment ... " Record review revealed Patient #21 was transferred to Hospital C at 1429 on 11/11/2018.

2. Hospital B Transfer Center Form (Rex Hospital)

Review of Hospital B ' s (Hospital B Rex Medical Center) transfer center documentation revealed on 11/11/2018 at 1203 " Summary: Pt (patient) came in with c/o (complaint of) flank pain- has an obstructing stone in the left ureter in the distal left ureter with pyelo. Saw Named MD in the past for stent to the same- they have no uro (Urologist) on-call ... " Review of transfer center documentation at 1210 revealed " I spoke with MD #1. He states Named MD is on call there today. I told him that the requesting PA #1 states they have no urology on call there this weekend, He then stated " then the pt can go to Hospital C then " . Review at 1213 revealed " MD #1 called back and stated that he checked the calendar and spoke to his " higher up " and there is someone on call for Hospital A ... He would not take the patient, the pt needs to go to Hospital C if Hospital A ' s urologist doesn't want to take care of their own patient. " Further review of 12:20 revealed "Request Canceled." Review of documentation at 1228 revealed " PA (Physician's Assistant) #1 has called back and states he has major concerns about out MD #1 not accepting the patient. I called MD #1 back and connected the providers ...MD #1 stated that the calendar states Named MD is on call for Hospital A. PA #1 confirms they have not called the Named MD to verify that he is not on call.... "


3. Hospital C Medical Record

The Medical Record from Hospital C for patient #21 was reviewed. The Medical record review revealed that Patient #21 arrived to Hospital C's ED on 11/11/2018 at 1548. Admission type: Emergency. The patient's Disposition was listed as: "Admit" level of care, Acute, Chief Complaint: Infected ureteral stone. Documentation by the ED provider dated 11/11/2018 at 1611 revealed that Patient #21 was transferred from Hospital A, for left infected urolithiasis (stones that form in the urinary tract) at UJV with WBC (White Blood Cell Count) of 15.8 (normal WBC 5,000 to 10,000) and lactate of 2.1. On arrival, the patient denies any pain or discomfort, endorses some mild nausea but declined medication. The patient's vital signs are stable on arrival. Urology resident arrived immediately to evaluate the patient and take to the OR (operating Room) for stenting. Review of the Urologist Consulting Note revealed in part, "Assessment: 62 y/o (year old) female with obstructive left 2 mm UVJ stone with high clinical obstruction for developing ascending UTI(urinary tract infection)/pyelonephritis-Given these findings , she will need urgent urinary decompression ... she was agreeable to ureteral stent placement. " Review of the OP (operative) Encounter notes dated 11/11/2019 at 1649 the Urologist documented in part, Preoperative Diagnosis: infected obstructed stone. Post-Operative Diagnosis: same. -cystourethoscopy; -left ureteral stent;-Left Retrograde pyelogram;-Intraoperative fluoroscopy < 1 hour."


4. Policy and Procedure

The facility's policy titled, "EMTALA Treatment of patients with Emergency Medical Conditions, Policy Stat ID: 2574427, Origination 9/11/2014, last revised 7/5/2016 was reviewed. The policy specified in part, "Definitions:: Capability means having a qualified personnel and facilities available at the hospital (including on-call physicians ... Capacity means the ability to accommodate the individuals requesting examination or treatment, and encompasses such things as: numbers and availability of qualified staff, beds and equipment. ... D. Accepting transfers and reporting improper patient transfers. 1. Rex Hospital must accept the requested transfer of a patient, who is in an Emergency medical condition when Rex Hospital has the capacity and specialized capabilities that are not available at the requesting hospital. Rex is obligated to accept a transfer if the requesting hospital has no beds, is overcrowded ..."

5. On Call Schedules

The facility's ED unassigned Call Schedule for surgery and OB/GYN November 2018 was reviewed. The on-call schedule dated November 11, 2018 verified that MD #1 was the Urologist on call when a request was made from the transferring hospital (Hospital A) requesting to transfer #21 with an identified emergency medical condition. The facility had the capability (Urologist on call) to accept patient #21.


6. Bed Census Report

The facility's bed census report dated 11/11/2018 was reviewed. The bed census report revealed the facility had capacity on 11/11/2018 to accommodate/accept patient #21 when the request was made. This was evidenced by the following beds were available on the following Nursing Units: Medical Surgical Intensive Care Unit had 2 beds available; Medical/Surgical Unit (2) beds available; and General Surgical Unit had 6 beds available.


7. Interviews

PA#1, conducted the MSE on Patient #21 on 11/11/2018 was not available for interview, during the investigation.

Interview with MD #1 on 01/03/2019 at 1425 revealed the two urology groups from Hospital A and Hospital B met over the summer and began to share on call rosters. Interview revealed he had a copy of Hospital A ' s call roster for urology and offered to email it to PA #1 but he declined. Interview revealed if there was no one on call for Hospital A, he would have accepted the patient transfer. Interview revealed after this incident the CMO of Hospital A called the Named MD (urologist) and confirmed he was on call. The facility failed to ensure that their policy and procedure was followed as evidenced by failing to accept a requested transfer of Patient #21 on 11/11/2018, who had an emergency medical condition. As this refusal to accept the patient resulted in an inappropriate delay in patient #21's care and treatment.

Interview with the ER Director for Hospital A on 01/03/2019 at 1500 revealed they were aware of this incident and conducted an investigation.