HospitalInspections.org

Based on hospital policy review, closed medical record review, physician interview, Medical Staff Rules and Regulations review, hospital census report review, Specialty Physician Call Schedule review, physician credential file review, Transfer Center audio recordings review, and staff interview, the hospital staff failed to comply with 42 CFR 489.24.

The Findings include:

1. The hospital staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 43 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment.

~cross refer to 489.24(r) and 489.24(c) Medial Screening Examination - Tag A2406

2. The hospital failed to provide stabilizing treatment within its capability and capacity for 2 of 7 sampled DED patients that were transferred with an emergency medical condition.

~cross refer to 489.24(d)(1-3) Stabilizing Treatment - Tag A2407

3. The hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to provide medical treatment within the hospital's capacity and failing to ensure the receiving facility had an available bed for 2 of 7 sampled DED patients that were transferred with an emergency medical condition.

~cross refer to 489.24(e)(1)-(2) Appropriate Transfer - Tag A2409

Based on hospital policy review, closed medical record review, and physician interview, the hospital staff failed to provide an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 1 of 43 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patient #30).

The findings include:

Review of current hospital policy entitled "Medical Screening" revised 10/18/2011 revealed, "POLICY: (Name of Hospital - Hospital A) provides a medical screening examination (MSE) and ancillary services, within the capabilities of the Health System's Emergency Department (ED), to patients requesting examination or medical treatment.... PURPOSE: To provide appropriate medical care to patients who present to the Health System and to comply with Emergency Medical Treatment and Active Labor Act (EMTALA) requirements related to medical screening examination....DEFINITIONS: 1. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, psychiatric disturbances, and/or symptoms of substance abuse, such that without immediate medical attention, the patient's health (or that of an unborn child) could reasonably be expected to be in serious jeopardy, or result in serious impairment or dysfunction of the patient's bodily functions or a bodily organ or part....2. Medical Screening Examination: An evaluation sufficient to determine if an emergency medical condition or pregnancy with contractions exists. The exam includes appropriate resources routinely available or accessible to (Hospital A). 3. Qualified Medical Personnel: For the purpose of this policy, a physician, a physician's assistant, nurse practitioner, a certified nurse midwife, and/or obstetrical Registered Nurse is the person qualified to provide medical screening examinations to rule out an emergency medical condition....GUIDELINES: 1. Patients presenting to (Hospital A) requesting or having request made on their behalf for examination, are to have a medical screening examination performed by qualified medical personnel to determine if an emergency medical condition exists...."

Closed medical record review for Patient #30 revealed a 55 year-old female that presented to Hospital A's DED via EMS (Emergency Management System - Ambulance) on 01/31/2012 at 0045. Review of EMS paramedic's documentation prior to arrival at the hospital revealed, "History of Present Illness: Pt (patient) states she had surgery on her bladder 2 weeks ago due to bladder cancer. Pt's bladder bag was leaking so pt went to (outpatient clinic at Hospital B) today to have bag changed out....Pt stated she has been unable to eat since yesterday. Pt began vomiting tonight, has been dizzy since she returned home from (outpatient clinic at Hospital B), and is also complaining of a headache times one day." Further review of EMS documentation revealed at 0016 the patient was given 4 milligrams (mg) of Zofran (antiemetic medication) via intramuscular injection. Record review revealed the triage nurse assessed the patient upon arrival at 0045, at which time the patient complained of a headache that she rated 10 of 10 (on a scale of 0-10, with 10 being the most intense pain). Record review revealed at 0145 Physician #1 (DED physician) evaluated the patient. Review of Physician #1's notes revealed at 0145 revealed, "HPI (history of present illness) chief complaint: vomiting...'I think I'm dehydrated'...Pt c/o (complains of) weakness, lightheadedness, dizziness + HA (headache). States s/s (signs and symptoms) began as HA, then N & V (nausea/vomiting)....current symptoms: nausea...vomiting....1/17 (01/17/2012) had surg(ery) (secondary) to bladder CA (cancer). Uncomplicated hosp(ital) course per pt...." Record review revealed at 0159 Physician #1 ordered the following lab and diagnostic studies: CBC (complete blood count), CMP (comprehensive metabolic panel), lipase, urinalysis, urine culture, PT/PTT (prothrombin time and partial thromboplastin time), and CT (computed tomography) scan of the head and brain. Record review revealed the head/brain CT scan was done at 0302 and was noted by the radiologist to be "unremarkable" at 0335. Record review revealed all labwork was completed and resulted by 0409. Further record review revealed at 0324 the patient was given an intravenous (IV) fluid bolus and Zofran 4 mg IV per Physician #1's orders. Review of nurse's notes revealed, "03:47...Patient remains stable....03:50...Pain Assessment...0/10 - Pain Free....03:56...Response to Medication...Feels better." Review of Physician #1's notes (not timed) revealed, "Pt stable, tachycardia improved s/p (after) hydration. Pt has (illegible) appt (appointment) w (with) (Hospital B) urology....r/o (ruled out) obvious evidence of infection. Plan f/u (follow up) am today w specialist....Disposition - discharge....Condition - improved, stable." Review of Physician #1's notes at 0642 revealed, "Discharge Diagnosis...Primary: Vomiting, persistant Secondary: Weakness fatigue Additional Diagnoses: Headache." Record review revealed at 0719 the patient was discharged to home with prescriptions for Phenergan (antiemetic medication) and Zofran. Record review revealed the patient was instructed to go to the outpatient clinic at Hospital B at 0900 on the same morning as discharge, to keep the appointment she already had with the specialist there. Record review revealed no radiological diagnostic studies of the patient's abdomen were done on 01/31/2012 when the patient presented with persistent vomiting 14 days following surgery.

Closed medical record review for Patient #30 revealed the patient presented to Hospital A's DED again on 02/02/2012 at 1728 via private transportation (2 days after first visit). Review of triage nurse's notes at 1739 revealed, "Pt arrived to front line triage via wheel chair with c/o chest and back pain. Pt is vomiting at this time at triage desk. Pt appears pale in color and recent surgery noted for bladder cancer." Record review revealed at 1733 the patient rated her pain to be a 10 out of 10. Record review revealed an electrocardiogram (EKG) was done at 1743. Record review revealed Physician #2 evaluated the patient at 1800. Review of Physician #2's notes at 1800 revealed, "Pt here with nausea and vomiting since this past Saturday (01/29/2012). She is S/P 'bladder surgery' this past January at (Hospital B). Was seen here with similar complaints 2 days ago." Record review revealed at 1802 the physician ordered the following lab studies: CBC, CMP, and Lipase. Record review revealed the patient was given intravenous fluids and Zofran 8 mg IV at 1825 per physician's orders. Record review revealed the patient waited in the waiting room until 2148, at which time she was taken to a treatment room. Review of nurse's notes at 2235 revealed, "...Pt states 0/10 cp (chest pain) @ this time, but states lower back pain...." Record review revealed at 2330 Physician #3 reviewed lab and EKG results. Record review revealed Physician #3 examined the patient at 2339. Review of Physician #3's notes at 2339 revealed the patient complained of "aching" epigastric pain and vomiting for one day (patient was unsure of how many times she had vomited). Review of Physician #3's notes at 2339 revealed the patient stated she had not had a bowel movement for 4-5 days. Further review of Physician #3's notes at 2339 revealed the patient had a urostomy and had bladder resection with urine diversion surgery on 01/17/2012 at Hospital B. Record review revealed a hemoccult test (swab of patient's stool checked for presence of blood) was done at on 02/03/2012 at 0245, per physician's orders, and was positive (blood present). Record review revealed Physician #3 ordered an abdominal Xray at 0221. Record review revealed the Xray was done at 0346. Review of abdominal Xray results dictated by the radiologist at 0353 revealed, "...Impression:...Abnormal bowel gas pattern, findings suggesting possible developing small bowel obstruction...." Further record review revealed at 0223 Physician #3 ordered an abdominal CT scan for "H/O (history of) Abdominal pain/Vomiting/Constipation." Record review revealed the abdominal CT scan was done at 0721. Review of CT scan results dictated by the radiologist at 0734 revealed, ""...Impression: 1. Small bowel obstruction thought to be related to adhesions with a transition zone in the left pelvic region. 2. Postoperative changes of what is thought to represent a cystectomy with ureteral stents extending through the ileal conduit into a collection bag without obstruction. 3. Small right renal cyst. 4. Prominent rectal fecal material." Review of Physician #1's notes on 02/03/2012 at 1039 revealed, "Discharge Diagnosis...Primary: Bowel Obstruction Secondary: Dehydration Additional Diagnoses: Renal failure, acute." Record review revealed the patient was transferred to Hospital B for further treatment on 02/03/2012 at 1952 (3 days after the patient first presented to the DED with persistent vomiting 14 days following surgery).

Interview on 02/23/2012 at 1530 with Physician #1 revealed the physician recalled seeing Patient #30 in the DED on 02/03/2012. Interview revealed when the physician saw the patient on 02/03/2012 he did not recognize her or recall that he had seen her before in the DED. The physician reviewed the patient's medical record from the 01/31/2012 DED visit during the interview. Interview revealed the patient presented on 01/31/2012 with nausea and vomiting and "not feeling well". Interview revealed the patient had an appointment later that same day to follow up with the specialist at the outpatient clinic at Hospital B. Interview revealed, "She had a routine nausea/vomiting evaluation. The (head) CT must have been done because of the headache she was having....The labwork showed she was slightly anemic and dehydrated. It looks like after hydration in the ED she was feeling better....I do not see films (Xray studies) of her belly. I didn't order any. It depends on what direction they (patients) are going in whether or not I order radiology studies of the abdomen....Not everyone gets a big workup with nausea and vomiting....With her (Patient #30) I didn't go down the road of thinking it was infection or bowel obstruction. If I was going down that road, I would have ordered an abdominal Xray, maybe even a CT....I don't know why I didn't go down that road."

Based on policy review, Medical Staff Rules and Regulations review, hospital census report review, Specialty Physician Call Schedule review, physician credential file review, closed medical record review and physician interview, Transfer Center audio recordings review, and staff interview, the hospital failed to provide stabilizing treatment within its capability and capacity for 2 of 7 sampled DED patients that were transferred with an emergency medical condition (Patients #30 and #31).

The findings include:

Review of current hospital policy entitled "Transfer of Patients from (name of hospital - Hospital A)" dated 06/27/2011 revealed, "POLICY:...In the interest of providing optimal care to the patient, (Hospital A) facilitates the orderly transfer of patients who, in the judgment of the physician, would benefit from transfer to another facility....PURPOSE: To comply with Emergency Medical Treatment and Labor Act (EMTALA). GUIDELINES:...B. The transferring physician determines that (Hospital A) does not have the bed capacity or resources to provide care for the patient, or the patient and/or family requests a transfer...."

Review of current Medical Staff Rules and Regulations, last revised 02/2006, revealed, "...Article VII. Clinical Rules & Regulations....Section 3. Emergency Department and Specialty Call Duties....D. Responsibilities: A Medical Staff member who is on call for any department or specialty shall be available for those unassigned Emergency Department admissions who would normally be the responsibility of that department or specialty...."

Review of current hospital policy entitled "Physician Call Roster" dated 10/11/2011 revealed, "PURPOSE:...to ensure the orderly and appropriate consultation and/or referral of emergency patients within the Scope of Service of the ED (Emergency Department). Administration will formulate and provide at monthly intervals a specialist on-call roster. The function of this panel is to accept emergency consultations from the ED and to provide immediate care of the patient if so needed as well as a mechanism for follow-up care of the patient....NOTES:...2.....Patients requiring admission will be referred to the specialist on-call at the time the decision is made that admission is warranted regardless of the time the patient presents to the ED....5. The on-call provider is responsible for seeing the patient when called by the ED...."

Review of hospital census report dated 02/03/2012 revealed the following surgical bed availability: at 0000 - 2 available beds and at 1200 - 3 available beds.

Review of Specialty Physician Call Schedule dated February 2012 revealed Physician #4 (a general surgeon) was on-call for General Surgery Services on 02/03/2012.

Review of Physician #4's credential file revealed the physician was currently an active member of Hospital A's medical staff in the Department of Surgery. File review revealed, "Specialty: General Surgery." Review of the physician's approved privileges revealed, "CORE PRIVILEGES - GENERAL SURGERY....Core: Surgery of the abdomen and its contents....Care of critically ill patients with underlying surgical conditions in the emergency department...."

1. Closed medical record review for Patient #30 revealed a 55 year-old female that presented to Hospital A's DED on 02/02/2012 at 1728 via private transportation. Review of triage nurse's notes at 1739 revealed, "Pt arrived to front line triage via wheel chair with c/o chest and back pain. Pt is vomiting at this time at triage desk. Pt appears pale in color and recent surgery noted for bladder cancer." Record review revealed at 1733 the patient rated her pain to be a 10 out of 10. Record review revealed an electrocardiogram (EKG) was done at 1743. Record review revealed Physician #2 evaluated the patient at 1800. Review of Physician #2's notes at 1800 revealed, "Pt here with nausea and vomiting since this past Saturday (01/29/2012). She is S/P 'bladder surgery' this past January at (Hospital B). Was seen here with similar complaints 2 days ago." Record review revealed at 1802 the physician ordered the following lab studies: CBC, CMP, and Lipase. Record review revealed the patient was given intravenous fluids and Zofran 8 mg IV at 1825 per physician's orders. Record review revealed the patient waited in the waiting room until 2148, at which time she was taken to a treatment room. Review of nurse's notes at 2235 revealed, "...Pt states 0/10 cp (chest pain) @ this time, but states lower back pain...." Record review revealed at 2330 Physician #3 reviewed lab and EKG results. Record review revealed Physician #3 examined the patient at 2339. Review of Physician #3's notes at 2339 revealed the patient complained of "aching" epigastric pain and vomiting for one day (patient was unsure of how many times she had vomited). Review of Physician #3's notes at 2339 revealed the patient stated she had not had a bowel movement for 4-5 days. Further review of Physician #3's notes at 2339 revealed the patient had a urostomy and had bladder resection with urine diversion surgery on 01/17/2012 at Hospital B. Record review revealed a hemoccult test (swab of patient's stool checked for presence of blood) was done at on 02/03/2012 at 0245, per physician's orders, and was positive (blood present). Record review revealed Physician #3 ordered an abdominal Xray at 0221. Record review revealed the Xray was done at 0346. Review of abdominal Xray results dictated by the radiologist at 0353 revealed, "...Impression:...Abnormal bowel gas pattern, findings suggesting possible developing small bowel obstruction...." Further record review revealed at 0223 Physician #3 ordered an abdominal CT scan for "H/O (history of) Abdominal pain/Vomiting/Constipation." Record review revealed the abdominal CT scan was done at 0721. Review of CT scan results dictated by the radiologist at 0734 revealed, ""...Impression: 1. Small bowel obstruction thought to be related to adhesions with a transition zone in the left pelvic region. 2. Postoperative changes of what is thought to represent a cystectomy with ureteral stents extending through the ileal conduit into a collection bag without obstruction. 3. Small right renal cyst. 4. Prominent rectal fecal material." Record review revealed at 0758 Physician #3 consulted with Physician #4 (on-call general surgeon) via telephone. Review of Physician #3's notes (no time) revealed, "Discussed with...(Physician #4). Transfer to (Hospital B)....(Hospital B) accepted by (Physician #10/Physician #11 [resident and attending urologists at Hospital B]). Record review revealed nursing staff inserted a nasogastric tube (NG tube) at 0829, as ordered by Physician #3. Review of "Interhospital Transfer Form", signed by Physician #3 at 0940, revealed, "...1. Reason for transfer:...Equipment or services not available at this facility...Other: specialist surgeon - general + urologist...." Review of Physician #1's notes on 02/03/2012 at 1039 revealed, "Discharge Diagnosis...Primary: Bowel Obstruction Secondary: Dehydration Additional Diagnoses: Renal failure, acute." Review of Registered Nurse (RN) #1's notes revealed, "10:59...Waiting for bed assignment, wait explained to patient....11:29...Pt awaiting transfer to (Hospital B), pt excepted (accepted) already, (Hospital B) stated that they are full at this time and have no beds available, and that it may be a long wait." Further record review revealed at 1509 Physician #1 (ED physician) called Physician #4 again. Review of Physician #1's notes at 1520 revealed, "Prior to sign-over, informed by (Physician #3) that pt would be transferred to (Hospital B) for further mgmnt (management) of a bowel obstruction. > 5 hrs later contacted (Hospital B) & informed there could be a 24-36 hr delay in transfer. Contacted (Physician #4) (gen surg), he had already discussed pt's presentation this morning with (Physician #3). He stated that he is uncomfortable managing this acute post-surgical issue & strongly suggests further efforts be made to secure transfer to (Hospital B). I discussed her presentation/care with (Physician #5) (ER supervisor). Although she has been stable throughout >20 hrs here in the ER, (I) feel it is inappropriate for her to remain in the ER for an ill defined period of time without oversight of her care by a surgical specialist. Initiated conversation with (Hospital B) regarding potential ER to ER transfer." Review of Physician #12's notes at 1634 revealed, "Spoke with (Hospital B) again....surgery here (Physician #4), not willing to admit the pt until bed available at (Hospital B). Per (Physician #8), the ED attending (at Hospital B), they will accept the pt to the ED at (Hospital B), until bed becomes available, so the pt can at least get care from a surgery standpoint. I have explained to the pt the issue, and she is aware she will be staying in the ED there also, until a bed is available. I have revised the transfer paperwork to reflect the new accepting doctor. Transfer will be arranged." Review of "Interhospital Transfer Form" revealed the following changes were made to the form: "Accepting physician:...Going to ED d/w (discussed with) (Physician #8)....Physician Signature:...(Physician #12 signed her name under Physician #3's name) 2/3/12 (at) 1430." Review of Physician #12's notes at 1944 revealed, "Lifelink (ambulance transport) here to get pt to transfer to (Hospital B)....requesting pain/nausea meds prior to going. morphine/zofran given." Record review revealed the patient was transferred to Hospital B's ED for further treatment on 02/03/2012 at 1952.

Review of Patient #30's closed medical record from Hospital B revealed the patient arrived at Hospital B's ED on 02/03/2012 at 2143. Review of the resident ED physician's notes at 2212 revealed, "...from OSH (outside hospital) sent for SBO (small bowel obstruction), direct admission by urology. Urology (Physician 10) notified for admission." Record review revealed the patient was transferred to an inpatient unit on 02/04/2012 at 0030. Review of the admission History and Physical revealed, "...recent radical cystectomy....she presented to an outside hospital today with complete obstruction. The patient states at this time that she has felt better since NG tube was placed, as such, we will maintain her on an NG tube...and treat her conservatively with her complete small-bowel obstruction...." Record review revealed the patient was discharged to home on 02/08/2012. Review of the urologist's discharge summary dated 02/08/2012 at 1422 revealed, "...The patient was admitted to our service....She was maintained on an NG tube, n.p.o. (nothing by mouth) with IV fluid rehydration. on 2/6/12, the NG tube was clamped and showed low residuals. The NG tube was removed in the late afternoon of 2/6/12 which she tolerated well. Her diet was slowly advanced and at the time of discharge she was tolerating a regular diet...."

Interview on 02/23/2012 at 0920 with Physician #3 revealed physician worked in the ED from 2200 on 02/02/2012 to 0800 on 02/03/2012. Interview revealed the physician evaluated Patient #30 in the DED on the evening of 02/02/2012. Interview revealed the patient had her bladder resected with urinary diversion on 01/17/2012 at Hospital B. Interview revealed, upon presentation to the ED on 02/02/2012, the patient complained of no bowel movement for 4-5 days, chest pain, and vomiting. Interview revealed the abdominal CT showed a small bowel obstruction. Interview revealed lab tests showed Urinary Tract Infection and dehydration. Interview revealed treatment for small bowel obstruction includes initially inserting a NG tube to decompress the abdomen and then consultation with a general surgeon. Interview revealed, "I consulted with (Physician #4 - on-call general surgeon). I presented the case to him and findings and results of studies. I gave him my impression of findings. The consultant then gives his recommendation. We don't normally request them to come in and see patients, but we present the case as a consultation....If the consultant physician decides to manage the patient, he comes in to see her....I mentioned to (Physician #4) the patient had surgery at (Hospital B), that she had a history of bladder cancer and had stents placed at (Hospital B), and the dates it was done. (Physician #4) felt due to the patient's history and complicated case, he felt it was too complex for him to handle here....We always consult (surgeon) here first, then the facility where the patient had previous surgery. If services can be offered here and our consultant physician can handle the case, the patient would be kept here....(Physician #4) felt it was a complex case and he couldn't handle here. He asked me to contact (Hospital B) to transfer (the patient). We called the Transfer Center (at Hospital B) and presented the patient and requested for them to contact her surgeon (Physician #10 or Physician #11). (Physician #10) accepted the patient....They told me they would call when they had a bed....I told the patient and her family we were waiting for a bed and would transfer her when (a bed was) available." Further interview revealed a small bowel obstruction could be a complication of the bladder resection surgery the patient had 2 weeks before at Hospital B.

Interview on 02/22/2012 at 1505 with RN #1 revealed the nurse was assigned to Patient #30 on 02/03/2012 from 0700-1900. Interview revealed, "It was thought, and the patient and family agreed, it would be best for her to go to (Hospital B) since she had recently had surgery there....(Physician #3) made that decision....(Physician #4) didn't see the patient....They didn't have a bed for her at (Hospital B). The patient was made aware that the wait (in Hospital B's ED) could be a couple of days....I don't think anyone tried to find a bed for her here, I don't know."

Interview on 02/23/2012 at 1000 with Physician #4 revealed the physician was on-call for general surgical services on 02/03/2012. Interview revealed as the on-call general surgeon the surgeon is called by the ED physician for any surgical problems with patients in the ED. Interview revealed whether or not the surgeon went to the ED to see the patient depended on the patient's problem. Interview revealed, "If they want me to come in and see the patient, I come in. I also serve as a consult on the phone to the ED physicians." Further interview revealed types of surgery Physician #4 performed included appendectomy, cholecystectomy, hernia repair, laparoscopy, and laparotomy, including treatment of small bowel obstructions. Interview revealed Physician #3 consulted the surgeon via telephone on 02/03/2012 regarding Patient #30. Interview revealed, "(Physician #3) did not ask me to come see the patient. He told me she had a cystectomy and ileo conduit at (Hospital B) about 10 days prior to presentation and that the CT showed a bowel obstruction....Ileo conduit is a very delicate and complicated procedure....Having a complicated urologic and general surgical procedure 10 days previously, I felt she would be better served to go back to her original surgeon, because he would be more familiar with her anatomy and would be better able to manage the patient. I felt if possible to transfer her, it would be in her best interest and she would get the best care possible....I later spoke with one of the ED physicians, I think (Physician #1), because I was in the ED seeing another patient. We talked quick in the hallway. He said the patient was accepted to (Hospital B) and they were working on getting a bed for her. I don't recall if he reviewed her present condition with me. I did not see the patient. He did not request for me to see the patient. I still felt it would be better for her to go to (Hospital B) even though she had to wait for a bed....I always do what I think is best for the patient. That is my job....If I had been told the patient was not accepted for transfer to (Hospital B) I would have taken the patient here."

Interview on 02/23/2012 at 1530 with Physician #1 revealed, "I took over (the care of Patient #30) at 7 or 8 in the morning (on 02/03/2012) from (Physician #3). In the afternoon I realized the patient was still in the ED. I called (Hospital B) and they said they didn't have any beds and the wait might be 24-36 hours. I didn't feel it was appropriate she remain in the ED. I contacted (Physician #4 - on-call general surgeon) again and told him the patient was accepted to (Hospital B) but I felt she needed to be under surgical care while here at (Hospital A). He said he didn't feel comfortable due to the recent surgery at (Hospital B) and he felt the patient should be at (Hospital B). I didn't feel she should remain in our ER in case she should begin to decompensate. I called (Hospital B) back to facilitate and ER to ER transfer....I spoke to one of the ER physicians there...he accepted the patient." Further interview revealed small bowel obstructions are "almost always" caused by previous surgery, due to adhesions. Interview revealed, "Surgeons, in general, don't like to operate where other surgeons have been. It is fairly common for a surgeon to want a patient to be followed up at the facility where the surgery was done at." Further interview revealed the physician notified the ED physician supervisor of the situation while the patient was waiting to be transferred. Interview revealed, "I discussed it with (Physician #5), because I could not provide definitive care for that patient for an indefinite period of time." Interview revealed the physician did not recall whether or not he asked Physician #4 to come in to the ED and see the patient. Interview revealed, "I did ask him to assume responsibility for the patient while she was at (Hospital A). He said he was not comfortable....I have asked him to come in and see patients before and he didn't come." Interview revealed the physician could not recall specific situations in which Physician #4 refused to come in when requested, or the number of times that had occurred.

Interview on 02/24/2012 at 1530 with Physician #12 revealed the physician was on duty in the ED on 02/03/2012 when Patient #30 was transferred to Hospital B. Interview revealed, "I got there at about 2 pm. (Physician #1) was on duty and was managing the patient....She (Patient #30) had been there a long time. She was diagnosed with a small bowel obstruction on night shift. She had had surgery at (Hospital B) 2 weeks prior (to 02/03/2012)....(Physician #1) said he had been trying to get her transferred to (Hospital B), but they didn't have a bed. he said he had talked to the surgeon (Physician #4) again and told him there was no bed available at (Hospital B). He said he tried to get him to admit the patient and care for her in the meantime, until a bed was available at (Hospital B). He said the surgeon said he wasn't comfortable with her because he thought she should go to (Hospital B) where she had her previous surgery. He wouldn't admit her....I don't know if he asked him to come see the patient (in the ED)....(Physician #1) got (Physician #5 - supervisor) involved because he couldn't get the surgeon to take care of the patient, even though there were no beds at (Hospital B). We could treat her pain, but couldn't manage her surgical problem." Interview revealed Physician #5 spoke with the Chief Medical Officer (CMO) about the situation, who suggested they call (Hospital B) back and request an ED to ED transfer. Interview revealed Physician #12 called Hospital B back and spoke with the attending ED physician. Interview revealed, "I told him the patient had been sitting there for more than 12 hours. He said they didn't have an inpatient bed, but would accept an ED to ED transfer, so the patient could have surgical oversight. He said she could be in the same situation in their ED and might wait for hours before getting a room....I spoke with the patient and told her we were trying to get her to a surgeon. I told her she would go to the (Hospital B) ED and might have to wait there many hours. She understood. She was feeling better with the NG tube and meds." Further interview revealed ED physicians at Hospital A sometimes have an issue getting on-call surgeons to come in and see patients. Interview revealed, "They are not always the easiest to deal with....If they refuse to come in, we should call the Chief of Surgical Services, but he is one of the worst to get to come in, so I'm not sure it would do any good to call him. I would call (the ED Medical Director) or (Physician #5) and they would handle it." Further interview revealed, "I'm not a surgeon, but I think it's ridiculous to not treat a small bowel obstruction at (Hospital A). The small bowel obstruction was not a complication from the actual surgery (the patient previously had at Hospital B). The CT showed it was probably due to adhesions. Adhesions could have been taken care of by any general surgeon, but again, I'm not a surgeon. I understand continuity of care is good, but if it's not possible then you need to treat the patient where she is at. It is my opinion that she could have been treated at (Hospital A)." Further interview revealed Physician #12 assumed care of the patient at about 1630. Interview revealed, "(Physician #3) had signed the transfer paper that morning. I changed the accepting physician's name on the form and signed it at the same time I did the note in the computer (1634). It couldn't have been (signed) at 1430, because the phone conversation with (Hospital B) hadn't even happened yet. I must have written 1430, instead of 1630, by mistake....I saw the patient again right before she transferred. She was having some nausea and pain. I ordered meds. She was stable at the time of transfer. I didn't note it on the transfer form, but I did put a note in the computer."

Interview on 02/23/2012 at 1315 with Physician #5 revealed on 02/03/2012 the physician was on duty in the ED as the Physician In Charge. Interview revealed Physician #1 contacted him during the afternoon of 02/03/2012 and told him Patient #30 was waiting to be transferred to Hospital B, but was having to wait a concerning length of time for an available bed. Interview revealed, "He wanted to know if there was anything else we could do....(Physician #1) was upset that the wait could be 24-36 hours....I talked with (the CMO), to see if there was anything we should be doing....As we were trying to work out a plan, (Hospital B) called back and said they would accept the patient as an ED to ED transfer. I was told this by (Physician #1) that night when I called back....I didn't call (Physician #4 - on-call general surgeon)." Further interview revealed Physician #5 thought the patient would be best served at Hospital B. Interview revealed the small bowel obstruction was most likely a complication of the surgery the patient had at Hospital B. Interview revealed, "(Small bowel obstruction) surgery could be done here, but should be done there for the patients best interest."

Interview on 02/27/2012 at 1330 with Physician #8 revealed the physician was on duty in Hospital B's ED on 02/03/2012 when Hospital A's ED physician called to request an ED to ED transfer of Patient #30. Interview revealed, "The patient had a small bowel obstruction after a surgical procedure here. We were quite full and didn't have (inpatient) capacity. It sounded like a bowel obstruction, rather than an acute surgical complication. I was surprised their surgeon couldn't handle it....There was some mention of the availability of the surgeon or a problem with surgical coverage....The ED physician sounded concerned with their surgical coverage and their ability to care for the patient....I don't recall exactly, but it should be on the (Transfer Center's call) recordings. It sounded like their ED physicians were trying to do the right thing for the patient, but were frustrated with the surgeon's response....(Per Hospital A's ED physician) it is a trend with their surgical coverage." Further interview revealed the physician contacted the Risk Management Department at Hospital B on 02/03/12 after the transfer request (for Patient #30) because he was concerned that Hospital A had a surgeon who said he couldn't manage a basic bowel obstruction. Interview revealed the physician notified Risk Management again on 02/03/2012 after a second transfer request from Hospital A (for Patient #31). Interview revealed, "I didn't know if this would qualify as an EMTALA issue. We had the capability, no capacity on inpatient units, but we did (have capacity) in the ED. They (Hospital A) didn't have capability, because the surgeon said he couldn't or wouldn't treat the patients."

Review of audio recordings of calls on 02/03/2012 from Hospital B's Transfer Center revealed at 0836 the DED secretary at Hospital A called on behalf of Physician #3 and informed the Transfer Center staff that Physician #3 wanted to transfer Patient #30 and also wanted to speak with Physician #13, who had performed surgery on the patient on 01/17/2012. Review revealed Physician #3 spoke with the Transfer Center staff. Review revealed the following conversation:
? Physician #3 - "Patient had bladder cancer. They did total cystectomy and...a ileo conduit and the patient now has got a small bowel obstruction....I spoke to our surgeon and he wants us to transfer the patient to (Hospital B)." The physician then proceeded to give the Transfer Center staff more patient information.
? Transfer Center Staff - "Is this referral an emergency medical condition at this time?"
? Physician #3 - "Yes, Ma'am."
? Transfer Center Staff - "Does your facility have the capability or capacity to care for the patient?"
? Physician #3 - "They don't because they said she's got a complicated surgery done recently and so they prefer the patient to be seen by the surgeon who did the surgery."
Further review of Transfer Center calls revealed Transfer Center Staff called Hospital B's nursing administration at 0842 and asked if there were any available surgery beds. Review revealed the nursing administration staff member said, "Nothing right now. We're totally full on surgery." Further review of Transfer Center calls revealed at 0918 Transfer Center Staff called and relayed the transfer request and the patient's information to Physician #10 (urology resident physician at Hospital B). Review revealed Transfer Center Staff then connected Physician #10 to Physician #3. Review revealed the following conversation:
? Physician #3 - "We did speak to our surgeon here and he felt that, you know, it's a little complicated, surgery recently, and she would be better served, you know, at (Hospital B)...."
? Physician #10 - I think that you've done all you can do at this point so we...can get her transferred up here. I think the transfer folks said our hospital is full, but whenever we can get her here, we'll get her here...(Physician #13) is out of town, so I guess we should do it under (Physician #11 - attending Urologist at Hospital B), who is the person on-call right now."
Further review of Transfer Center calls revealed at 1527 (6 hours later) Physician #1 called the Transfer Center and spoke, first with Staff and then with Physician #8 (attending ED physician at Hospital B). Review revealed Physician #1 told the Transfer Center Staff, "If this patient is, if there is a significant delay in getting her transferred, and what I mean by significant delay greater than a few hours, then I run into an issue of management. My surgeons have told me that they are uncomfortable managing this patient, because of the procedure that she had performed a couple of weeks ago. I was hoping I could speak to someone in the ER and see if she may be appropriate for and ER to ER transfer." Review revealed Transfer Center Staff then connected Physician #1 to Physician #8, at which time Physician #1 gave Physician #8 the patient's history and diagnostic information and told him the patient had been accepted to (Hospital B's) surgery services, but he had been told it may be 36 hours before a bed was available for the patient. Review revealed the following conversation:
? Physician #1 - "I talked with my surgeon here, as well as to my medicine service and I got all kinds of push back as far as them thinking that, hey, this is a procedure that my surgeon who's on call actually says 'It's a procedure I don't even perform. I'm not qualified to perform this. I don't think it is appropriate for me to take care of, take over care of, this patient in the intervening time'."
? Physician #8 - "In terms of managing a bowel obstruction?"
? Physician #1 - "In terms of managing a patient who had this particular procedure performed who now has a bowel obstruction. I'm uncomfortable with her being just sitting here in the Emergency Department without the ability for me to get a surgeon involved who is comfortable taking care of this patient." Physician #8 then asked the physician's name and service at Hospital B that had accepted the patient. He said he wanted to see what was going on with them.
? Physician #8 - "Currently, I'm still holding patients waiting for beds upstairs in my Emergency Department as well."
? Physician #1 - "I was informed of that also. I just want to make sure that I've got a good disposition for this lady and that she's going to have appropriate stop-gap care. she has been literally hemodynamically stable for the entire...day. But, she was a sign-over patient to me, and she would be a sign-over to my colleague who just came in, and could end up being a sign-over of a sign-over of a sign-over of a sign-over with no one here who can perform definitive care if necessary."
? Physician #8 - "I understand your point. But at the same time, she's had a procedure, but a complication of it, a small bowel obstruction, that most surgeons can handle. Let me find out what's going on from our urology standpoint and I'll give you a call back."
Further review of Transfer Center calls revealed at 1624 Physician #8 called Hospital A and spoke with Physician #12, who had relieved Physician #1 of duty. Review revealed the following conversation:
? Physician #8 - "Apparently your surgeons felt uncomfortable taking care of her there?"
? Physician #12 - "Yeah. We're having issues with our surgeons down here. You know, we've even tried to talk with administration and stuff and just not really getting any where. So, we just really want the patient to get the best care."
? Physician #8 - "Right now what we're dealing with is I've got no beds at all in our hospital either, so she's going to be sitting in our ED, just the same as she would be in your ED. I'm happy to take her, but if you have a bed available it may make the most sense to have her admitted and do an inpatient to inpatient transfer. I mean, you know, if it's a small bowel obstruction, which most surgeons can manage non-op with an NG tube."
? Physician #12 - "Absolutely. I one hundred percent agree with you. The problem is we just can't get anyone to do that. We've talked with the Chief, you know, we've talked with a couple of different surgeons and haven't been able to get any one willing to take on a case because it was done there (at Hospital B). So, no one is willing to admit her to take care of it...in the meantime....So, she's going to have to, I guess, be here in the ER. But the problem is that we don't have a, you know, a specialist. We're just, you know, the ER doctors would just be taking care of her, rather than a specialist coming to the ER, is our concern. So if you can take her in your, I mean I understand, obviously we all know this is not the ideal situation and not the was things, you know, should happen. But if you're able to, obviously we would greatly appreciate that. If not, then we'll just have to keep plugging along and doing what we're doing."
? Physician #8 - "Well, I mean, I'm not going to put the patient as a pawn in the middle, which is inappropriate from many different aspects. So, we'll obviously take her here. If you could just let the patient and her family know that they will be sitting in the Emergency Department until a bed becomes available, which may be late into tomorrow or Sunday." Physician #12 asked who would be the accepting physician, to which Physician #8 replied he was the accepting physician.
? Physician #12 - "Well, I want you to know that we greatly appreciate it. L

Based on policy review, Medical Staff Rules and Regulations review, hospital census report review, Specialty Physician Call Schedule review, physician credential file review, closed medical record review and physician interview, Transfer Center audio recordings review, and staff interview, the hospital's dedicated emergency department (DED) failed to ensure an appropriate transfer by failing to provide medical treatment within the hospital's capacity and failing to ensure the receiving facility had an available bed for 2 of 7 sampled DED patients that were transferred with an emergency medical condition (Patients #30 and #31).

The findings include:

Review of current hospital policy entitled "Transfer of Patients from (name of hospital - Hospital A)" dated 06/27/2011 revealed, "POLICY:...In the interest of providing optimal care to the patient, (Hospital A) facilitates the orderly transfer of patients who, in the judgment of the physician, would benefit from transfer to another facility....No patient is transferred from (Hosital A) until:...B. The receiving facility and physician have agreed to accept the patient and verified that space is available....PURPOSE: To comply with Emergency Medical Treatment and Labor Act (EMTALA). GUIDELINES:...B. The transferring physician determines that (Hospital A) does not have the bed capacity or resources to provide care for the patient, or the patient and/or family requests a transfer. C. The transferring physician calls the receiving facility for bed availability...."

Review of current Medical Staff Rules and Regulations, last revised 02/2006, revealed, "...Article VII. Clinical Rules & Regulations....Section 3. Emergency Department and Specialty Call Duties....D. Responsibilities: A Medical Staff member who is on call for any department or specialty shall be available for those unassigned Emergency Department admissions who would normally be the responsibility of that department or specialty...."

Review of current hospital policy entitled "Physician Call Roster" dated 10/11/2011 revealed, "PURPOSE:...to ensure the orderly and appropriate consultation and/or referral of emergency patients within the Scope of Service of the ED (Emergency Department). Administration will formulate and provide at monthly intervals a specialist on-call roster. The function of this panel is to accept emergency consultations from the ED and to provide immediate care of the patient if so needed as well as a mechanism for follow-up care of the patient....NOTES:...2.....Patients requiring admission will be referred to the specialist on-call at the time the decision is made that admission is warranted regardless of the time the patient presents to the ED....5. The on-call provider is responsible for seeing the patient when called by the ED...."

Review of hospital census report dated 02/03/2012 revealed the following surgical bed availability: at 0000 - 2 available beds and at 1200 - 3 available beds.

Review of Specialty Physician Call Schedule dated February 2012 revealed Physician #4 (a general surgeon) was on-call for General Surgery Services on 02/03/2012. Further review of the Schedule revealed Physician #6 (a urologist) was on-call for Urology Services on 02/03/2012.

Review of Physician #4's credential file revealed the physician was currently an active member of Hospital A's medical staff in the Department of Surgery. File review revealed, "Specialty: General Surgery." Review of the physician's approved privileges revealed, "CORE PRIVILEGES - GENERAL SURGERY....Core: Surgery of the abdomen and its contents....Care of critically ill patients with underlying surgical conditions in the emergency department...."

1. Closed medical record review for Patient #30 revealed a 55 year-old female that presented to Hospital A's DED on 02/02/2012 at 1728 via private transportation. Review of triage nurse's notes at 1739 revealed, "Pt arrived to front line triage via wheel chair with c/o chest and back pain. Pt is vomiting at this time at triage desk. Pt appears pale in color and recent surgery noted for bladder cancer." Record review revealed at 1733 the patient rated her pain to be a 10 out of 10. Record review revealed an electrocardiogram (EKG) was done at 1743. Record review revealed Physician #2 evaluated the patient at 1800. Review of Physician #2's notes at 1800 revealed, "Pt here with nausea and vomiting since this past Saturday (01/29/2012). She is S/P 'bladder surgery' this past January at (Hospital B). Was seen here with similar complaints 2 days ago." Record review revealed at 1802 the physician ordered the following lab studies: CBC, CMP, and Lipase. Record review revealed the patient was given intravenous fluids and Zofran 8 mg IV at 1825 per physician's orders. Record review revealed the patient waited in the waiting room until 2148, at which time she was taken to a treatment room. Review of nurse's notes at 2235 revealed, "...Pt states 0/10 cp (chest pain) @ this time, but states lower back pain...." Record review revealed at 2330 Physician #3 reviewed lab and EKG results. Record review revealed Physician #3 examined the patient at 2339. Review of Physician #3's notes at 2339 revealed the patient complained of "aching" epigastric pain and vomiting for one day (patient was unsure of how many times she had vomited). Review of Physician #3's notes at 2339 revealed the patient stated she had not had a bowel movement for 4-5 days. Further review of Physician #3's notes at 2339 revealed the patient had a urostomy and had bladder resection with urine diversion surgery on 01/17/2012 at Hospital B. Record review revealed a hemoccult test (swab of patient's stool checked for presence of blood) was done at on 02/03/2012 at 0245, per physician's orders, and was positive (blood present). Record review revealed Physician #3 ordered an abdominal Xray at 0221. Record review revealed the Xray was done at 0346. Review of abdominal Xray results dictated by the radiologist at 0353 revealed, "...Impression:...Abnormal bowel gas pattern, findings suggesting possible developing small bowel obstruction...." Further record review revealed at 0223 Physician #3 ordered an abdominal CT scan for "H/O (history of) Abdominal pain/Vomiting/Constipation." Record review revealed the abdominal CT scan was done at 0721. Review of CT scan results dictated by the radiologist at 0734 revealed, ""...Impression: 1. Small bowel obstruction thought to be related to adhesions with a transition zone in the left pelvic region. 2. Postoperative changes of what is thought to represent a cystectomy with ureteral stents extending through the ileal conduit into a collection bag without obstruction. 3. Small right renal cyst. 4. Prominent rectal fecal material." Record review revealed at 0758 Physician #3 consulted with Physician #4 (on-call general surgeon) via telephone. Review of Physician #3's notes (no time) revealed, "Discussed with...(Physician #4). Transfer to (Hospital B)....(Hospital B) accepted by (Physician #10/Physician #11 [resident and attending urologists at Hospital B]). Record review revealed nursing staff inserted a nasogastric tube (NG tube) at 0829, as ordered by Physician #3. Review of "Interhospital Transfer Form", signed by Physician #3 at 0940, revealed, "...1. Reason for transfer:...Equipment or services not available at this facility...Other: specialist surgeon - general + urologist...." Review of Physician #1's notes on 02/03/2012 at 1039 revealed, "Discharge Diagnosis...Primary: Bowel Obstruction Secondary: Dehydration Additional Diagnoses: Renal failure, acute." Review of Registered Nurse (RN) #1's notes revealed, "10:59...Waiting for bed assignment, wait explained to patient....11:29...Pt awaiting transfer to (Hospital B), pt excepted (accepted) already, (Hospital B) stated that they are full at this time and have no beds available, and that it may be a long wait." Further record review revealed at 1509 Physician #1 (ED physician) called Physician #4 again. Review of Physician #1's notes at 1520 revealed, "Prior to sign-over, informed by (Physician #3) that pt would be transferred to (Hospital B) for further mgmnt (management) of a bowel obstruction. > 5 hrs later contacted (Hospital B) & informed there could be a 24-36 hr delay in transfer. Contacted (Physician #4) (gen surg), he had already discussed pt's presentation this morning with (Physician #3). He stated that he is uncomfortable managing this acute post-surgical issue & strongly suggests further efforts be made to secure transfer to (Hospital B). I discussed her presentation/care with (Physician #5) (ER supervisor). Although she has been stable throughout >20 hrs here in the ER, (I) feel it is inappropriate for her to remain in the ER for an ill defined period of time without oversight of her care by a surgical specialist. Initiated conversation with (Hospital B) regarding potential ER to ER transfer." Review of Physician #12's notes at 1634 revealed, "Spoke with (Hospital B) again....surgery here (Physician #4), not willing to admit the pt until bed available at (Hospital B). Per (Physician #8), the ED attending (at Hospital B), they will accept the pt to the ED at (Hospital B), until bed becomes available, so the pt can at least get care from a surgery standpoint. I have explained to the pt the issue, and she is aware she will be staying in the ED there also, until a bed is available. I have revised the transfer paperwork to reflect the new accepting doctor. Transfer will be arranged." Review of "Interhospital Transfer Form" revealed the following changes were made to the form: "Accepting physician:...Going to ED d/w (discussed with) (Physician #8)....Physician Signature:...(Physician #12 signed her name under Physician #3's name) 2/3/12 (at) 1430." Review of Physician #12's notes at 1944 revealed, "Lifelink (ambulance transport) here to get pt to transfer to (Hospital B)....requesting pain/nausea meds prior to going. morphine/zofran given." Record review revealed the patient was transferred to Hospital B's ED for further treatment on 02/03/2012 at 1952.

Review of Patient #30's closed medical record from Hospital B revealed the patient arrived at Hospital B's ED on 02/03/2012 at 2143. Review of the resident ED physician's notes at 2212 revealed, "...from OSH (outside hospital) sent for SBO (small bowel obstruction), direct admission by urology. Urology (Physician 10) notified for admission." Record review revealed the patient was transferred to an inpatient unit on 02/04/2012 at 0030. Review of the admission History and Physical revealed, "...recent radical cystectomy....she presented to an outside hospital today with complete obstruction. The patient states at this time that she has felt better since NG tube was placed, as such, we will maintain her on an NG tube...and treat her conservatively with her complete small-bowel obstruction...." Record review revealed the patient was discharged to home on 02/08/2012. Review of the urologist's discharge summary dated 02/08/2012 at 1422 revealed, "...The patient was admitted to our service....She was maintained on an NG tube, n.p.o. (nothing by mouth) with IV fluid rehydration. on 2/6/12, the NG tube was clamped and showed low residuals. The NG tube was removed in the late afternoon of 2/6/12 which she tolerated well. Her diet was slowly advanced and at the time of discharge she was tolerating a regular diet...."

Interview on 02/23/2012 at 0920 with Physician #3 revealed physician worked in the ED from 2200 on 02/02/2012 to 0800 on 02/03/2012. Interview revealed the physician evaluated Patient #30 in the DED on the evening of 02/02/2012. Interview revealed the patient had had her bladder resected with urinary diversion on 01/17/2012 at Hospital B. Interview revealed, upon presentation to the ED on 02/02/2012, the patient complained of no bowel movement for 4-5 days, chest pain, and vomiting. Interview revealed the abdominal CT showed a small bowel obstruction. Interview revealed lab tests showed Urinary Tract Infection and dehydration. Interview revealed treatment for small bowel obstruction includes initially inserting a NG tube to decompress the abdomen and then consultation with a general surgeon. Interview revealed, "I consulted with (Physician #4 - on-call general surgeon). I presented the case to him and findings and results of studies. I gave him my impression of findings. The consultant then gives his recommendation. We don't normally request them to come in and see patients, but we present the case as a consultation....If the consultant physician decides to manage the patient, he comes in to see her....I mentioned to (Physician #4) the patient had surgery at (Hospital B), that she had a history of bladder cancer and had stents placed at (Hospital B), and the dates it was done. (Physician #4) felt due to the patient's history and complicated case, he felt it was too complex for him to handle here....We always consult (surgeon) here first, then the facility where the patient had previous surgery. If services can be offered here and our consultant physician can handle the case, the patient would be kept here....(Physician #4) felt it was a complex case and he couldn't handle here. He asked me to contact (Hospital B) to transfer (the patient). We called the Transfer Center (at Hospital B) and presented the patient and requested for them to contact her surgeon (Physician #10 or Physician #11). (Physician #10) accepted the patient....They told me they would call when they had a bed....I told the patient and her family we were waiting for a bed and would transfer her when (a bed was) available." Further interview revealed a small bowel obstruction could be a complication of the bladder resection surgery the patient had 2 weeks before at Hospital B.

Interview on 02/22/2012 at 1505 with RN #1 revealed the nurse was assigned to Patient #30 on 02/03/2012 from 0700-1900. Interview revealed, "It was thought, and the patient and family agreed, it would be best for her to go to (Hospital B) since she had recently had surgery there....(Physician #3) made that decision....(Physician #4) didn't see the patient....They didn't have a bed for her at (Hospital B). The patient was made aware that the wait (in Hospital B's ED) could be a couple of days....I don't think anyone tried to find a bed for her here, I don't know."

Interview on 02/23/2012 at 1000 with Physician #4 revealed the physician was on-call for general surgical services on 02/03/2012. Interview revealed as the on-call general surgeon the surgeon is called by the ED physician for any surgical problems with patients in the ED. Interview revealed whether or not the surgeon went to the ED to see the patient depended on the patient's problem. Interview revealed, "If they want me to come in and see the patient, I come in. I also serve as a consult on the phone to the ED physicians." Further interview revealed types of surgery Physician #4 performed included appendectomy, cholecystectomy, hernia repair, laparoscopy, and laparotomy, including treatment of small bowel obstructions. Interview revealed Physician #3 consulted the surgeon via telephone on 02/03/2012 regarding Patient #30. Interview revealed, "(Physician #3) did not ask me to come see the patient. He told me she had a cystectomy and ileo conduit at (Hospital B) about 10 days prior to presentation and that the CT showed a bowel obstruction....Ileo conduit is a very delicate and complicated procedure....Having a complicated urologic and general surgical procedure 10 days previously, I felt she would be better served to go back to her original surgeon, because he would be more familiar with her anatomy and would be better able to manage the patient. I felt if possible to transfer her, it would be in her best interest and she would get the best care possible....I later spoke with one of the ED physicians, I think (Physician #1), because I was in the ED seeing another patient. We talked quick in the hallway. He said the patient was accepted to (Hospital B) and they were working on getting a bed for her. I don't recall if he reviewed her present condition with me. I did not see the patient. He did not request for me to see the patient. I still felt it would be better for her to go to (Hospital B) even though she had to wait for a bed....I always do what I think is best for the patient. That is my job....If I had been told the patient was not accepted for transfer to (Hospital B) I would have taken the patient here."

Interview on 02/23/2012 at 1530 with Physician #1 revealed, "I took over (the care of Patient #30) at 7 or 8 in the morning (on 02/03/2012) from (Physician #3). In the afternoon I realized the patient was still in the ED. I called (Hospital B) and they said they didn't have any beds and the wait might be 24-36 hours. I didn't feel it was appropriate she remain in the ED. I contacted (Physician #4 - on-call general surgeon) again and told him the patient was accepted to (Hospital B) but I felt she needed to be under surgical care while here at (Hospital A). He said he didn't feel comfortable due to the recent surgery at (Hospital B) and he felt the patient should be at (Hospital B). I didn't feel she should remain in our ER in case she should begin to decompensate. I called (Hospital B) back to facilitate and ER to ER transfer....I spoke to one of the ER physicians there...he accepted the patient." Further interview revealed small bowel obstructions are "almost always" caused by previous surgery, due to adhesions. Interview revealed, "Surgeons, in general, don't like to operate where other surgeons have been. it is fairly common for a surgeon to want a patient to be followed up at the facility where the surgery was done at." Further interview revealed the physician notified the ED physician supervisor of the situation while the patient was waiting to be transferred. Interview revealed, "I discussed it with (Physician #5), because I could not provide definitive care for that patient for an indefinite period of time." Interview revealed the physician did not recall whether or not he asked Physician #4 to come in to the ED and see the patient. Interview revealed, "I did ask him to assume responsibility for the patient while she was at (Hospital A). He said he was not comfortable....I have asked him to come in and see patients before and he didn't come." Interview revealed the physician could not recall specific situations in which Physician #4 refused to come in when requested, or the number of times that had occurred.

Interview on 02/24/2012 at 1530 with Physician #12 revealed the physician was on duty in the ED on 02/03/2012 when Patient #30 was transferred to Hospital B. Interview revealed, "I got there at about 2 pm. (Physician #1) was on duty and was managing the patient....She (Patient #30) had been there a long time. She was diagnosed with a small bowel obstruction on night shift. She had had surgery at (Hospital B) 2 weeks prior (to 02/03/2012)....(Physician #1) said he had been trying to get her transferred to (Hospital B), but they didn't have a bed. he said he had talked to the surgeon (Physician #4) again and told him there was no bed available at (Hospital B). He said he tried to get him to admit the patient and care for her in the meantime, until a bed was available at (Hospital B). He said the surgeon said he wasn't comfortable with her because he thought she should go to (Hospital B) where she had her previous surgery. He wouldn't admit her....I don't know if he asked him to come see the patient (in the ED)....(Physician #1) got (Physician #5 - supervisor) involved because he couldn't get the surgeon to take care of the patient, even though there were no beds at (Hospital B). We could treat her pain, but couldn't manage her surgical problem." Interview revealed Physician #5 spoke with the Chief Medical Officer (CMO) about the situation, who suggested they call (Hospital B) back and request an ED to ED transfer. Interview revealed Physician #12 called Hospital B back and spoke with the attending ED physician. Interview revealed, "I told him the patient had been sitting there for more than 12 hours. He said they didn't have an inpatient bed, but would accept an ED to ED transfer, so the patient could have surgical oversight. He said she could be in the same situation in their ED and might wait for hours before getting a room....I spoke with the patient and told her we were trying to get her to a surgeon. I told her she would go to the (Hospital B) ED and might have to wait there many hours. She understood. She was feeling better with the NG tube and meds." Further interview revealed ED physicians at Hospital A sometimes have an issue getting on-call surgeons to come in and see patients. Interview revealed, "They are not always the easiest to deal with....If they refuse to come in, we should call the Chief of Surgical Services, but he is one of the worst to get to come in, so I'm not sure it would do any good to call him. I would call (the ED Medical Director) or (Physician #5) and they would handle it." Further interview revealed, "I'm not a surgeon, but I think it's ridiculous to not treat a small bowel obstruction at (Hospital A). The small bowel obstruction was not a complication from the actual surgery (the patient previously had at Hospital B). The CT showed it was probably due to adhesions. Adhesions could have been taken care of by any general surgeon, but again, I'm not a surgeon. I understand continuity of care is good, but if it's not possible then you need to treat the patient where she is at. It is my opinion that she could have been treated at (Hospital A)." Further interview revealed Physician #12 assumed care of the patient at about 1630. Interview revealed, "(Physician #3) had signed the transfer paper that morning. I changed the accepting physician's name on the form and signed it at the same time I did the note in the computer (1634). It couldn't have been (signed) at 1430, because the phone conversation with (Hospital B) hadn't even happened yet. I must have written 1430, instead of 1630, by mistake....I saw the patient again right before she transferred. She was having some nausea and pain. I ordered meds. She was stable at the time of transfer. I didn't note it on the transfer form, but I did put a note in the computer."

Interview on 02/23/2012 at 1315 with Physician #5 revealed on 02/03/2012 the physician was on duty in the ED as the Physician In Charge. Interview revealed Physician #1 contacted him during the afternoon of 02/03/2012 and told him Patient #30 was waiting to be transferred to Hospital B, but was having to wait a concerning length of time for an available bed. Interview revealed, "He wanted to know if there was anything else we could do....(Physician #1) was upset that the wait could be 24-36 hours....I talked with (the CMO), to see if there was anything we should be doing....As we were trying to work out a plan, (Hospital B) called back and said they would accept the patient as an ED to ED transfer. I was told this by (Physician #1) that night when I called back....I didn't call (Physician #4 - on-call general surgeon)." Further interview revealed Physician #5 thought the patient would be best served at Hospital B. Interview revealed the small bowel obstruction was most likely a complication of the surgery the patient had at Hospital B. Interview revealed, "(Small bowel obstruction) surgery could be done here, but should be done there for the patients best interest."

Interview on 02/27/2012 at 1330 with Physician #8 revealed the physician was on duty in Hospital B's ED on 02/03/2012 when Hospital A's ED physician called to request an ED to ED transfer of Patient #30. Interview revealed, "The patient had a small bowel obstruction after a surgical procedure here. We were quite full and didn't have (inpatient) capacity. It sounded like a bowel obstruction, rather than an acute surgical complication. I was surprised their surgeon couldn't handle it....There was some mention of the availability of the surgeon or a problem with surgical coverage....The ED physician sounded concerned with their surgical coverage and their ability to care for the patient....I don't recall exactly, but it should be on the (Transfer Center's call) recordings. It sounded like their ED physicians were trying to do the right thing for the patient, but were frustrated with the surgeon's response....(Per Hospital A's ED physician) it is a trend with their surgical coverage." Further interview revealed the physician contacted the Risk Management Department at Hospital B on 02/03/12 after the transfer request (for Patient #30) because he was concerned that Hospital A had a surgeon who said he couldn't manage a basic bowel obstruction. Interview revealed the physician notified Risk Management again on 02/03/2012 after a second transfer request from Hospital A (for Patient #31). Interview revealed, "I didn't know if this would qualify as an EMTALA issue. We had the capability, no capacity on inpatient units, but we did (have capacity) in the ED. They (Hospital A) didn't have capability, because the surgeon said he couldn't or wouldn't treat the patients."

Review of audio recordings of calls on 02/03/2012 from Hospital B's Transfer Center revealed at 0836 the DED secretary at Hospital A called on behalf of Physician #3 and informed the Transfer Center staff that Physician #3 wanted to transfer Patient #30 and also wanted to speak with Physician #13, who had performed surgery on the patient on 01/17/2012. Review revealed Physician #3 spoke with the Transfer Center staff. Review revealed the following conversation:
? Physician #3 - "Patient had bladder cancer. They did total cystectomy and...a ileo conduit and the patient now has got a small bowel obstruction....I spoke to our surgeon and he wants us to transfer the patient to (Hospital B)." The physician then proceeded to give the Transfer Center staff more patient information.
? Transfer Center Staff - "Is this referral an emergency medical condition at this time?"
? Physician #3 - "Yes, Ma'am."
? Transfer Center Staff - "Does your facility have the capability or capacity to care for the patient?"
? Physician #3 - "They don't because they said she's got a complicated surgery done recently and so they prefer the patient to be seen by the surgeon who did the surgery."
Further review of Transfer Center calls revealed Transfer Center Staff called Hospital B's nursing administration at 0842 and asked if there were any available surgery beds. Review revealed the nursing administration staff member said, "Nothing right now. We're totally full on surgery." Further review of Transfer Center calls revealed at 0918 Transfer Center Staff called and relayed the transfer request and the patient's information to Physician #10 (urology resident physician at Hospital B). Review revealed Transfer Center Staff then connected Physician #10 to Physician #3. Review revealed the following conversation:
? Physician #3 - "We did speak to our surgeon here and he felt that, you know, it's a little complicated, surgery recently, and she would be better served, you know, at (Hospital B)...."
? Physician #10 - I think that you've done all you can do at this point so we...can get her transferred up here. I think the transfer folks said our hospital is full, but whenever we can get her here, we'll get her here...(Physician #13) is out of town, so I guess we should do it under (Physician #11 - attending Urologist at Hospital B), who is the person on-call right now."
Further review of Transfer Center calls revealed at 1527 (6 hours later) Physician #1 called the Transfer Center and spoke, first with Staff and then with Physician #8 (attending ED physician at Hospital B). Review revealed Physician #1 told the Transfer Center Staff, "If this patient is, if there is a significant delay in getting her transferred, and what I mean by significant delay greater than a few hours, then I run into an issue of management. My surgeons have told me that they are uncomfortable managing this patient, because of the procedure that she had performed a couple of weeks ago. I was hoping I could speak to someone in the ER and see if she may be appropriate for an ER to ER transfer." Review revealed Transfer Center Staff then connected Physician #1 to Physician #8, at which time Physician #1 gave Physician #8 the patient's history and diagnostic information and told him the patient had been accepted to (Hospital B's) surgery services, but he had been told it may be 36 hours before a bed was available for the patient. Review revealed the following conversation:
? Physician #1 - "I talked with my surgeon here, as well as to my medicine service and I got all kinds of push back as far as them thinking that, hey, this is a procedure that my surgeon who's on call actually says 'It's a procedure I don't even perform. I'm not qualified to perform this. I don't think it is appropriate for me to take care of, take over care of, this patient in the intervening time'."
? Physician #8 - "In terms of managing a bowel obstruction?"
? Physician #1 - "In terms of managing a patient who had this particular procedure performed who now has a bowel obstruction. I'm uncomfortable with her being just sitting here in the Emergency Department without the ability for me to get a surgeon involved who is comfortable taking care of this patient." Physician #8 then asked the physician's name and service at Hospital B that had accepted the patient. He said he wanted to see what was going on with them.
? Physician #8 - "Currently, I'm still holding patients waiting for beds upstairs in my Emergency Department as well."
? Physician #1 - "I was informed of that also. I just want to make sure that I've got a good disposition for this lady and that she's going to have appropriate stop-gap care. She has been literally hemodynamically stable for the entire...day. But, she was a sign-over patient to me, and she would be a sign-over to my colleague who just came in, and could end up being a sign-over of a sign-over of a sign-over of a sign-over with no one here who can perform definitive care if necessary."
? Physician #8 - "I understand your point. But at the same time, she's had a procedure, but a complication of it, a small bowel obstruction, that most surgeons can handle. Let me find out what's going on from our urology standpoint and I'll give you a call back."
Further review of Transfer Center calls revealed at 1624 Physician #8 called Hospital A and spoke with Physician #12, who had relieved Physician #1 of duty. Review revealed the following conversation:
? Physician #8 - "Apparently your surgeons felt uncomfortable taking care of her there?"
? Physician #12 - "Yeah. We're having issues with our surgeons down here. You know, we've even tried to talk with administration and stuff and just not really getting any where. So, we just really want the patient to get the best care."
? Physician #8 - "Right now what we're dealing with is I've got no beds at all in our hospital either, so she's going to be sitting in our ED, just the same as she would be in your ED. I'm happy to take her, but if you have a bed available it may make the most sense to have her admitted and do an inpatient to inpatient transfer. I mean, you know, if it's a small bowel obstruction, which most surgeons can manage non-op with an NG tube."
? Physician #12 - "Absolutely. I one hundred percent agree with you. The problem is we just can't get anyone to do that. We've talked with the Chief, you know, we've talked with a couple of different surgeons and haven't been able to get any one willing to take on a case because it was done there (at Hospital B). So, no one is willing to admit her to take care of it...in the meantime....So, she's going to have to, I guess, be here in the ER. But the problem is that we don't have a, you know, a specialist. We're just, you know, the ER doctors would just be taking care of her, rather than a specialist coming to the ER, is our concern. So if you can take her in yours, I mean I understand, obviously we all know this is not the ideal situation and not the way things, you know, should happen. But if you're able to, obviously we would greatly appreciate that. If not, then we'll just have to keep plugging along and doing what we're doing."
? Physician #8 - "Well, I mean, I'm not going to