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Based on policy review, medical record review, on call log review, audio recording review and staff and physician interviews, the hospital failed to comply with 42 CFR §489.20 and §489.24.

Findings included:

The hospital failed to accept a request for transfer of a patient with an Emergency Medical Condition (EMC) from a referring Dedicated Emergency Department (DED) for specialized inpatient care when the receiving/recipient hospital had the capacity and capability to provide care for 2 of 10 sampled intake calls reviewed. (Patient #29 and #23).

Cross refer to 489.24(f), Recipient Hospital Responsibilities - Tag A2411.

Based on policy review, medical record review, on call log review, audio recording review and staff and physician interviews, the hospital failed to accept a request for transfer of a patient with an Emergency Medical Condition (EMC) from a referring Dedicated Emergency Department (DED) for specialized inpatient care when the receiving/recipient hospital had the capacity and capability to provide care for 2 of 10 sampled intake calls reviewed. (Patient #29 and #23).

Findings included:

Review of the "EMTALA: Treatment of Patients with Emergency Medical Conditions" policy approved 06/11/2019 revealed, "... D. 1. (Rex Hospital-Hospital A) must accept the requested transfer of a patient who is in an emergency medical condition when (Hospital A) has the capacity and specialized capabilities that are not available at the requesting hospital. (Hospital A) is obligated to accept a transfer if the requesting hospital has no beds, is overcrowded, or does not have the specialized capability of (Hospital A) to treat the patient. ..."

Review of the "Transfer Center Policy and Procedure" approved and last revised 06/08/2018 revealed, "... One of our primary missions is to expedite the safe flow to (Hospital A) from our community and surrounding counties. ... The Transfer Center nurse will connect the referring physician with the accepting/consulting physician by phone to confirm acceptance and for the safe handoff of the patient. ... The Transfer Center Nurse will document the request for transfer, the patient information, and any clinical or operational information related to the transfer in EPIC (electronic record). For all inbound STEMI patients, the Transfer Center Nurse may initiate air transport as appropriate and activate the STEMI alert prior to arrival of the patient. ... All declined or canceled transfers to (Hospital A) are reviewed for reason for decline or cancellation. ..."

1. Review of Hospital A Transfer Center's "Inbound STEMI (ST elevation myocardial infarction) Transfer Algorithm" revealed " ... Auto-Accept / Auto-Launch . Regardless of bed status at (Hospital A), patient will be AUTOMATICALLY ACCEPTED under NCHV Interventionalist on-call. ..."

Review of Patient #29 DED record from Hospital C (sending hospital) revealed a 66 year-old female that presented to the DED on 09/17/2019 at 1828 with a chief complaint of "midsternal chest pain on and off for 10 days." Review of the record revealed the patient had a past medical history of hypertension, hyperlipidemia, and insulin dependent diabetes. Review of the DED progress notes revealed a cardiac workup was completed that included laboratory studies, EKG and chest x-ray. Review of the progress notes revealed a cardiology consult note at 2105 with a recommendation after review of the EKG to "call STEMI alert and transfer patient." Review of the DED progress notes at 2120 recorded "clerk reports that (Hospital A) transfer center states that the on call STEMI doc said they were in another case and could not accept. I spoke with (Hospital D) cardiology fellow (name) who accepted patient to ICU under (MD Name). Transfer center stated during that call that they were able to provide a bed. Upon calling STEMI alert (name of EMS) was immediately at bedside to transport patient. ... Patient well appearing and HD (hemodynamically) stable throughout the ED course. ..." Review of the DED physician's notes revealed a clinical impression of "ST elevation myocardial infarction (STEMI), unspecified artery; elevated troponin" with a final disposition of "Transfer to (Hospital D." Review of the "EMTALA Transfer Form" signed by the DED physician on 02/17/2019 at 2139 recorded the benefits of transfer as "obtain a level of care/service not available at this facility." Review of the DED record revealed the patient was transported via EMS ground transport and departed Hospital C's DED on 09/17/2019 at 2124.

Review on 10/16/209 at 1000 of an audio recording from Hospital A's (requested recipient hospital) Transfer Center revealed a series of calls received on 09/17/2019 between Hospital C's (sending hospital) DED staff and physicians and Hospital A's staff and on call physician. Review of the audio recording revealed the first call was received by Hospital A's Transfer Center registered nurse (RN #3) at 2103:18 from Hospital C's staff.
Hospital C staff: "I've got a STEMI."
Hospital A's nurse (RN #3): "I can't take it right now."
Hospital C's staff: "Okay, so what do you want me to do?"
Hospital A's RN #3: "I mean, I don't know. I've never had two come in at one time. I mean literally."
Hospital C's staff: "Is there another person I can call to?"
Hospital A's RN #3: "I can call you back in just a second. Let me call (name of staff) in the cath lab, okay?"
Hospital C staff: "All right."

Review of an audio recording revealed a second call occurred between RN #3 in Hospital A's Transfer Center and the cath lab on 09/17/2019 at 2104:12.
RN #3: "Look, I've got (Hospital C) that's got a STEMI. He can't do but one at a time. I don't know what to tell them to do."
Cath lab staff member: "Call the doctor. I mean we can have them send here and send them to the unit but call (name of STEMI physician on call)."
RN #3: "Okay"
Cath lab staff member: "They're loading up now."
RN #3: (name of another outside hospital)
Cath lab staff member: confirmed.

Review of an audio recording revealed a third call occurred between RN #3 in Hospital A's Transfer Center and the STEMI physician on call (MD #4) on 09/17/2019 at 2105:01.
RN #3: "All right, so you've got to tell me how to do this now. I've got another STEMI at (Hospital C)."
MD #4: "What do you guys do in the past?"
RN #3: "I mean generally we don't get two STEMIs back to back."
MD #4: "Send them to (Hospital D). Send them to (Hospital D)."
RN #3: "Okay."
MD #4: "That's the way I would do it."
RN #3: "Okay, all right. Yes sir. Thank you,"

Review of an audio recording revealed a fourth call occurred between RN #3 in Hospital A's Transfer Center and the staff at Hospital C's DED on 09/17/2019 at 2106:00.
RN #3: "So, our STEMI doctor said send that one to (Hospital D)."
Hospital C staff: "(Hospital C)?"
RN #3: "Yes, they do STEMIs"
Hospital C staff: "All right."
RN #3: "He can't do it."
Hospital C staff: "That's just so far away."
RN #3: "He can't do two at a time."
Hospital C staff: "All right. Thank you."

Review on 10/16/209 at 1000 of an audio recording from a cardiologist (MD #5) at Hospital C to Hospital A's Transfer Center on 09/18/2019 (time unknown).
MD #5: "There's a lady last night, a STEMI here that they called about. The patient's name was (Patient #29)."
Transfer Center RN: "Did she come in?"
MD #5: "Well, no. You guys refused here and that's the call"
Transfer Center RN: ""Oh my. Do you have the medical record number?"
MD #5: (medical record number provided). Shipped her after that to (Hospital D), oddly enough where her troponin went from 1 which it was here to almost 5 and she had ST elevation clear cut. Now it's 15. She still hasn't been cathed. (MD name) is following up, like what the (explicative) is going on? Why would I transfer you future patients because you're refusing STEMIs. That's the question, right? (difficult to hear audio clearly) patients who need their intervention (difficult to hear audio) 50 miles away in Chapel Hill."
Transfer Center RN: "I am going to have to defer this to our team leader cause I don't show a case at all here at (Hospital A) for that patient."
MD #5: "Saying you didn't get a call for the transfer?"
Transfer Center RN: "If we did, a case wasn't started. Ummm, so I'm gonna have to have her pull the. What time did the, do you know about what time they
MD #5: "Yes, it was 8:57 PM."
Transfer Center RN: "Shortly thereafter. I am going to have her pull the recordings and see if we got the call. Nothing was in our, like no one here started the case. So I'm not sure what happened. I see the (Hospital D) case, but I don't see anything that we started."
MD #5: "So what's circulating now at (Hospital C) is that the call went through the Interventionalist and they were in another case and refused this patient to come there which would be really odd. I'm an Interventionalist, right. What do you say, bring it. Yea, bring it."
Transfer Center RN: "So let me just look. I have the voided intake highlighted. Let me look here. Yea, I don't see any case started. So let me speak with (manager's name) and we will call you back."
MD #5: "Ok. No, that would be great. There's a big brouhaha here."
Transfer Center RN: "I bet."
MD #5: "Yea."
Transfer Center RN: "(MD #5 name), right?"
MD #5: "Yes, the call went out from the transfer center last night. I actually happened to be on call. They ran the EKG by me and I agree that the patient with active chest pain and troponin 1 should have gone to the lab. The EKG is pretty clear cut. There's at least a millimeter, maybe 2 millimeters ST elevation precordial leads. The patient is still at (Hospital D). Ironically weird in the unit, not being cathed yet, with a troponin of 15 now."
Transfer Center RN: "I can see the notes. (Hospital D physician) accepted the patient under cardiology service. The patient was to go to CCU, not to the cardiac cath lab."
MD #5: "Yes, no lytics on board, it's weird, no lytic on board."
Transfer Center RN: "okay"
MD #5: "Yes, lytic going to the unit; no lytic, you know, active pain. I'd like to know because this affects how I behave with you guys."
Transfer Center RN: "absolutely"
MD #5: "I hope this is recorded, right?"
Transfer Center RN: "Yes"
MD #5: "This affects how I behave with you guys when I call (Hospital A) Transfer Center. If you're not taking STEMIs, we need to know that. It's a problem."
Transfer Center RN: "Yes and we would have any call recorded from last night so we would know what was said from a provider. You know, cause if a provider said to us, like, no we can't take it. We would normally still have a case and I know for myself because that's so unusual, it would be something I would fully document."
MD #5: "Yea"
Transfer Center RN: "So, we'll look into it and give you a call back."
MD #5: "Thank you. Bye."

Review of Patient #29 medical record from Hospital D revealed the patient presented to Hospital D on 09/17/2019 at 2249 and was admitted to the cardiac intensive care unit (CICU). Review of a physician's history and physical recorded on 09/18/2019 at 0012 revealed " ...STEMI vs NSTEMI: Patient presents with anginal chest pain, elevated troponin (1.356 at OSH [outside hospital], now 2.31), and ischemic EKG changes, notably 1-3 mm ST segment elevations in V1 - V3 with EMS (emergency medical system team), though these appear to have resolved on presentation. Bedside echo reveals apical hypokinesis (generalized, uniform decrease in the amplitude of left ventricular wall motion) but no other major wall motion abnormalities or reduced EF (ejection fraction). This constellation of findings is compelling for MI, though given the chronicity of her pain, it is difficult to determine the age of the insult. Her TIMI (risk score for unstable angina/non-ST elevation MI) is score is 6 (41% risk at 14 days). Patient will need a LHC (left heart catherization), though we are hoping, given her overall well-appearance and hemodynamic stability, that this can occur non-urgently in the morning. Clinical picture is less convincing for PE (pulmonary embolus) (Well's score of 0), aortic dissection, or new-onset HF(heart failure). ..." Review revealed the patient was sent to the cardiac cath lab on 09/18/2019 at 0816, then to the operating room on 09/18/2019 at 1114 for a coronary artery bypass grafting (CABG) of four vessels. Review of the physician discharge summary documented on 09/25/2019 at 1350 recorded, " ... (Patient #29) is a 66 y.o. (year-old) female with history of T2DM (type 2 diabetes mellitus) (A1c 9.8 on 9/17), HTN (hypertension), and HLD (hyperlipidemia - elevated cholesterol) who presented to OSH (outside hospital) with angina pectoris, elevated troponin, and EKG changes concerning for STEMI vs NSTEMI. Pt was transferred to (Hospital D) and underwent cardiac catheterization which revealed multivessel disease not amenable to PCI (percutaneous coronary intervention - coronary angioplasty). IABP (Intra-aortic balloon pump) was placed in cath lab and patient proceeded to the OR (operating room) for emergent CABG. ..." Review of the record revealed the patient was discharged to a Skilled Nursing Facility on 09/27/2019 at 1540.

Review of Hospital A's cath lab log for 09/17/2019 revealed eight procedure rooms listed. Review revealed a scheduled case in room 2 beginning at 1700 through 1800 and room 1 beginning at 1800 through 1930. Interview on 10/16/2019 at 1430 with RN #2 revealed MD #4 's call started at 1700 and other cases were already going in the cath lab. Interview revealed there were six cath lab procedure rooms open and available for use.

Interview on 10/15/2019 at 1355 with RN #1 revealed she was the manager of the Transfer Center. Interview revealed the call from MD #5 at Hospital C was brought to her attention on 09/18/2019. Interview revealed MD #5 was "upset because we didn't accept a STEMI transfer" from Hospital C. RN #1 stated the Transfer Center calls were reviewed from 09/17/2017 and a call was found that RN #3 had received for a request for a transfer for a STEMI for Patient #29. Interview revealed the two nurses in the Transfer Center were working on a transfer request for a STEMI from another facility when the call came in from Hospital C. Interview revealed RN #3 called MD #4 and there was a "brief conversation." Interview revealed "(RN #3) was flustered on the phone and had not worked multiple STEMIs at one time. (MD#4) recommended to send the patient to (Hospital D). She called them (Hospital C) back and told them to call (Hospital D). She (RN #3) returned to the other case and failed to add the (Hospital C) call to the call log. She failed to notify leadership when the denial occurred. She failed to auto accept the patient for a STEMI transfer."

Interview on 10/16/2019 at 0905 with RN #3 revealed she was the nurse working at Hospital A's Transfer Center on 09/17/2019 when she received a call requesting a transfer for Patient #29 from Hospital C. RN #5 stated she was completing paperwork for another patient with a transfer request for a STEMI when she got the call requesting transfer for a STEMI transfer for Patient #29. RN #5 stated this was the first time she had received back to back STEMI requests. The nurse stated, "I wasn't sure what to do, so I called the STEMI doctor (MD #4). He asked me what I normally do in that situation. He said it would be best to send that patient to a different facility. I called (Hospital C) back and told the doctor that." Interview revealed there was no further discussion and no patient name was provided. The nurse reported that the "Inbound STEMI Transfer Algorithm" was available, but she did not use it at that time. Interview revealed that the algorithm steps were to "auto accept the patient, dispatch transport, then get the remaining information." The nurse further reported that MD #6 was to be notified of all DED transfer requests that were denied.

Interview on 10/16/2019 at 0910 with RN #1 revealed there were back up on call cardiologists available and that the hospital can have multiple STEMI cases come in. Interview revealed multiple STEMI cases come in simultaneously during bad weather and there is an MD to MD conference if they think there will be a delay beyond 90 minutes in getting the procedure started. RN #1 stated, "We always accept." The nurse reported they could send the patient to the Intensive Care Unit (ICU) and manage medically until they can get the patient to the cath lab.

Interview on 10/16/2019 at 1235 with MD #4 revealed he remembered the situation with Patient #29. The physician stated he was driving to the hospital to treat the STEMI patient that was coming via air from another outside hospital when he got the call from the nurse at the Transfer Center asking what to do with the request from Hospital C. MD #4 stated he asked the nurse at the Transfer Center if she wanted to check with Hospital D to see if they would take the patient (#29). The physician stated he heard later that Hospital D accepted the patient. MD #4 stated he was familiar with the "Inbound STEMI Transfer Algorithm" and the policy to "auto accept" all STEMI requests for transfer. MD #4 stated "He still felt it was the right decision to send the patient to (Hospital D)." The physician stated there were less resources at night and they would have needed to call in another provider.

Interview on 10/16/2019 at 1245 with MD #6 revealed she was the Chief Medical Officer. Interview revealed during the day there are multiple rooms (8 cath lab rooms) available. Interview revealed from 1700 through 0700 and on weekends, there were two physicians on-call, a medical cardiology physician and an Interventionalist. Interview revealed one Interventionalist would be available to do STEMI procedures. Interview revealed multiple STEMI patients coming at the same time would be difficult to manage during the evening and weekend hours and they were currently working on details regarding how to handle that situation.

2. Review of the "Medical Staff - On Call Coverage for Physicians" policy approved and last revised 05/21/2019 revealed, "... It is the policy of (Hospital A) to meet the needs of its patients by arranging for appropriate physician coverage for its patients. ... These physicians are on-call to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. ...For purposes of this policy, an "on-call physician" is the physician listed on the hospital's unassigned on-call list or identified by the physician's practice as on-call for patients of the practice who are present or admitted to (Hospital A). ... If the on call physician cannot timely respond due to circumstances outside of his/her control (such as transportation failures or personal illness), then, if possible, the on-call provider will send a similarly-qualified provider to respond to the call ..."

Review of Hospital A's ED Unassigned Call Schedule revealed MD #8 was listed as on-call for urology services on September 1, 2019.

Review of Patient #23 DED record from Hospital C (sending hospital) revealed a 45 year-old male that presented to the DED on 09/01/2019 at 1825 with a chief complaint of "having the kidney stone stuck at the end of his penis for 2 days." Review of Hospital C's DED physician's medical screening examination recorded at 1839 revealed "(Patient #23) is a 45 y.o. (year-old) male who presents to the ED for evaluation of a possible urinary calculus stuck in his urethra. He states he was recently diagnosed with a kidney stone and feels that this has been lodged in the urethra for the last 2 days. He notes that he is only able to urinate by pinching the penis and allowing flow of urine around the stone, and that this flow is minimal. He feels that he constantly needs to urinate but has no noted blood in the urine and no fever. No flank pain. At this time, the only pain is centered around the urethra and the glans of the penis. There is no penile or testicular swelling. No other complaints. ..." Review of the physician's notes revealed a physical examination and lab studies were completed, including a review of a prior CT imaging study that showed a large ureteral calculus. Review of the DED physician's notes recorded " ... We do not have urology on call. Given the persistent pain in the patient's reported continued need to urinate and inability to do so, I felt the transfer was warranted. I discussed the case with the on-call urologist at (Hospital A), though they were unable to accept the patient. Subsequently. The case was discussed with (MD name), the on-call urologist at (Hospital E). He has accepted the patient. Both he and I are amenable to transfer by POV (private vehicle), driven by the wife. The patient has been instructed to go directly to (Hospital E) for further management." Review revealed a clinical impression of "Urethral calculus, UTI (urinary tract infection)." Review of the DED record revealed the patient departed Hospital C's DED on 09/02/2019 at 0129.

Review on 10/16/209 at 1000 of an audio recording from Hospital A's (requested recipient hospital) Transfer Center revealed a series of calls received on 09/01/2019 between Hospital C's (sending hospital) DED staff and physicians and Hospital A's staff and on call physician. Review of the audio recording revealed the first call was received by Hospital A's Transfer Center registered nurse (RN #7) from Hospital C's staff on 09/01/2019 at 2342.
Review of the recording revealed a staff member from Hospital C called RN #7 requesting a transfer for Patient #23 for urology services. Review of the audio recording revealed Hospital C staff reported Patient #23 had a kidney stone that was "stuck in his urethra.
Hospital C MD: "I have a gentleman with a known large urinary calculus that was diagnosed on August 21 at (another acute hospital). He is here today with that same calculus lodged in his urethra. Probably about a 1 and ½ centimeter back from the hip of his penis, and he's really unable to urinate. Aside from some leaking around it. I think he probably needs to have it surgically removed by urology."
Hospital A's nurse (RN #7): "Umm. You said a centimeter and a half?"
Hospital C's MD: "Roughly, I mean we're going by palpitation externally. I just tried to finger it out and found it directly. Yea, probably, maybe 2 centimeters."
Hospital A's RN #7: "All right, I will page our urologist on call who is (MD #8) and give you a call back"
Hospital C's MD: "All right, sounds good. Thank you."
Hospital A's RN #7: "Thank you. Bye bye."
Hospital C MD: "Bye."

Review of the audio recording from Hospital A's Transfer Center revealed a call between RN #7 at the Transfer Center and MD #8 (urologist on call) at 2354. RN #7 gave a summary report of Patient #23 to MD #8 and told MD #8 that the ED physician at Hospital C wanted to talk with MD #8 about transfer of this patient. The nurse reported that the ED physician stated he felt the stone needed to be surgically removed.
Hospital A's MD #8: I've had a very bad, long day. I'm very tired. It's a long weekend for me. It's my third day. Tell them to call somewhere else. I've had enough. Very busy day. I'm full."
RN #7: "Okay, I'll let them know."
Call ended

Review of an audio recording from Hospital A's RN #7 to the ED MD at Hospital C at 2357:
Hospital A's RN #7: "Hi (ED MD name). This is (RN #7) in the Transfer Center at (Hospital A). I spoke with (MD #8), our urologist on call this evening and he advised that he is at capacity and is unable to assist you with your patient this evening and advised to call another facility."
Review of the audio revealed the ED physician advised he would call elsewhere, and the call concluded.

Review revealed a fourth recorded call from RN #7 at Hospital A to MD #6 (Chief Medical Officer at Hospital A) on 09/02/2019 at 0017. RN #7 reported that MD #8 had refused a transfer for Patient #23.
Hospital A RN #23: " ... It was (MD #8) with urology and umm, I remembered we were supposed to let you know if something like this occurred. So I was calling to let you know about this patient."
Hospital A's MD #6: (unable to determine words spoken)
Hospital A's RN #7: "Yes ma'am. The patient is a 45 year-old by the name of (Patient #23 name) ... (patient summary given) ... (Hospital C ED physician) felt it needed to be surgically removed. I paged (MD #8) and he called me back shortly thereafter and I was telling him about the patient and he just said, 'No, No.' He's like 'I'm tired. I've had a very long day.' And he's like 'I'm full. You need to tell them he needs to call somewhere else'."
Hospital A's MD#6: "Oh, geez."
Hospital A's RN #7: "I'm sorry. I couldn't understand."
Hospital A's MD #6: "Yes, we do need urology on this one because sometimes they send us things that the hospitals can manage. Umm, but if you don't mind calling (MD #8) back. We need to accept the patient, and we can kind of, but the time the patient gets here, probably will be morning anyway that he needs to pick up the patient unless somebody has already accepted the patient when you call back. Because he didn't want his group to have another EMTALA violation."
Hospital A's RN #7: "I need to call him back about this?"
Hospital A's MD #8: "Well. Or you could give me the number and I can call him back. But if you could see if somebody else has accepted the patient first."
Hospital A's RN #7: "Okay, I will call (ED physician at Hospital C) and see if he has found another place. ... I'm looking at (Hospital C's ED physician's) note. I discussed the case with the on call urologist at (Hospital A) ... MD did not speak with me directly. Subsequently, the case was discussed with (MD name), the on call urologist at Hospital E. He accepted the patient."

Review of Patient #23's medical record from Hospital E revealed the patient arrived on 09/02/2019 at 0220. Review of the Urology Admission History and Physical recorded on 09/02/2019 at 0210 revealed "(Patient #23) is a 45 y.o. male with past medical history of HTN and nephrolithiasis presenting to the ED with difficulty voiding x 2 days. He was recently seen at an OSH ER and diagnosed with bilateral ureteral stones along with a 1.5 cm bladder stone. He was discharged home on pain medication and Flomax. He presented to (Hospital C) ER last night stating that he feels like a stone is stuck in his urethra. He is able to void small amounts around the stone. He denies any fever, chills, gross hematuria, dysuria, or n/v. He was transferred to (Hospital E) for further Urological care. ... Plan: -Will admit patient to urology service and plan for cystoscopy, urethral stone removal with possible laser lithotripsy. -Bladder scan patient. If >350 cc will attempt to place Foley catheter. ..." Review of a procedural note recorded by a urology PA on 09/02/209 at 0559 revealed a Foley catheter insertion was attempted without success. Review revealed "strenuous resistance" was met and inability to advance the catheter past the calculus. Review revealed the procedure was terminated due to increased pain. Review of the notes revealed a Bladder scan showed 700 cc prior to attempting the Foley catheter placement. The patient was able to void ~150 cc on his own. Review revealed a plan to take the patient to operating room for removal of urethral stone. Review revealed the patient had a "cystoscopy with bilateral retrograde pyelogram and bilateral ureteral stent insertion, laser lithotripsy and stone basketing of a large urethral stone" surgical procedure done on 09/02/2019 at 0953 without complications. Review of the record revealed the patient's pain was controlled with oral medication and the patient was discharged home on 09/04/2019 at 0946.

Interview on 10/17/2019 at 0945 with RN #7 revealed she was the nurse involved with the call received on 09/01/2019 from Hospital C requesting transfer of Patient #23. The nurse stated she remembered the call. She stated "I talked with (MD #8). He was tired. He was full. That meant he was at capacity." The nurse stated she was told to call the Chief Medical Officer who told her to call the hospital back to see if they still needed to send the patient. Interview revealed the nurse reviewed the patient record and saw that the patient was accepted at Hospital E.

Telephone interview on 10/16/2019 at 1600 with MD #8 revealed he was the urologist on call on 09/01/2019. Interview with the physician revealed it had been a busy week. The physician reported he was covering two hospitals and had been in surgery on Friday night and had been making rounds at another hospital and "dealing" with other transfer calls. The physician reported he had operated that evening and just got home when the Transfer Center call came. He reported he had a bad headache and was "sleep deprived." MD #8 stated RN #7 presented the patient's history and reported that they were requesting transfer. The physician stated he "felt bad. There was a hurricane coming in. He never talked with the ED doctor. I Didn't feel good. I was not able to get on the road. I just felt if was not a real medical or surgical emergency. I told her to call someplace else to get the patient elsewhere." The physician stated it was brought to his attention around a week later that he didn't accept the patient. He stated he was "not physically feeling good and had no capacity physically." The physician stated his call started on Friday morning at 0800 and went through Tuesday at 0700. MD #8 stated "I felt I was beginning to crack. I was not safe to take call." The physician stated hospital need to have call limitations. He stated "My capacity was impaired. I had reached my limitations."

Interview on 10/16/2019 at 1240 with MD #6 revealed she was the Chief Medical Officer at Hospital A. MD #6 stated the Transfer Center called her about MD #8 refusing to accept Patient #23. MD #6 stated that she told the Transfer Center RN to call back to the ED physician and tell them that Hospital A would accept the patient. She stated they found out the patient was already accepted at (Hospital E). The physician stated she talked with MD #8 and was told that he declined the patient because he had a migraine and had taken some medication. MD #6 stated MD #8 reported he declined the patient because he did not feel safe. Interview revealed there was a process in place for the on call physician to get replacement coverage if they were unable to carry out their on call responsibilities.

Subsequently, Hospital A failed to accept two requests for transfers (Patient #23 and Patient #29) from the transferring hospital's DED for a higher level of care when Hospital A had the capacity and capability to treat the individuals.

NC00156201