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Based on interviews and reviews medical records, bed census reports, on -call schedules, and policies and procedures, it was determined Facility #1 failed to accept an appropriate transfer of an individual (from Facility #2) who required the specialized services (Urology) not provided by the transferring Facility (Facility #2) or facilities and the receiving hospital (Facility #1-Pikeville Medical Center) had the capacity to treat for 1 (Patient #1) of 20 sampled medical records reviewed. Refer to 42 CFR 489.24 (A-2411).

Based on interviews and reviews of medical records, bed census reports, on -call schedules, and policies and procedures, it was determined Facility #1 failed to accept an appropriate transfer of an individual (from Facility #2) who required the specialized services (Urology) not provided by the transferring Facility (Facility #2) or facilities and the receiving hospital (Facility #1 Pikeville Medical Center) had the capacity to treat for 1 (Patient # 1) of 20 sampled medical records reviewed.

The findings include:

The policy titled "EMTALA Duty to Accept" GUIDELINE #:8441-.0006 was reviewed. The policy revealed in part, " Purpose: To ensure that appropriate transfers are accepted by the hospital and medical staff on-call ...Policy: PMC (Pikeville Medical Center) shall accept any emergency transfer from another facility which meets the following conditions: 1. the individual being transferred has an emergency medical condition which requires treatment or services available at PMC, but not available at the transferring hospital; 2. PMC has the available space and qualified staff to treat the individual; 3.) an appropriate member of the medical staff with active admitting privileges has accepted the patient and agreed to accept.. Note: if the transferring hospital and physician do not have an identified accepting physician at PMC, the emergency Room medical director will facilitate communication with the appropriate on-call specialist. "

The policy entitled " EMTALA- Transfer Process " Effective 07/16/10 Reference (Blank) specified in part, " Purpose: To ensure that a patient requesting or requiring a transfer for further medical care and follow-up is transferred appropriately ... DEFINITIONS: Capabilities refer to the hospital ' s physical space, equipment, supplies and services (e.g. trauma care, surgery, intensive care, pediatrics, obstetrics ...) ...The capabilities of the facility ' s staff mean the level of care the hospital ' s personnel can provide within the training and scope of their professional licenses. Capacity means the ability of the hospital to accommodate the individual requesting examination or treatment of the transferred individual. Capacity encompasses number and availability of qualified staff, beds, equipment, and the hospital's past practices of accommodating additional patients in excess of it occupancy limits...Emergency Medical Condition means: a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain ...) such that the absence of immediate medical attention could reasonably be expected to result in (A) placing the health of the individual...in serious jeopardy."

A review of Facility #1's policy titled "Organizational Compliance," dated 07/16/10, revealed the facility had a procedure to ensure that a patient who requested or required a transfer for further medical care and follow-up was transferred appropriately. According to the policy, the transfer of a patient would not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race or religion. The policy further stated if a patient came to the hospital and had an emergency medical condition, the hospital must provide either: (a) further medical examination and treatment, including hospitalization if necessary, as required to stabilize the medical condition within the capabilities of the staff and facilities available at the hospital; or (b) a transfer to another more appropriate or specialized facility.

A review of the medical record of Patient #1 revealed Facility #1 admitted the patient on 08/03/14 with diagnoses that included Prostatism (obstruction/blockage of the urethra) , Hematuria (blood in Urine) from anticoagulants and urethral trauma, and Coronary Artery Disease. Documentation revealed Urologist #2 at Facility #1 performed a cystoscopy (surgical procedure with evacuation of blood clots and transurethral resection) on 08/07/14 on Patient #1. Medical record review revealed Patient #1 was discharged from Facility #1 on 08/11/14 after the patient underwent a urological surgical procedure. Record review revealed Patient #1 received continuous bladder irrigation through an indwelling urinary catheter from 08/07/14 until 08/10/14 during admission to Facility #1. Review of the physician's orders revealed staff was to remove the patient's indwelling urinary catheter on 08/11/14 and the patient was to be discharged home.

A review of documentation in Patient #1's ED medical record at Facility #2 revealed Patient #1 presented to the ED of Facility #2 on 08/11/14 at approximately 9:28 PM with complaints of urinary retention and he/she was unable to urinate. Further review revealed Patient #1 had a history of Myocardial Infarction with stent placement. Review of the ED physician's notes revealed Patient #1 had been discharged from Facility #1 on 08/11/14. Staff at Facility #2 inserted an indwelling urinary catheter into Patient #1's bladder and obtained bright red blood with blood clots. Staff in the ED irrigated the patient's catheter periodically due to blood clots in the patient's urine that clogged the catheter and did not allow the flow of urine. According to the physician's progress note, Urologist #1 (on-call physician for Urologist #2) at Facility #1 was contacted and the ED physician at Facility #2 informed Urologist #1 of the patient's medical condition and of laboratory tests that had been obtained and were "abnormal"; however, Urologist #1 refused to accept Patient #1's transfer to Facility #1. Documentation revealed the ED physician at Facility #2 did not think Patient #1 should be discharged home due to the blood in the patient's urine and the patient's history of cardiac problems. A second call was made by Facility #2 to Facility #1 and the urologist (Urologist #1) and the on-call Administrator at Facility #1 refused to accept the transfer of Patient #1 to Facility #1. On 08/12/14 at 3:30 AM, the ED physician at Facility #2 contacted Facility #3 (facility that also had the capability to provide urological services) to request a transfer of Patient #1 to Facility #3 for urological services that could not be provided by Facility #2. The ED physician discussed Patient #1's medical condition with Urologist #3, and Facility #3 accepted the patient's transfer to their facility, due to the patient ' s (#1) condition (Bloody urine). Facility #2 transferred Patient #1 to Facility #3 on 08/12/14 at approximately 3:30 AM. Patient #1 was admitted to Facility #3, received a blood transfusion, and underwent surgery to stop the patient's bleeding.

A review of the medical record provided by Facility #3 for review revealed Patient #1 arrived at Facility #3 on 08/12/14 at 6:44 AM by ambulance and was admitted to the facility, to the services of Urologist #3, on an "emergency" basis. Further review of the medical record revealed Patient #1's diagnosis included Urinary complications, Hemorrhage complicating a procedure, Hyposmolality and/or Hyponatremia, Hemorrhage into bladder wall, acute post-hemorrhagic anemia, Retention of urine, unspecified, and gross hematuria.

A telephone interview was conducted on 08/21/14 at 4:15 PM with a family member of Patient #1. According to the family member, Patient #1 was unable to take the telephone call because his/her physician had directed the patient not to "be up" walking and/or lifting. The family member stated Patient #1 had been discharged from Facility #1 on 08/11/14 and shortly after the patient arrived home, the patient started bleeding and "could not make water." The family member stated he/she thought Facility #1 discharged Patient #1 too soon, "we thought they should have kept [him/her] another night." The family member stated Facility #2's ED physician made several attempts to transfer Patient #1 back to Facility #1 where the patient had surgery and the transfer was denied. The family member stated Patient #1 was transferred to Facility #3 where the patient underwent another surgery to stop the bleeding. According to the family member, Patient #1 was on blood thinner medication and was bleeding from the surgical site where polyps had recently been removed. The family member stated Facility #3 performed another surgery to stop the bleeding.

A telephone interview was conducted on 08/21/14 at 6:30 PM with Urologist #3. According to the urologist, he spoke with Facility #2 on the night of 08/11/14 about accepting the transfer of Patient #1 to his services at Facility #3 and "didn't see any other choice but to transport the patient because someone had to do something." Urologist #3 stated the ED physician at Facility #2 had contacted Facility #3 and reported Patient #1 had undergone urological surgery on 08/07/14 and presented to Facility #2's ED after being discharged from Facility #1 on 08/11/14 with complaints of bleeding and being unable to void. Urologist #3 stated the ED physician reported Patient #1 was bleeding "bad" and had a history of heart problems. Urologist #3 stated it was reported that Facility #2's ED physician had attempted to transfer Patient #1 back to the urologist who performed the surgery and the transfer was denied twice. Urologist #3 stated it was his professional opinion that Urologist #1 should have evaluated the patient at Facility #1 and stated, "I personally would have."

An interview was conducted with Facility #1's Intake Nurse on 08/21/14 at 11:20 PM who stated a call was received on 08/11/14 at approximately 1:00 AM from Facility #2, who reported Patient #1 had presented to their ED with complaints of urine retention and blood clots. The Intake Nurse called the on-call urologist (Urologist #1) who was familiar with the patient because Urologist #1 had just discharged the patient from Facility #1 that same day. The Intake Nurse stated Urologist #1 gave instructions for Facility #2 to insert a catheter and send the patient home with instructions to return to Facility #1's urology clinic the following morning. However, the ED physician at Facility #2 did not feel comfortable sending Patient #1 home because the patient was bleeding with abnormal labs and a history of cardiac problems. The Intake Nurse then notified the Hospitalist who compared the patient's lab results from Facility #2 to the results at the time of discharge from Facility #1. According to the Intake Nurse, the Hospitalist determined it was a urology case and suggested Urologist #1 discuss the case with Facility #2's ED physician. According to the Intake Nurse, Facility #2 placed a second call to Facility #1 and Urologist #1, who again refused to accept the patient's transfer. The Intake Nurse stated the Hospitalist and House Supervisor were both notified, but the on-call Administrator agreed with Urologist #1 and the transfer was denied.

A telephone interview was conducted on 08/21/14 at 8:30 AM with Facility #2's ED physician who had worked at Facility #2 on 08/11/14 when Patient #1 presented to the ED at approximately 9:30 PM seeking medical treatment for bleeding/blood clots and inability to urinate. The ED physician stated Urologist #1 "did not believe" the ED physician when he/she said Patient #1 was bleeding. The ED physician spoke with Facility #1's on-call hospital Administrator who agreed with Urologist #1 and denied the transfer of Patient #1 to Facility #1. According to Facility #2's ED physician, staff performed several bladder flushes but the patient continued to bleed and after speaking with Urologist #1 on two occasions along with Facility #1's on-call Administrator, a phone call was made to Facility #3 and Patient #1 was transferred to that facility at approximately 3:30 AM. The ED physician stated Facility #2 could not provide urology services and Facility #1 refused the transfer.

An interview was conducted at the facility on 08/21/14 at 12:30 PM with Urologist #1 who was the on-call urologist on 08/11/14 when Patient #1 had presented to Facility #2. Urologist #1 stated Patient #1 was discharged from Facility #1 on 08/11/14 and later presented to Facility #2 with complaints that he/she was bleeding and could not void. Urologist #1 did not think it was a urology emergency and did not believe the patient was actively bleeding. Urologist #1 stated he instructed Facility #2's ED physician to insert a large catheter, irrigate, and tell the patient to come to Facility #1's urology clinic the following morning. "I knew what it was and the patient did not need to be readmitted." According to Urologist #1, Facility #2's ED physician did not inform him that Patient #1's hemoglobin level had dropped. Urologist #1 stated, "I've never refused a patient that I thought should be here." Pikeville Medical Center failed to ensure that their policy and procedure "Duty to Accept" was followed as evidenced by failing to ensure that on 08/11/14 Patient #1 was accepted from the transferring hospital (Facility #2) by hospital and medical staff on -call (Urology). Patient #1 required Urology services that were available at PMC, but not available at Facility #2 for patient #1 on 08/11/14.

An interview was conducted on 08/21/14 at 1:10 PM with Urologist #2 who performed the urological surgery for Patient #1 on 08/07/14. Urologist #2 stated, "This was a dispute between two people." Urologist #2 stated he was on vacation at the time of the incident and Urologist #1 provided coverage. Urologist #2 stated he was familiar with Patient #1's "case" and stated the patient had heart issues, which required the patient to remain on blood thinners that most likely caused the patient to bleed. Urologist #2 stated Urologist #1 told Facility #2's ED physician to insert a larger catheter; however, there was no evidence the ED physician followed the recommendation. It was Urologist #2's opinion that Patient #1's abnormal laboratory results did not meet criteria for an emergency admission.

An interview was conducted on 08/25/14 at 2:00 PM with the Administrator that was on-call for Facility #1 on 08/10/14. The on-call Administrator stated Urologist #1 had instructed Facility #2's ED physician to insert a catheter and for the patient to go to the urologist's office the next day. The on-call Administrator stated even though the facility did not accept the transfer of Patient #1, Patient #1 would have been assessed the following day by the urologist in the office. The Administrator failed to ensure that their "Organizational Compliance" policy and procedure was followed as evidenced by failing to ensure that when the request was made for transfer on 08/11/14 for Patient #1, the patient was appropriately transferred to Pikeville Medical Center.

The hospital's Urological On-Call Schedule for August 2014 was reviewed. The On-Call schedule verified that Pikeville Medical Center had an Urologist on call (Urologist #1) on 08/11/14. The facility had Urology Capabilities and/or facilities as stated in their policy on 08/11/14 to provide the specialty care that Patient #1 needed on 08/11/14.

Pikeville Medical Center midnight census report for 08/11/14 was also reviewed. The hospital has 261 licensed beds. Review of the midnight census report dated 08/11/14 revealed that on 08/11/14, the facility had 93 vacant beds. The facility had the capacity to provide further treatment and evaluation for Patient #1 on 08/11/14 for the emergent medical condition (Urological) that was identified and was not available at Facility #2.