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Based on interview, record review, and review of the facility's policies, it was determined the facility failed to comply with 42 CFR 489.24(f) regarding an appropriate transfer for two (2) of twenty-one (21) sampled patients, Patient #1 and Patient #7. Facility #2 initially accepted Patient #1 as a transfer patient but then Physician #3 declined Patient #1 as a transfer. Patient #1 was then accepted to Facility #3 as a transfer patient to treat his/her emergency medical condition. Additionally, Patient #7 was denied transfer for interventional radiology services although Facility #2 had the capability to provide the service.

The findings included:

Refer to findings in Tag A-2411

Based on review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) policies and education documents, on-call schedule, call center timeline, access center documentation, record review and interviews, it was determined the facility failed to comply with 42 CFR 489.24(f) regarding an appropriate transfer for patients requiring specialized services for which the hospital provides (Podiatry and Interventional Radiology-[IR]) for two (2) of twenty-one (21) sampled patients, Patient #1 and Patient #7. Patient #1 had initially been accepted by Facility #2 as a transfer patient with an emergency medical condition; however, Physician #3 then declined to accept Patient #1 as a transfer. Patient #1 was then accepted as a transfer patient with an emergency medical condition to Facility #3 where he/she received medical care. In addition, Patient #7 was denied transfer from Facility #4 to Facility #2 for interventional radiology services although Facility #2 had the capacity and capability to provide the service.

The findings include:

Review of Facility #2's policy titled "Physician On-Call Coverage and In Lieu of Availability of On-Call Physician Services", last reviewed 04/2023, revealed a Physician on the facility specific roster of Physicians on-call to the Emergency Department (ED) of that facility has a legal obligation under EMTALA (emergency medical treatment and active labor act) to come to the facility.

1. Review of Facility #2's Emergency Department (ED) Speciality On-call schedule revealed Physician #3 was on-call for Podiatry on 03/02/2023.

Review of power-point education titled "EMTALA: Basics and Application, dated 06/29/2022, revealed EMTALA education had been provided to Physicians, Qualified Medical Providers (QMP) and Nursing staff. The education was not limited to the Emergency Department (ED) and included Hospitalists and Leadership.

Review of power-point education titled "EMTALA: Basics and Application, dated 04/11/2023, revealed education had been presented to seventeen (17) Service Specialty Physicians.

Review of the attendance sign-in sheets revealed Physician #5 attended this education. Physician #3 was not listed as receiving the education presented on 06/29/2022 or 4/11/2023.

Review of Patient #1's ED clinical record from Facility #1 revealed he/she arrived via privately owned vehicle (POV), on 03/02/2023 at 12:10 PM. Review of History of Past Medical Illness (HPI) revealed that on 02/15/2023, Patient #1 had presented to a hospital sixteen (16) miles from his/her home; while there, blood cultures were drawn that resulted (on 02/19/2023) Methicillin-Resistant Staphylococcal Aureus (MRSA) - a bacterial infection resistant to certain antibiotics. Further review revealed that on 03/02/2023, Patient #1 was notified by the wound clinic of the positive blood cultures and advised to present to the Emergency Department at Facility #1.

Physician #2 is no longer employed by Facility #1.

Review of the Medical Doctor (MD)/ED Course (part of a Practitioner's documentation within the medical record) revealed the Advanced Practice Registered Nurse (APRN #1), working in collaboration with Physician #1, had contacted the Director of the Wound Clinic (Physician #4) to discuss where Physician #2's patients were being admitted. It was documented that Physician #4 stated he would be happy to see Patient #1 in an out-patient setting but no longer treated in-patients. He stated Patient #1 would benefit from a specialist service such as Podiatry.

Continued review of the Course revealed APRN #1 contacted Facility #2 about a transfer. It was documented that Facility #2 initially consented to the transfer but after back and forth conversations Facility #1 had with Physician(s) #2 and #3, Facility #2 declined the transfer.

Additional review revealed Physician #3 had stated he felt it was inappropriate that Physician #2 had not arranged follow-up care for his patients during his transition to Facility #2. It was documented that Physician #3 suggested Facility #1 reach out to two (2) other local hospitals.

Further review of the Medical Doctor (MD)/ED Course revealed Facility #3 accepted the transfer.

Patient #1 was transferred to Facility #3 on 03/03/2023.

Review of the call center timeline for canceled request for Patient #1's transfer revealed that on 03/02/2023, at 1:51 PM, Facility #2's Command Center received a call from Facility #1's Call Center about a possible transfer of Patient #1. At 2:06 PM, Physician #5 (Hospitalist) was notified by Placement Registered Nurse (P-RN) #2 of transfer request. At 2:20 PM, Physician #5 returned the call and stated he was with a patient and would call back. Continued review revealed Physician #5 returned the call, received the details for Patient #1. It was documented Physician #5 wanted Physician #3 to speak directly to Facility #1's referring provider.

Interview with Physician #5, on 04/20/2023, at 2:35 PM, revealed he had "implied" consent to accept the transfer when speaking with the Command Center but wanted Physician #3 to also speak directly to the referring provider.

Continued review of the Timeline revealed that at 2:31 PM, contact information was given to Physician #3's office by P-RN #2.

Further review revealed that on 03/02/2023, at 3:19 PM, P-RN #2 had called APRN #1, at Facility #1 as to Physician #3 speaking with her.

It was documented that at 3:26 PM, APRN #1 spoke with P-RN #2, that Physician #3 had spoken to her and wanted Physician #2 advised of the possible transfer of Patient #1.

Further review of the timeline revealed that at 3:29 PM, Physician #2 was paged; at 3:39 PM, he returned the page, stated he was not yet approved to see patients and would speak directly to Physician #3.

Interview with P-RN #2, on 04/20/2023, at 9:58 AM revealed the process of the Command Center was to stay on the line and document conversations in real time. She continued the interview by stating that at the point when Physician #2 and Physician #3 started to converse directly to each other, the Command Center was out of the loop.

Further interview revealed that at 3:58 PM, she had called Physician #3's office to inquire if he had spoken to Facility #1's Medical Provider. She stated that at 4:19 PM, he returned her call, stated that he had spoken to Physician #2, and he would not be covering Patient #1 since Physician #2's privileges were not yet in place and had relayed to Facility #1's Medical Provider that Patient #1 should go to another facility.

Additional interview with P-RN #2 revealed that on 03/02/2023, at 5:02 PM, she spoke with Physician #1, at Facility #1, about Physician #3 not accepting Patient #1. She stated that Physician #1 stated he had spoken to Physician #3 and planned on reporting the incident as an EMTALA violation, since Facility #2 had the needed specialty service.

Continued interview revealed, it was this point she escalated the incident up the chain of command.

Interview on 04/19/2023, at 9:10 AM, with Physician #2, revealed that Patient #1 had been a patient of his at the Wound Clinic for Facility #1; however, at the time of the requested transfer, his privileges for Facility #2 were not yet approved so he was unable to provide care for Patient #1.

He continued the interview by stating that usually when a patient was hospitalized, the Hospitalist would oversee the day to day care and he would only see patients on a consultant basis.

Interview with Physician #3, on 04/20/2023, at 10:37 AM, revealed he was aware of the EMTALA process but could not remember when or where he had received EMTALA education. He stated he would never turn down a patient in an emergent situation. Continued interview revealed he typically did not admit patients, he relied on the Hospitalist to accept/admit the patient and then he (Physician #3) would be consulted.

Further interview revealed he had contacted Physician #2 about Patient #1 and they both agreed Patient #1 should go to another facility. Physician #3 stated he had received very little clinical information regarding Patient #1 from Facility #1; only that he/she had a wound and had MRSA, it was not disclosed to him that Patient #1 had Osteomyelitis (bone infection) or that it was an emergent situation.

Additional interview revealed he had been contacted by the Chief Medical Officer (CMO) on 03/03/2023 to discuss the incident on 03/02/2023. He stated that during the conversation, he expressed that he just was trying to get the most appropriate care for Patient #1.

Interview on 04/21/2023, at 12:46 PM, with Facility #2's Chief Operating Officer/Chief Nursing Officer (COO/CNO) revealed she had been made aware of the incident on 03/02/2023. She stated that on 03/02/2023, a call center timeline review was completed; it was through this review, that it was ascertained a process breakdown had occurred.

Further interview revealed that Command Center documentation was reviewed daily and could provide recognition of opportunities to upgrade/streamline patient care.

Additional interview with the COO/CNO revealed it was a diverse collaborative effort within the hospital system to recognize/solve issues.

2. Review of Patient #7's emergency department (ED) clinical record from Facility #4 revealed he/she arrived to Facility #4 on 02/24/2023, via privately owned vehicle (POV), at 12:41 PM. The Chief Complaint was shortness of air (SOA).

Review of the medical decision making (MDM) narrative revealed Patient #7 presented to the ED, complaining of abdominal pain and SOA. It was documented in the narrative that Patient #7's work-up revealed, among other things, bilateral pulmonary emboli (blood clots in the lungs) and an intra-abdominal abscess. It was documented the ED Physician consulted the on-call General Surgeon at Facility #4, who recommended transferring Patient #7 to a facility with Interventional Radiology-IR, capabilities, in light of the pulmonary emboli.

Further review of the MDM revealed that on 8:30 PM, on 02/24/2023, Facility #4's command center had been consulted to arrange transfer. It was documented the command center contacted three (3) out of state facilities and one in-state facility that was twenty-eight (28) miles/thirty-five (35) minutes to Facility #4.

Review of Facility #2's Access Center Note, on 02/24/2023 at 8:37 PM, revealed
P-RN #4 received a call from Facility #4's Command Center staff requesting a transfer for Patient #7 to Facility #2. Facility #4 staff stated Patient #7 had an intra-abdominal abscess, pneumonia, and bilateral pulmonary emboli (PE) and was on an intravenous (IV) heparin (anti-coagulant) drip for the PE. In addition, Facility #4 staff stated Patient #7 had a Splenectomy on 02/11/2023 at an out-of-state facility, but that facility did not have the capacity to accept Patient #7.

Review of Facility #2's Access Center Note, on 02/24/2023 at 9:18 PM, revealed Physician #6 from Facility #2 contacted P-RN #4 and told her that general surgery would have to accept Patient #7 because of the intra-abdominal abscess.

Review of Facility #2's Access Center Note, on 02/24/2023 at 9:47 PM, revealed Physician #7, a general surgeon from Facility #2, called P-RN #4 and told her Patient #7 needed to return to the out-of-state hospital where the patient had a Splenectomy on 02/11/2023. Per the note, Physician #7 declined to call Facility #4.

Review of Facility #2's Access Center Note, on 02/24/2023 at 10:02 PM, revealed P-RN #4 called staff at Facility #4's Command Center and told her Physician #7 had stated Patient #7 needed to return to the out-of-state facility that performed Patient #7's Splenectomy on 02/11/2023.

Review of Facility #2's Access Center Note, on 02/24/2023 at 10:10 PM, revealed P-RN #4 received a call (caller identity unknown) that stated Patient #7's case was canceled because Physician #7 declined to accept the case. Per the note, the declination was because Facility #2 was not appropriate and did not follow continuity of care.

Review of Facility #2's Access Center Note, on 02/24/2023 at 11:43 PM, revealed Physician #6 was contacted about Patient #7's case being canceled and the reason for the denial of transfer.

Review of Facility #2's Access Center Note, on 02/24/2023 at 11:47 PM, revealed P-RN #4 stated the request for Patient #7's transfer from Facility #4 was canceled because the facility was not appropriate.