HospitalInspections.org

Based on policy review, medical record review, audio recording review, on call schedule 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 transfer request of a patient with an emergency medical condition from a referring Dedicated Emergency Department for specialized care when the receiving hospital had the capability and capacity in one of 3 audio recordings requesting transfer. (Patient #16)

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

Based on policy review, medical record review, audio recording review, on call schedule review, and staff and physician interviews, the hospital failed to accept a transfer request of a patient with an emergency medical condition from a referring Dedicated Emergency Department (DED) for specialized care when the receiving hospital had the capability and capacity in one (1) of 3 audio recordings requesting transfer. (Patient #16)

The findings included:

Review of the hospital policy titled, EMTALA-Emergency Medical Treatment and Labor Act, last revised 5/2023 revealed "I. Scope/Purpose This applies to all (named) facilities that have a "dedicated emergency department" and any hospital that has an Emergency Medical Treatment and Labor Act (EMTALA) obligation to accept patients in transfer ... D. Receiving transfers from other facilities 1. Duty to accept individuals requiring specialized capabilities - Any (named) hospital that has specialized capabilities or facilities (such as burn unit, shock-trauma units, neonatal intensive care units, or with respect to rural areas, regional referral centers) shall not refuse to accept an appropriate transfer of an individual with a emergency medical condition who requires specialized capabilities or facilities if the receiving facility has the capacity to treat the individual. This duty applies to any hospital with specialized capabilities, whether or not they have a dedicated emergency department ... E. Availability of on-call physicians 1. On-call list - Each hospital must maintain a list of physicians on its medical staff who are on-call to provide services to the hospital's patients ...3. Physician Responsibilities ...1) The responsibility of on-call physicians to respond, examine, and treat patients with emergency medical conditions ..."

Review of Medical Staff Rules & Regulations, effective 01/18/2023 revealed " ...D. Transfers ...5. Accepting transfers ...If the hospital has specialized capabilities, it shall not refuse to accept an appropriate transfer of an individual with an EMC (emergency medical condition) who requires specialized capabilities or facilities if the hospital has the capacity to treat the individual ..."

Review of Hospitals B's (Novant Health Presbyterian Medical Center) unassigned call schedule on 01/28/2025 revealed MD #3 was the provider on call for neurosurgery service.

Visit #1. Hospital A (hospital requesting transfer to Novant Health Presbyterian Medical Center). 1/28/2025. Closed dedicated emergency department (DED) medical record review of Patient #16 revealed an 82-year-old female presented to Hospital A for confusion and lower extremity weakness. Review of Provider Note (MD) on 01/28/2025 at 1812 revealed " ...Spoke with (named) with neurosurgery at (Hospital B), recommending transfer back to (Hospital C) for continuity of care at recommendation of attending. Spoke with (Hospital C) transfer center, they are currently closed all transfers but will see if the supervisor will make an exception ..." Review of Provider Note (PA) on 01/28/2025 at 1958 revealed "Discussed case and appropriate transfer location with team at OSH and (Hospital C). Ultimately agreed that maintaining care with (Hospital C) is appropriate given they initiated care recs and her inciting issue necessitated follow-up care that had yet to be completed. ID and all other care teams at (Hospital C) as well. Patient requires urgent neurosurgical evaluation ED to ED. Dispo pending evaluation. NSU team at (Hospital C) agreeable to accepting for their continued care. Patient completed T/L-MRI and was reviewed with on-call attending, (named-MD #3). Patient with noted incomplete spinal cord injury, prelim read pending. Discussion with (named Provider) that (named) PA-C from (Hospital C) is willing to accept patient for continuity of care given established patient is previously known to their service. For continuity of care, transfer to (Hospital C) is deemed appropriate given this patient will likely require decompression at T11 level. Above discussion relayed to (named provider). Plan formulated with attending on call, (named-MD #3)." Review of Provider Note on 01/28/2025 at 2058 revealed "Had multiple lengthy conversations with neurosurgery PAs and attendings both at (Hospital B) and at (Hospital C), ultimately (Hospital B) recommending transfer to (Hospital C) for continuity of care, (named-Resident MD) at (Hospital C) recommending ED to ED transfer. Spoke with (named Provider) in the (Hospital C) ED who accepted patient for transfer." Record review revealed the patient discharged on 01/28/2025 at 2140 via EMS.

Visit #2. Hospital C. 1/28/2025. Closed dedicated emergency department (DED) medical record review of Patient #16 revealed an 82-year-old female who presented to Hospital C's DED via EMS on 01/28/2025 for a neurosurgery consultation. Review of the ED Provider Note on 01/28/2025 at 2232 revealed " ...Patient transferred here for evaluation by neurosurgery ...presents to the ED as a transfer from outside hospital for evaluation of worsening altered mental status in the context of T11 epidural abscess with surrounding osteomyelitis and discitis. Neurosurgery consulted ...To be admitted to the ICU ..." Review of the History and Physical on 01/28/2025 at 2250 revealed " ...Patient transferred from (Hospital A) for emergent surgery for incomplete spinal cord ...Neurosurgery consulted for the management of this patient ...Plan: Admit to PCC No emergent surgical intervention ..." Review of the Discharge Summary on 02/04/2025 at 1132 revealed " ...Transferred to (Hospital C) ED for NSGY evaluation, and patient was admitted to NSICU... Review of the visit #2 EMS record revealed the patient was transferred due to services not available at referring facility. Review revealed the patient was transported via air transport due to time and distance.

No medical record review was completed at Hospital B, as the patient was not accepted.

Review of an audio recording on 01/28/2025 revealed a three-way call connected by the transfer center and included the ED Provider at Hospital A (hospital requesting transfer), MD #3 at Hospital B, and a PA and Resident MD at Hospital C.
Hospital B (MD #3) Hey (named) are you the PA covering for (Hospital C).
Hospital C (PA) Yeah
Hospital B (MD #3) Great I'm (MD #3). I'm aware you spoke with my PA regarding this patient. It sounds like they're at an outside facility and the request is for transfer for evaluation with neurologic exam. So I think it's appropriate to keep the patient in your team services given the previous established care and recommendations for her discitis, as well as the recommendation for biopsy previously with ultimately no bug determined at that time and now progression of that issue. So, I understand you're on divert, certainly the ED's are not on divert they can always accept patients with needs for urgent evaluations by specialty services. And if she were to need surgery certainly, I'm sure your OR's are functioning tonight. They're not closed, correct?
Hospital C (PA) Yeah correct but this is not a continuity of care from a situation where she had in the past. This is an acute neurologic decline with deficits that she did not have before.
Hospital B (MD #3) Right but it's related to the issue that you guys weighed in on, so it's the same problem and now it's worsened based on previous recommendations that maybe we're not adequate to cover the problem.
Hospital C (PA) So you're not adequate to cover an acute spinal cord incomplete spinal cord injury patient.
Hospital B (MD #3) No, the progression of the discitis that led to the retropulsion of the bone (unknown)
Hospital C (PA) But do you manage discitis ...
Hospital B (MD #3) So if we see a patient in clinic or you see a patient in clinic they remain in the same care of that team.
Hospital C (PA) But this isn't a clinic situation.
Hospital B (MD #3) Right, but we're a consult. So, did your team not follow up the patient with discitis in clinic.
Hospital C (PA) No
Hospital B (MD #3) Exactly, so that needed continuity of care clinic follow up which was not performed so I'm recommending that it remains with your team because that continuity of care was needed for her (unknown).
Hospital C (PA) However it's a nonoperative problem.
Hospital B (MD #3) Right, but you need to follow to ensure it doesn't transition to that. Did you follow up imaging with your guys team to ensure that it didn't progress.
Hospital C (Resident MD) Hey this is (named). The argument is not did we do the recommendation and the patient get worse, that's not an argument. The argument is that if there's a patient at a (named) facility who needs emergent neurosurgical intervention they go to the place that could treat them the quickest. Not that you guys saw the patient a few months ago.
Hospital B (MD #3) So the operating rooms are not on divert at any facility ever, so if the patient does need in fact urgent care you could take a patient from the ED that does neurosurgery and do the neurosurgery that day. They don't need a bed to go straight to neuro surgery ...Your operating room is not on divert. You can have them transferred to the ED and take them to the operating room. The bed situation if we all decide this is not operative, which is not what I'm saying, but if that's the case and you think they can wait for a bed to become available or when your hospital is not on divert then that can also happen tomorrow. I think we both agree she warrants an evaluation with a neurologic exam ...Is this appropriate to send to the ED for an evaluation.
Hospital C (Resident MD) I didn't say anything about a bed. I said there's a patient at a (Hospital A) facility right now that needs emergent intervention and you're saying they were seen by someone else so let's send them somewhere else.
Hospital B (MD #3) No, well we don't have neurosurgical in-house coverage at that (Hospital A) facility.
Hospital C (Resident MD) Right, but just like we only have neurosurgery at two hospitals, it's the same thing. I'm just saying they're at a (named) facility, (named) has neurosurgery at their facilities but you are saying that if this patient needs emergent intervention, we aren't doing it because they were seen somewhere else. Is that not an EMTALA violation?
Hospital B (MD #3) No, I'm saying I'm happy to take the patient, but I recommend continuity of care and that would be with you all.
Hospital C (Resident MD) Continuity of care has (unknown) emergent situations. We are happy to take a patient from a (named) facility if your team is denying them care at your facility. We are happy to take them. We are just saying they're at a (named) facility and need urgent intervention it sounds like.
Hospital B (MD #3) No I haven't examined the patient. I haven't determined that they need urgent intervention. I'm saying they need an evaluation.
Hospital C (Resident MD) So a patient that's not moving their legs you do not (unknown) whoever they can go that's fine.
Hospital B (MD #3) I was told she has weakness by the ED's report.
Hospital A (ED MD) This is the ED doc here. I just went back in and re-examined her... I can't get her to wiggle her toes anymore. The MRI report has come back now showing acute compression of the thoracic cord with a large abscess ...
Hospital C (Resident MD) Well if (named) feels like they cannot take care of the patient we are happy to take care of the patient, sounds like they need emergent neurosurgical evaluation and (unknown) intervention. If they do not want that patient then we are happy to take them, but they should be the first to get dibs on the patient as it is at their (named) facility. Sorry, can you remind me of your name?
Hospital B (MD #3) MD #3-named
Hospital C (Resident MD) Ok were happy to take care of them if they're not able to take care of them at (named).
Transfer line staff Where do you want the patient to be brought.
Hospital C (Resident MD) (Hospital C)

Request for written transcript from the transfer center revealed a written transcript was not available.

Interview on 06/03/2025 at 1130 with NM #1 revealed the nursing staff only knew of accepted transfers via CBM (centralized bed management). Interview revealed that when patients were accepted to the ED a notification from CBM alerts the nurse and gives all the patient information. Interview revealed that outgoing transfers were either direct provider to provider calls or the provider calls the transfer center of the receiving facility to request a transfer. Interview revealed that the provider on call schedule was maintained through a system called Qgenda and was updated regularly. Interview revealed that there were some specialty services the hospital did not have the capabilities for. Interview revealed that the nurse staff were not made aware of transfer denials since that was handled by CBM, only when patients were accepted.

Interview on 06/05/2025 at 1200 with Manager #2 revealed that CBM handles transfer center calls and bed placement. Interview revealed that calls placed to outside facilities or from an outside facility are on a recorded line. (Named to named) calls are not recorded and are usually direct calls from MD to MD. Interview revealed that when transfers were requested and patient's accepted, a transfer order was put in the system and CBM gets the order with all the patient information and the referring and accepting providers. Interview revealed that bed capacity was assessed by CBM. In the case of a transfer patient, even if the hospital had no capacity but still had the capability the patient would not be refused and would go as an ED-to-ED transfer. Interview revealed that all patients should be accepted unless the service was not available at the facility. Interview revealed that the (MD #3-Hospital B) did not outright deny the patient but thought the patient would do better with continuity of care. Interview revealed that the patient went from Hospital A's ED to Hospital C's ED.

Interview on 06/05/2025 at 1334 with MD #3 revealed the provider recalled the patient. Interview revealed that Hospital A does not have neuro coverage. The provider from Hospital A paged the PA from Hospital B to discuss consultation and transfer from Hospital A to Hospital B. The PA spoke to MD #3 (Hospital B) to discuss if the patient should go to Hospital B or Hospital C since Hospital C had all the patient records and imaging. After MD #3 looked reviewed the imaging from Hospital A it was determined the patient needed a neurologic evaluation. Interview revealed that the patient had been treated by Hospital C's neurosurgery for a spinal abscess/infection and that infection had become worse. Interview revealed that MD #3 recommended that team continue to follow the patient and thought they should be involved. Interview revealed that MD #3 felt she was advocating for the patient by including Hospital C and recommending that the patient transfer there. Interview revealed that MD #3 reached out to Hospital C. MD #3 stated they tried to make it seem like I was refusing the patient. I wasn't denying the patient, I just felt they would better care for the patient and her history. I think they misunderstood why I was calling, but my intent was not to deny but to better care for the patient. Interview revealed that Hospital B did not have any beds available. Interview revealed that Hospital A called Hospital C first and they said no to accepting the patient at first and stated we could take care of it. Interview revealed that MD #3 then requested to talk with the Attending provider at Hospital C but got the PA instead. Interview revealed that MD #3 stated that she was trying to educate the Resident at Hospital C and now realized that it should not have been a back-and-forth conversation. Interview revealed MD #3 was the neuro provider on call.

Interview on 06/05/2025 at 1415 with Director #4 revealed the director was not aware of the patient but had reviewed the record for the interview. Interview revealed that bed capacity was not a problem. In the situation where there were no available beds the patient would just transfer ED to ED. Interview revealed that unless the facility did not have the resources to care for the patient or a patient requested a transfer to a specific facility the culture was to always accept all transfer patients.